All Reports

Develop and approve a system security plan and an authorization to operate for the special-purpose system.

Verify that access control lists have been applied to network segments that contain medical systems.

Validate that appropriate physical and environmental security measures are implemented and functioning as intended.

The Under Secretary for Health evaluates the efficacy of the May 2022 Veterans Integrated Service Network and Office of Mental Health and Suicide Prevention oversight structure for suicide risk training and considers inclusion of an oversight structure for lethal means safety training compliance.

The Under Secretary for Health evaluates the adequacy of the one-time lethal means safety training requirement and takes action as appropriate.

The Under Secretary for Health ensures clinician completion of comprehensive suicide risk evaluations including the discussion and documentation of firearms access and safe storage as required, and monitors compliance.

The Under Secretary for Health evaluates staff’s perceived barriers to completion of the suicide risk identification strategy and takes action as appropriate.

Monitor facility follow-up rates by type of care and on a month-over-month basis, establish monitoring metrics, and assist facilities if they fall below these metrics.

Evaluate and update, as appropriate, whether activities that occurred before cancellation and notations of “No Action Other Reason” should be tracked as follow-up.

Absent such relief, provide information detailing the limitations that prevent VA from reporting the average number of days that potential title 38 or hybrid title 38 hires spent in each phase of the hiring model in accordance with section 3008(a)(E)(iii) of the Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020.

Assign specific roles and responsibilities to the Office of Integrated Veteran Care to ensure effective oversight of the Referral Coordination Initiative.

Make certain that staff with Referral Coordination Initiative responsibilities are sufficiently trained on how to triage, communicate key information on options to veterans, schedule, or document consults, according to their respective duties.

Direct relevant VA medical facilities to establish local processes by which VA medical facility staff identify and share available community care wait time data with referral coordination team members within each facility, and then establish controls to help ensure that this information is consistently communicated to patients.

Establish a mechanism or update the Referral Coordination Initiative checklist to effectively track and monitor each facility’s challenges with implementation and progress toward implementing the initiative for all relevant specialty services.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facility surgical work groups consistently review surgical deaths.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that chiefs of staff and associate directors for patient care services ensure all required members attend disruptive behavior committee or board meetings.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that medical center directors ensure staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work area.

Assess compliance weaknesses identified by VA Office of Procurement Policy, Systems and Oversight internal reviews, and implement corrective actions determined appropriate.

Require contracting officers responsible for Buy American Act compliance deficiencies identified by contract file reviewers and VA Office of Procurement Policy, Systems and Oversight internal reviews to attend refresher Buy American Act–specific training.

The Under Secretary for Health ensures that Intimate Partner Violence Assistance Program protocols are developed at all medical centers consistent with the national requirement.

The Under Secretary for Health evaluates the sufficiency of current guidance and operational status regarding Intimate Partner Violence Assistance Program coordinators’ dedicated time and population needs, and takes action as warranted.

The Under Secretary for Health determines the appropriate guidance for dedicated administrative staff support in consideration of the Intimate Partner Violence Assistance Program coordinators’ responsibilities, and takes action as warranted.

The Under Secretary for Health considers the establishment of standardized Intimate Partner Violence staff training content and format as well as the evaluation of training efficacy, and takes action as warranted.

The Under Secretary for Health develops intimate partner violence screening requirements based on the current guidance and patient population needs, and takes action as warranted.

The Under Secretary for Health expedites standardized program evaluation processes with oversight and reporting responsibilities to ensure identification of implementation and program deficiencies and monitoring of corrective action and performance improvement plans.

The Under Secretary for Health evaluates the current guidance and operational status related to the roles and oversight functions of the Veterans Integrated Service Network Intimate Partner Violence Assistance Program champions and lead coordinators and clarifies expectations and requirements.

Perform security control assessments of the video surveillance system and obtain an authorization to operate in accordance with set policy.

Establish clear oversight roles and responsibilities of the program office and of regional network telehealth and medical facility leads to monitor medical facility social worker and telehealth staff compliance with the “Digital Divide Standard Operating Procedure” for conducting assessments, ordering, and scheduling.

Develop and implement a mechanism to alert the requesting clinic that a patient has a loaned device and can now be scheduled for a VA Video Connect appointment.

Update the digital divide consult training to include procedure updates and ensure social workers and facility telehealth and Remote Order Entry System coordinators who process digital divide consults and video device orders complete the training and take refresher training as needed.

Implement procedures to require responsible staff to check for duplicate devices before submitting a device order consult.

Establish an alert in the Remote Order Entry System to notify the responsible staff member that a patient already has an issued device before ordering another, and initiate retrieval activities for duplicate devices.

Delegate in the “Digital Divide Standard Operating Procedure” facility staff to monitor the tablet dashboard for VA Video Connect appointment activity and device use, and clearly define regional network telehealth leads’ oversight responsibilities to ensure facilities initiate retrieval activities when warranted.

Establish an automated mechanism using the tablet dashboard to routinely identify the devices that meet retrieval priorities and also initiate retrieval of those that already meet retrieval requirements.

Address restrictions in the refurbishment process, implement accessible and trackable reporting of devices waiting to be refurbished, and implement a structured purchasing model to guide new device purchases and maintain an appropriate inventory level.

Provide appropriate oversight and ensure coordination between designated program offices to implement a comprehensive identity, credential, and access management policy.

Update and publish a VA directive and handbook associated with identity and access management that includes current National Institute of Standards and Technology requirements.

Implement a formal procedure to ensure all improperly created debts identified by the review team are corrected, and certify the results to the OIG.