Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 21-03203-239 | Surgical Adverse Clinical Outcomes and Leaders’ Responses at the Columbia VA Health Care System in South Carolina | Hotline Healthcare Inspection | ||
1 The Southeast Network Director facilitates a comprehensive review of Patient A’s episode of care, from the time and date of the patient’s hospitalization through the date and time of the patient’s death, to identify practitioner and process improvements that may reduce the potential for future incidents, and takes appropriate actions.
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2 The Columbia VA Health Care System Director ensures providers carefully consider facility resources when evaluating medically-complex patients for admission and when determining whether admitted patients’ medical complexities exceed the facility’s capabilities to meet patients’ needs.
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3 The Columbia VA Health Care System Director ensures that the peer review committee record the committee members formal discussions specific to the peer review in meeting minutes, and monitors ongoing compliance.
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4 The Columbia VA Health Care System Director evaluates quality management practices that impede the timeliness of institutional disclosures, ensures current practices are in alignment with Veterans Health Administration policy, and takes action as warranted.
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5 The Columbia VA Health Care System Director ensures that root cause analyses are completed within the required 45-day time frame to promptly identify and address system vulnerabilities.
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6 The Columbia VA Health Care System Director facilitates a comprehensive administrative review of the vascular surgeon’s disregard of surgical and invasive procedure protocols and Stop the Line principles, consults with the Office of Regional Counsel and human resource specialists, and takes administrative actions, as appropriate.
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7 The Columbia VA Health Care System Director evaluates facility staff’s informed consent and time-out practices, to include the review of pertinent medical images, and ensures practices are consistent with correct surgery and invasive procedure requirements, takes action as appropriate, and monitors compliance.
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| 21-02145-243 | Alleged Failures to Adequately Equip Executive Protection Personnel Are Substantiated in Part | Administrative Investigation | ||
1 Ensure the director of the Office of Operations, Security, and Preparedness creates a written policy establishing minimum standards for ballistic armor for Executive Protection Division personnel based on agents’ input, industry best practices and research, and relevant threat levels, which is routinely reassessed for adequacy.
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2 Make certain that the director of the Office of Security and Law Enforcement develops onboarding procedures for new Executive Protection Division personnel who are or may be assigned to protective details or motorcades of the VA Secretary or Deputy Secretary, including procedures for measuring personnel and procuring new ballistic vests or assessing and approving the use of an employee’s own vest to ensure it meets minimum safety standards.
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3 Require the director of the Office of Security and Law Enforcement to establish procedures to track the maintenance and expiration of ballistic vests assigned to Executive Protection Division personnel and to ensure their replacement as needed.
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4 Instruct the director of the Office of Security and Law Enforcement to create procedures for monitoring compliance with the standard operating procedure requirement to wear ballistic armor, such as periodic inspections, and establish consequences for noncompliance.
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5 The OIG recommends that the director of the Office of Security and Law Enforcement conducts a review of the condition of all firearms currently assigned to EPD special agents and determines whether any are in need of replacement.
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| 22-00973-215 | Inspection of Information Technology Security at the Harlingen VA Health Care Center in Texas | Information Security Inspection | ||
1 Implement a more effective process to maintain consistent inventory information for all network segments.
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2 Implement a vulnerability management program that ensures system changes occur within organization timelines.
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3 Implement effective system life-cycle processes to ensure network devices meet standards mandated by the VA Office of Information and Technology Configuration Control Board.
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4 Develop and implement a process to retain database logs for a period consistent with VA’s record retention policy.
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5 Validate that appropriate physical and environmental security measures are implemented and functioning as intended.
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| 21-03906-226 | Home Improvements and Structural Alterations Program Needs Greater Oversight | Audit | ||
1 Coordinate with the Prosthetic and Sensory Aids Service executive director to (1) develop and issue guidance clearly articulating eligibility requirements for the lifetime benefit amounts to address non-service-connected disabilities and (2) communicate this guidance in an effective manner, such as including specific language in handbooks, providing examples of scenarios to reinforce the requirements, and requiring annual training to make sure all prosthetic staff responsible for the program understand these eligibility requirements.
2 Coordinate with the Prosthetic and Sensory Aids Service executive director to make sure Veterans Integrated Service Network prosthetic representatives look at veteran eligibility for non-service-connected disability benefits in their annual reviews of medical facilities’ prosthetics programs.
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3 Coordinate with the Prosthetic and Sensory Aids Service executive director to correct and update inaccurate information on the publicly accessible Home Improvements and Structural Alterations Program website.
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4 Coordinate with the assistant under secretary for health for operations and the Prosthetic and Sensory Aids Service executive director to make sure medical facilities or Veterans Integrated Service Networks implement procedures for verifying that veterans’ Home Improvement and Structural Alterations packages include documentation of approval and justification for all improvements and alterations paid for with program benefits.
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5 Coordinate with the assistant under secretary for health for operations and the Prosthetic and Sensory Aids Service executive director to ensure medical facilities and Veterans Integrated Service Network directors implement procedures to capture when key documentation is received and monitor these dates to ensure facilities adhere to timelines for the Home Improvements and Structural Alterations Program and take corrective action when they are not meeting standards outlined in 38 C.F.R. §§ 17.3100 through 17.3130 and VHA Directive 1173.14.
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| 22-00971-217 | Inspection of Information Technology Security at the Alexandria VA Medical Center in Louisiana | Information Security Inspection | ||
1 Implement a more effective process to maintain consistent inventory information for all network segments.
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2 Improve the vulnerability and flaw remediation program to accurately identify vulnerabilities and enforce flaw remediation.
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3 Implement effective configuration control processes that ensure network devices maintain vendor support.
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4 Perform security control assessments of the video surveillance system and obtain an authorization to operate in accordance with set policy.
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5 Ensure installation of distributed network infrastructure equipment that meets VA installation standards, to include proper equipment mounting and clearance.
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6 Ensure routine maintenance is conducted on uninterruptible power supplies.
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7 Implement database authentication processes that comply with VA security requirements.
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8 Implement a physical access control system for the data center and core switch room that is supportable and can meet VA logging requirements.
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| 21-00887-211 | New York/New Jersey VA Health Care Network (VISN 2) Should Improve Boiler Maintenance to Reduce Safety Risks and Prevent Care Disruptions | Audit | ||
1 The director of Veterans Integrated Service Network 2 should ensure useful life assessments are conducted for those boilers operating past their expected or extended lifespans outlined in this report to ensure safe operation. 23
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2 The director of the Office of Healthcare Engineering should clarify policies and procedures for scheduling useful life assessments of boilers prior to the end of expected lifespans and after an extension has been granted.
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3 The director of the Office of Healthcare Engineering should update VHA Directive 1810 to ensure that medical facility boiler policies are updated to reflect site-specific safety device testing procedures, including justifications for each test prescribed in the VHA Boiler and Associated Plant Safety Device Testing Manual that the medical facility does not plan to perform.
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4 The director of the Office of Healthcare Engineering should update VHA Directive 1810 to clarify which tests and inspections require the use of third-party inspectors, as well as the frequency of these tests and inspections.
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5 The director of Veterans Integrated Service Network 2 should review medical facilities’ boiler operation policies to ensure procedures for notifying management and documenting corrective action plans and timelines for addressing safety incidents are consistent with VHA Directive 1810 requirements.
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6 The director of Veterans Integrated Service Network 2 should employ a management information system to ensure all individuals with oversight responsibility are granted access to records for boiler maintenance deficiencies and corresponding corrective actions, boiler inventory, testing and inspection compliance, and useful life assessment completeness.
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| 22-00815-232 | Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021 | National Healthcare Review | ||
1 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures medical facility directors make certain that a written policy is in place and implemented for the safe, appropriate, orderly, and timely transfer of patients.
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2 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures chiefs of staff and associate directors of patient care services monitor and evaluate all transfers as part of Veterans Health Administration’s Quality Management Program.
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3 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain chiefs of staff ensure that transferring providers send patients’ active medication lists and copies of advance directives to receiving facilities during inter-facility transfers.
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4 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain chiefs of staff and associate directors of patient care services ensure nurse-to-nurse communication occurs during the inter-facility transfer process.
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| 21-02326-233 | Community Care Coordination Delays for a Patient with Oral Cancer at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas | Hotline Healthcare Inspection | ||
1 The Veterans Health Care System of the Ozarks Facility Director ensures that Office of Community Care staff take action on active consults within seven days and schedule community care appointments within the 30-day clinically indicated date requirement and monitors compliance.
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2 The Veterans Health Care System of the Ozarks Facility Director evaluates the process for authorization of requests for community care and for coordinating care for patients receiving oncology treatment in the community, and takes corrective action to address any deficiencies identified.
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3 The Under Secretary of Health ensures the Veterans Health Administration Office of Community Care defines a standardized process for community care coordination related to follow-up requests for additional services from community providers.
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| 22-00404-207 | VBA Could Improve the Accuracy and Completeness of Medical Opinion Requests for Veterans’ Disability Benefits Claims | Review | ||
1 Implement electronic system enhancements to require claims processors to identify relevant evidence before a medical opinion request can be submitted.
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2 Enhance mandated training for all claims processors on making medical opinion requests and demonstrate progress showing that the training is achieving its intended impact.
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3 Strengthen monitoring controls by improving the national and local quality review processes to identify medical opinion request areas in need of improvement and demonstrate progress toward ensuring compliance with established procedures.
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| 22-00208-221 | Financial Efficiency Review of the VA Cincinnati Healthcare System | Financial Inspection | ||
1 Ensure that healthcare system finance office staff are made aware of policy requirements and that reviews are conducted on all inactive open obligations as required by VA Financial Policy, vol. 2, chap. 5, “Obligations Policy.”
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2 Require the finance office to perform quarterly compliance reviews of pharmacy invoice reconciliations.
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3 Develop a plan to work with the prime vendor to address having adequate stock to meet orders, reducing the need for the healthcare system to use nonprime vendors.
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4 Ensure the healthcare system submits Medical/Surgical Prime Vendor–Next Generation waiver requests and obtains approval before purchasing available formulary items from nonprime vendor sources.
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5 Ensure logistics staff and the contracting officer’s representative use the tools available to inform the Medical Supplies Program Office and Strategic Acquisition Center of prime vendor performance concerns and challenges.
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6 Develop formalized processes for monitoring and achieving identified efficiency targets and use available pharmacy data to make business decisions.
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7 Develop and implement a plan to increase inventory turnover to the Veterans Health Administration‑recommended level.
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8 Develop and implement a plan to complete facility-based inventory audits of noncontrolled drug line items in compliance with Veterans Health Administration policy.
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14957