Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 21-01237-127 | Contract Medical Exam Program Limitations Put Veterans at Risk for Inaccurate Claims Decisions | Review | ||
1 Assess and modify contracts and any renewals to ensure that vendors can be heldaccountable for unsatisfactory performance by applying monetary disincentives.
Closure Date:
2 Assess and modify contracts and any renewals to ensure procedures are established for vendors to correct errors identified by the Medical Disability Examination Office.
Closure Date:
3 Implement procedures requiring the Medical Disability Examination Office tocommunicate exam errors to the Office of Field Operations and the regional officesand demonstrate progress in correcting the identified errors.
Closure Date:
4 Implement procedures requiring the Medical Disability Examination Office toanalyze all available error data and provide systemic exam issues and error trends tovendors.
Closure Date:
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| 20-02186-78 | Suicide Prevention Coordinators Need Improved Training, Guidance, and Oversight | Review | ||
1 Ensure program officials in collaboration with regional and local leaders address call management system data integrity issues before they use data to assess the management of referrals.
Closure Date:
2 Have the program office develop formal training and guidance for coordinators on how to use patient outcome codes and regional and local leaders ensure the training is completed.
Closure Date:
3 Ensure regional and local managers regularly review crisis line referral information in the electronic health records to verify coordinators are completing and documenting appropriate follow-up on referrals and the program office performs regular audits, monitors, reports upon, and initiates actions, as needed, to ensure compliance with and completion of referral follow-up.
Closure Date:
4 Consider guidance within coordinators’ training tools to clarify the expectations for coordinators to follow up on referred veterans who have been hospitalized in a non-VA hospital, admitted to an emergency department (VA and non-VA), or provided a welfare check.
Closure Date:
5 Have regional and local managers monitor coordinators’ call attempts to ensure they are interspersed over a three-day period and provide them with referral closure information to assist in their monitoring.
Closure Date:
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| 21-00286-163 | Comprehensive Healthcare Inspection of the Beckley VA Medical Center in West Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons fornoncompliance and makes certain that the Surgical Workgroup Committee meets atleast monthly.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons fornoncompliance and ensures staff complete mandatory suicide safety plan trainingprior to developing suicide safety plans.
Closure Date:
3 The Chief of Staff and Associate Director/Patient Care Services evaluate anddetermine any additional reasons for noncompliance and ensure staff send activemedication lists to receiving facilities during inter-facility transfers.
Closure Date:
4 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures all staff complete the required prevention and management of disruptive behavior training based on the risk level assigned to their work area.
Closure Date:
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| 21-00293-170 | Comprehensive Healthcare Inspection of the Hershel Woody Williams VA Medical Center in Huntington, West Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons fornoncompliance and ensures leaders conduct institutional disclosures for all sentinelevents.
Closure Date:
2 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Systems Redesign Coordinator participates on the Quality, Safety & Value Council.
Closure Date:
3 The Medical Center Director evaluates and determines any additional reasons fornoncompliance and makes certain that the Facility Surgical Work Group meets atleast monthly.
Closure Date:
4 The Medical Center Director evaluates and determines any additional reasons fornoncompliance and ensures that core members consistently attend Facility SurgicalWork Group meetings.
Closure Date:
5 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure that the referring physician completes all required elements of the VA Inter-Facility Transfer Form or facility-defined equivalent note.
Closure Date:
6 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that required representatives attend the Disruptive Behavior Committee meetings.
Closure Date:
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| 21-02453-99 | Inspection of Information Technology Security at the Consolidated Mail Outpatient Pharmacy in Tucson, Arizona | Information Security Inspection | ||
1 Implement more effective inventory management tools for all network segments.
Closure Date:
2 Implement a more effective vulnerability and flaw remediation program that can accurately identify vulnerabilities and enforce flaw remediation.
Closure Date:
3 Develop and implement methods to ensure delivery, receipt, and understanding of assigned roles and responsibilities for Consolidated Mail Outpatient Pharmacy activities to ensure full implementation of approved policy.
Closure Date:
4 Develop and implement a disaster recovery plan and capability that will restore operations in the event of a disruption to critical operations.
Closure Date:
5 Task the facility manager to change the default username and password for the security camera system.
Closure Date:
6 Request the Office of Information and Technology to configure audit logging on the misconfigured devices in accordance with established baselines, policy, and procedures.
Closure Date:
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| 21-01123-97 | Veterans Data Integration and Federation Enterprise Platform Lacks Sufficient Security Controls | Audit | ||
1 The assistant secretary for information and technology and chief information officer will ensure the Veterans Data Integration and Federation Enterprise Platform security objectives are all set at a categorization level of high based upon both the sensitive personal information maintained in the system and the approved risk assessment.
Closure Date:
2 The assistant secretary for information and technology and chief information officer will act to reestablish the Veterans Data Integration and Federation Enterprise Platform in the Enterprise Mission Assurance Support Service to ensure appropriate security controls are implemented and the system is assessed at the high risk level.
Closure Date:
3 The assistant secretary for information and technology and chief information officer will ensure the Office of Information Technology provides appropriate oversight and follows proper program management processes and protocols when establishing and monitoring security controls for IT systems.
Closure Date:
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| 21-03305-139 | Inspection of Information Technology Security at the Consolidated Mail Outpatient Pharmacy in Dallas, Texas | Information Security Inspection | ||
1 Implement an effective inventory management system for all network segments.
Closure Date:
2 Implement an effective vulnerability and flaw remediation program that can
accurately identify vulnerabilities and enforce flaw remediation
Closure Date:
3 Develop and implement methods to ensure delivery, receipt, and understanding of assigned roles and responsibilities for local activities to ensure full implementation
of approved policy.
Closure Date:
4 Implement effective configuration control processes that ensure network devices maintain standards mandated by the VA Office of Information and Technology Configuration Control Board.
Closure Date:
5 Remove or disable group accounts to comply with established requirements and criteria.
Closure Date:
6 Ensure employees lock devices when they are unattended.
Closure Date:
7 Implement database authentication processes that comply with National Institute of
Standards and Technology standards and VA security requirements.
Closure Date:
8 Implement a process to retain database logs for a period consistent with VA’s record
retention policy.
Closure Date:
9 Establish a process for validating and logging the sanitization of hard drives.
Closure Date:
10 Implement parking barriers that meet VA Physical Security & Resiliency Design Manual
requirements.
Closure Date:
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| 21-03020-168 | Deficits with Metrics Following Implementation of the New Electronic Health Record at the Mann-Grandstaff VA Medical Center in Spokane, Washington | Hotline Healthcare Inspection | ||
1 The Deputy Secretary completes an evaluation of gaps in new electronic health record metrics and takes action as warranted.
Closure Date:
2 The Deputy Secretary completes an evaluation of factors affecting the availability of metrics and takes action as warranted.
Closure Date:
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| 21-00240-158 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 2: New York/New Jersey VA Health Care Network in Bronx, New York | Comprehensive Healthcare Inspection Program | ||
1 The Chief Medical Officer evaluates and determines additional reasons for noncompliance and makes certain to review the credentials file and approve the VA appointment for physicians who had a potentially disqualifying licensure action.
Closure Date:
2 The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the Emergency Management Committee conducts annual reviews of the Emergency and Continuity of Operations Plans; Hazards Vulnerability Analysis; and Veterans Integrated Service Network-wide strengths, weaknesses, priorities, and requirements for improvement, and submits the reviews to executive leaders for approval.
Closure Date:
3 The Network Director evaluates and determines any additional reasons for noncompliance and appoints a permanent Veterans Integrated Service Network lead women veterans program manager.
Closure Date:
4 The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that a lead women veterans program manager conducts yearly visits at each facility in the Veterans Integrated Service Network.
Closure Date:
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| 20-04443-167 | Failure to Provide Emergency Care to a Patient and Leaders’ Inadequate Response to that Failure at the Malcom Randall VA Medical Center in Gainesville, Florida | Hotline Healthcare Inspection | ||
1 The VA Sunshine Healthcare Network Director ensures a review of the patient incident is conducted to determine whether further administrative action or reporting to state licensing board(s), or both, is warranted for facility staff involved in the incident, and takes action as appropriate.
Closure Date:
2 The Malcom Randall VA Medical Center Director ensures that Emergency Department nurses and Administrative Officers of the Day prioritize patient care before patient eligibility status when patients present with an emergency medical condition, holds staff accountable when violations occur, and monitors for ongoing compliance.
Closure Date:
3 The Malcom Randall VA Medical Center Director ensures that Emergency Department nurse competencies are current, complete, and validated as required, and monitors for ongoing compliance.
Closure Date:
4 The Malcom Randall VA Medical Center Director conducts an internal review of the Emergency Department Nurse Educator’s replication of the 2019 Ongoing Competency Assessments and attestation of competency completion to determine whether administrative action is warranted and takes action as appropriate.
Closure Date:
5 The Malcom Randall VA Medical Center Director evaluates the status of action plans referenced in this report and monitors the implementation and efficacy of action items to closure.
Closure Date:
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14957