Recommendations
2056
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-00617-118 | Healthcare Facility Inspection of the VA Augusta Health Care System in Georgia | Healthcare Facility Inspection | ||
1 The OIG recommends the Under Secretary for Health evaluates facility leaders for appropriate supervisory behavior and professional communication and takes actions as needed.
2 The OIG recommends the Under Secretary for Health determines whether the Veterans Integrated Service Network Director and other Veterans Integrated Service Network leaders were aware of, but did not address, facility leaders’ unprofessional behavior and communication, and takes actions as needed.
3 The OIG recommends the Under Secretary for Health ensures the Veterans Integrated Service Network and facility directors oversee the inventory management system, resolve medical supply deficiencies, and monitor actions for sustained improvement.
4 The OIG recommends facility leaders develop action plans to ensure providers communicate test results to patients timely.
5 The OIG recommends the Under Secretary for Health directs the national VHA Quality and Patient Safety Program staff to review the facility’s quality management program and determine whether actions by facility and Veterans Integrated Service Network leaders effectively addressed system issues affecting patient safety, including nursing leaders’ lack of access to safety reports, and missed opportunities for institutional disclosures, and takes action as needed.
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| 24-02359-123 | Deficiencies in Emergency Care for a Female Veteran at Martinsburg VA Medical Center in West Virginia | Hotline Healthcare Inspection | ||
1 The Martinsburg VA Medical Center Director reviews communication between emergency department staff to ensure timely patient care coordination, and takes action as warranted.
2 The Martinsburg VA Medical Center Director ensures emergency department nurses monitor, assess, and document patient care as required by Veterans Health Administration and Martinsburg VA Medical Center policy, and monitors compliance.
3 The Martinsburg VA Medical Center Director ensures processes are in place to ensure blood transfusions are administered according to policy, and monitors compliance.
4 The Martinsburg VA Medical Center Director conducts a review of actions implemented as a result of the factfinding to include administrative actions and performance improvement plans and ensures quality of care concerns have been remediated, and takes action as warranted.
5 The Martinsburg VA Medical Center Director evaluates the functionality of emergency room equipment, including an exam table with footrests, for conducting gynecologic examinations with dignity and comfort, and takes action as warranted.
6 The Martinsburg VA Medical Center Director reviews concerns related to fire department overtime practices, takes action as appropriate, and follows up to ensure compliance.
7 The Martinsburg VA Medical Center Director reviews the transport delay for the abdominal pain patient, and takes action as appropriate.
8 The Martinsburg VA Medical Center Director reviews the factfinding related to transportation concerns, ensures an adequate review is conducted, and takes action as warranted.
9 The Martinsburg VA Medical Center Director ensures all reported patient safety concerns related to emergency transport delays are investigated to identify root causes and contributing factors that require action to prevent future events.
10 The Martinsburg VA Medical Center Director ensures clear guidance is in place for clinical and administrative staff on the use of facility emergent and non-emergent transport resources.
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| 24-03777-113 | Review of VA’s Compliance with the Payment Integrity Information Act for Fiscal Year 2024 | Review | ||
1 Reduce improper and unknown payments to below 10 percent for the Pension Program.
2 Reduce improper and unknown payments to below 10 percent for the Purchased Long-Term Services and Supports Program.
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| 24-00604-121 | Healthcare Facility Inspection of the VA North Florida/South Georgia Veterans Health System in Gainesville | Healthcare Facility Inspection | ||
1 The OIG recommends the Associate Director of Operations ensures staff maintain, inspect, and test medical equipment.
2 The OIG recommends the Deputy Chief of Staff ensures staff secure all medications from unauthorized access.
3 The OIG recommends the Associate Director of Patient Care Services ensures staff appropriately store oxygen tanks.
4 The OIG recommends the Associate Director ensures staff clean all food storage areas.
5 The OIG recommends the Associate Director of Operations ensures staff remove expired supplies from storage areas.
6 The OIG recommends the Associate Director of Operations ensures staff mark equipment that needs repair and separate it from equipment available for use and remove dirty items from clean storage areas.
7 The OIG recommends facility leaders ensure sustained compliance with Joint Commission accreditation standards.
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| 24-02575-50 | Inspection of Information Security at the Battle Creek Healthcare System in Michigan | Information Security Inspection | ||
1 Improve vulnerability management processes to ensure all vulnerabilities are identified and plans of action and milestones are created for vulnerabilities that cannot be mitigated by VA deadlines.
Closure Date:
2 Implement a more effective baseline configuration process to ensure network devices are running authorized software that is configured to approved baselines and free of vulnerabilities.
3 Improve the remediations reporting process for the Continuous Readiness in Information Security Program to verify that corrective actions are taken to fully mitigate vulnerabilities for biomedical devices at the Battle Creek facility.
Closure Date:
4 Implement improved physical access controls to restrict access to the server room and communications closets.
Closure Date:
5 Ensure network segmentation controls are applied to all network segments hosting special-purpose systems or medical devices.
Closure Date:
6 Implement improved, consistent environmental controls for network communications closets.
Closure Date:
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| 23-02157-106 | Former Orlando VA Medical Center Executive Violated Ethics Rules | Administrative Investigation | ||
1 The Veterans Health Administration chief operating officer establishes a written policy or procedure to reasonably ensure that potential conflicts of interest or appearance of partiality concerns involving VHA employees are identified and remediated before contractor presentations to Veterans Integrated Service Network or facility leaders.
2 The Veterans Integrated Service Network 8 director confirms that VA has initiated the process to seek recoupment of the critical skill incentive paid by VA to Ms. Skala that was attributable to a service period that she did not complete due to her retirement.
3 The assistant secretary for Human Resources and Administration/Operations, Security, and Preparedness directs a review to determine whether any VHA employee ranked GS‑15 or above awarded a critical skill incentive has left VA before completing their required service obligation, and, if so, whether VA has established a debt and initiated recoupment in the amount of the CSI attributable to the uncompleted period, and takes further corrective actions as warranted.
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| 24-01566-100 | Deficiencies in Trainee Onboarding, Physician Oversight, and a Root Cause Analysis at the Overton Brooks VA Medical Center in Shreveport, Louisiana | Hotline Healthcare Inspection | ||
1 The Overton Brooks VA Medical Center Director reviews and monitors compliance with Veterans Health Administration health professions trainee onboarding requirements, and takes action as indicated.
Closure Date:
2 The Overton Brooks VA Medical Center Director makes certain that oversight of the intensive care unit physician credentialing and privileging process is completed prior to physicians being scheduled and providing patient care, and monitors compliance.
3 The Overton Brooks VA Medical Center Director ensures root cause analyses are completed according to Veterans Health Administration policy including team composition, root cause analysis process steps, and timeliness.
4 The Under Secretary for Health evaluates the additional root cause analysis concurrence step used within Veterans Health Administration medical centers to ensure alignment with National Center for Patient Safety guidance, and takes action as indicated.
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| 24-00645-84 | Integrated Financial and Acquisition Management System Interface Development Process Needs Improvement | Audit | ||
1 Incorporate all business-essential processes and related interfaces, as defined by product owners, during validation sessions, user acceptance testing, or equivalent procedures to accurately present system capability.
2 Enhance the test plan to incorporate a more robust, risk-based testing process that incorporates user-testing requirements for functional and nonfunctional business-essential processes related to interfaces.
3 Develop a process to confirm with affected administrative offices whether they are aware of needed changes to test environments and that they have sufficiently executed them before interface test events.
4 Develop a method to evaluate whether test deficiencies necessitate changes to the deployment schedule to ensure deficiencies are properly addressed before wave go-live and implement these changes.
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| 24-01330-29 | Improper Sharing of Sensitive Information on Cloud-Based Collaborative Applications | Review | ||
1 Take corrective actions to ensure that facilities and programs remove unauthorized sensitive information from collaborative application sites.
2 Direct facilities and programs to standardize SharePoint administration, inventory and consolidate their SharePoint sites, and enforce the recommended architecture to better control access and content at the facility or program level.
Closure Date:
3 Implement enforcement mechanisms to ensure that facilities and programs are following standardized processes to secure SharePoint and Teams sites.
Closure Date:
4 Expand roles and responsibilities of facility and program information system security officers and privacy officers to include the routine review of SharePoint and Teams site permissions and content.
5 Implement automated tools and policies, supported with training, to enable the timely and routine detection and correction of improper sharing and unauthorized content throughout VA.
6 Mandate standardized training for SharePoint administrators and owners to clarify and reinforce data security requirements.
Closure Date:
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| 24-00990-99 | Delayed Diagnosis and Treatment for a Patient’s Lung Cancer and Deficiencies in the Lung Cancer Screening Program at the VA Eastern Kansas Healthcare System in Topeka and Leavenworth | Hotline Healthcare Inspection | ||
1 The VA Eastern Kansas Healthcare System Director ensures the chief of primary care reviews, strengthens, and implements system Patient Aligned Care Team processes for tracking and following up on community care consults ordered, particularly diagnostic consults, to verify patients receive care and to review and act upon consult results, as clinically indicated.
2 The VA Eastern Kansas Healthcare System Director reviews institutional disclosures conducted by the system over the past 12 months, including the patient’s institutional disclosure, and ensures these disclosures fully adhere to Veterans Health Administration Directive 1004.08, Disclosure of Adverse Events to Patients, October 31, 2018, including documenting the details of the adverse event and discussion points of the disclosure, and takes action needed to remediate disclosures that do not meet these standards.
3 The VA Eastern Kansas Healthcare System Director ensures community care staff make the required three attempts to obtain patients’ community care records within 90 days of completed appointments, and monitors for compliance.
4 The VA Eastern Kansas Healthcare System Director collaborates with the Kansas City VA Medical Center Director to review the frequency and circumstances of community care records being sent to the incorrect VA facility, develops, and implements a process for ensuring community care records are delivered to the correct ordering VA facility, educates staff on the process, and monitors for compliance.
5 The Under Secretary for Health establishes and monitors compliance with a process that ensures the Veterans Health Administration ordering provider receives urgent non-life-threatening abnormal test results from care obtained in the community, such as the diagnostic positron emission tomography scan results described in this report, within a time frame that allows timely attention and appropriate action to be taken.
6 The Veterans Integrated Service Network Director, in conjunction with the Veterans Health Administration National Center for Lung Cancer Screening Program Office, evaluates the VA Eastern Kansas Healthcare System’s Lung Cancer Screening Program to ensure operational adherence to the Lung Cancer Screening Program requirements, and takes action as needed.
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