All Reports

The Oklahoma City VA Health Care System Director, with Pathology and Laboratory Medicine Service leaders, conducts a comprehensive review of the quality of care for the four patients identified in this report, including determinations of cytopathology processing delays and assessment of patient harm, and takes action as warranted.

The Oklahoma City VA Health Care System Director ensures that routine non-gynecological turnaround time corrective actions are documented and monitored for effectiveness, as required by the Veterans Health Administration.

The Oklahoma City VA Health Care System Director conducts a comprehensive review of the quality of care provided by the Chief of Pathology and Laboratory Medicine Service, identifies deficiencies, and takes action as warranted. 

The Oklahoma City VA Health Care System Director reviews the Pathology and Laboratory Medicine Service event reporting requirements for variance events and ensures completion according to facility policy and Veterans Health Administration requirements.

The Oklahoma City VA Health Care System Director, in conjunction with the National Center for Patient Safety, evaluates patient safety event reporting processes within the Pathology and Laboratory Medicine Service, and ensures completion according to Veterans Health Administration requirements.

Implement 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.

Implement a more effective baseline configuration process to ensure network devices and databases are running authorized software that is configured to approved baselines and free of vulnerabilities.

Perform a cost-benefit analysis and implement appropriate controls within the federal Electronic Health Record to limit disclosure of veteran personally identifiable information based on job responsibility.

Segregate the duties of maintaining key stock and making keys.

Place network infrastructure equipment in a communications closet or approved enclosure to restrict access to only authorized personnel.

Complete the installation of grounding measures for all telecommunications closets to protect information technology equipment against electromagnetic pulse attack or electrostatic discharge. Ensure the work completed by contractors adheres to the requirements as defined in the work order.

Add anti-ram barriers to protect all sides of a fueling station’s fuel tank.

Implement a plan with the Office of Acquisition and Logistics Project Management Office to ensure system access is more granular and the intent of the principle of least privilege is met.

Ensure all roles and accesses, including those provided by default access, are reviewed and certified periodically as required.

Implement a permanent solution to provide supervisors and information owners with visibility of all roles and accesses, including those provided by default access, granted to users.

The Executive Director ensures staff receive education about badge holders’ responsibilities in preventing unauthorized access to VA facilities and computer systems and safeguarding electronic databases including electronic health care records.

The Executive Director ensures signs are present and accurate throughout the facility.

The Executive Director ensures staff maintain privacy curtains, preventive maintenance on medical equipment, and splash resistant bottom shelves on supply carts.

The Executive Director ensures staff monitor patient care areas for expired, damaged, and contaminated medications and remove them as needed.

The Executive Director ensures staff store medications in pharmaceutical grade refrigerators.

The Executive Director ensures primary care staffing is sufficient for patients to receive appropriate health care.

The Executive Director reviews staffing levels for the Housing and Urban Development–Veterans Affairs Supportive Housing program and takes action as needed.

The Medical Center Director ensures staff properly store clean medical equipment.

Facility leaders develop written workflows for each service to ensure timely communication of test results to providers and patients.

The Director ensures staff keep the environment clean and safe.

The Director ensures Healthcare Technology Management Service staff inspect, test, and properly document all medical equipment maintenance per their required schedule.

The Director ensures staff implement processes to prevent repeat environment of care findings identified in this report.

Facility leaders ensure service-level workflows include each staff member’s role in the communication of test results process.

The Assistant Director ensures staff maintain a consistently clean environment throughout the facility to prevent repeat environment of care findings.

Executive leaders review the change in laboratory scheduling practices and minimize its effect on clinic efficiency.

The Executive Director ensures staff consistently label reusable medical equipment to show it is clean and ready for use.

The Executive Director of Operations for a national cancer testing program ensures the project has met the requirements for Institutional Review Board review for research with human subjects and takes action as needed.

The Executive Director of Operations for a national cancer testing program ensures national cancer prevention, treatment, and research program staff are trained on Institutional Review Board project submission and privacy requirements. 

The National Specialty Care Program Office Chief Officer ensures the national cancer prevention, treatment, and research program staff reviews and provides required approvals before the release of protected health information for research. 

The National Specialty Care Program Office Chief Officer, in conjunction with the Office of Research & Development ensures that VA privacy officers report privacy incidents involving data obtained from or for national cancer prevention, treatment, and research program activities timely and monitors for compliance.

The Office of Research Oversight Executive Director in conjunction with the Chief Research and Development Officer, VHA Office of Research & Development, reviews the national cancer prevention, treatment, and research program final mitigation plan and ensures corrective actions address system-wide issues for determining whether a national cancer prevention, treatment, and research program project constitutes research, safeguarding privacy when data is shared for projects, and ensuring data security requirements are met. 

The National Specialty Care Program Office Chief Officer ensures the national cancer prevention, treatment, and research program has safeguards in place including biostatistician expertise to ensure that data containing sensitive patient information and protected health information is deidentified before sharing outside of VA as required.

Implement 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.

Develop and approve an authorization to operate for the special-purpose systems.

Include facility personnel during the security categorization process to ensure all necessary information types are considered when determining the security categorization for special-purpose systems.

Segregate the pharmacy application administrative access from individuals who are custodians of the pharmaceutical inventory.

Ensure a witness observes the destruction of temporary paper files that contain personally identifiable information and protected health information.

Facility leaders install detectable warning surfaces where crosswalks transition onto a vehicle roadway.

Facility leaders ensure clinical staff who perform toxic exposure screenings complete mandatory training.

The Director ensures staff implement processes to prevent repeat environment of care findings related to dusty sprinkler heads.

Facility leaders evaluate all areas where biohazardous materials are located to ensure staff store clean and dirty items separately.

The Director ensures staff keep the environment clean and safe.

Facility leaders ensure their policy aligns with VHA Directive 1088(1) and develop workflows for all services that communicate test results to patients.

The Chief of Staff and Associate Director for Patient Care Services ensure corrective actions address unfavorable trends in communication of test result data.

The Director ensures the Chief of Staff chairs and attends the Peer Review Committee meetings as required by VHA.

The Director ensures patient safety managers identify adverse events as sentinel events when they meet criteria.

Facility leaders evaluate and improve processes to identify adverse events that warrant an institutional disclosure.

The Director implements processes to ensure staff track action plans until they are completed and report to leaders those that are outstanding.

The Director ensures leaders train staff on their roles and responsibilities when responding to a medical emergency, including the location of equipment used for medical emergencies.

The Director ensures leaders revise the emergency response policy based on recertification time frames in VHA Directive 0999(1) or sooner, if warranted.

Facility leaders ensure all applicable staff maintain basic life support certification and take appropriate action for those staff without it.

The Director ensures facility leaders manage primary care teams’ panel sizes to support patients’ access to care.

The Veterans Integrated Service Network Director develops and implements a plan to provide sustained support and oversight in a constructive manner to the VA Dublin Healthcare System leaders and programs.

The Veterans Integrated Service Network Director ensures that following Veterans Integrated Service Network site reviews with findings, Veterans Integrated Service Network staff review the associated VA Dublin Healthcare System action plans to confirm proposed actions adequately address findings, track action items through implementation, evaluate effectiveness to ensure resolution, and monitor for sustainment.

The Under Secretary for Health considers standardizing the Veterans Integrated Service Network Chief Medical Officer’s and Chief Nursing Officer’s role and responsibilities to include the authority to hold systems leaders accountable for resolving identified deficiencies.

The VA Nebraska—Western Iowa Health Care System Director ensures the installation of night lighting changes to accommodate patient comfort and facility staff’s ability to safely conduct rounding in applicable inpatient mental health unit patient rooms.

The VA Nebraska—Western Iowa Health Care System Director ensures establishment and implementation of guidance related to the facility inpatient mental health unit staff’s use and security of handheld flashlights to ensure appropriate education and training of handheld flashlights usage and storage.

The VA Nebraska—Western Iowa Health Care System Director establishes and ensures implementation of a patient safety observation rounds standard operating procedure consistent with Veterans Health Administration requirements.

The VA Nebraska—Western Iowa Health Care System Director reviews facility Mental Health Environment of Care Checklist processes related to development of mitigation plans as required by the Veterans Health Administration, and monitors compliance.

The VA Nebraska—Western Iowa Health Care System Director ensures compliance with Veterans Health Administration staffing requirements for areas identified as high-risk, such as the inpatient mental health unit, and monitors compliance.

The Under Secretary for Health evaluates the Veterans Health Administration written guidance for high-risk workplace staffing and determines if clarification is needed.

The VA Nebraska—Western Iowa Health Care System Director ensures staff that may provide coverage on the inpatient mental health unit receive applicable Prevention and Management of Disruptive Behavior training for high-risk units.

The VA Nebraska—Western Iowa Health Care System Director strengthens processes to ensure that supervisors are made aware of staff members that have not completed the applicable Prevention and Management of Disruptive Behavior training for high-risk units, to include the hands-on component, and monitors compliance.

The Under Secretary for Health considers written guidance regarding risk for violence assessment use in units identified as a high-risk workplace that can be used to temporarily change a unit’s acuity level and staffing needs.

The VA Nebraska—Western Iowa Health Care System Director reviews and ensures consistent application of facility nursing leaders’ use of risk for violence assessment on the inpatient mental health unit, and monitors for compliance.

The VA Nebraska—Western Iowa Health Care System Director evaluates the root cause analysis processes regarding reporting of action items and outcome measures in accordance with Veterans Health Administration requirements, takes action as needed, and monitors compliance.

The VA Nebraska—Western Iowa Health Care System Director evaluates processes requesting and reporting changes to authorized and operating beds on the inpatient mental health unit, takes action as needed, and monitors compliance.

The VA Midwest Health Care Network Director strengthens processes to ensure adequate oversight and adherence to Veterans Health Administration requirements pertaining to changes to authorized and operating inpatient mental health unit beds.

The New York/New Jersey VA Healthcare Network Director evaluates the circumstances that led to Network and Syracuse VA Medical Center leaders not following clinical restructuring requirements according to VHA Directive 1043.

The Syracuse VA Medical Center Director evaluates the implementation of high reliability organization principles when communicating changes to clinical operations that include stakeholders, service and section leaders, and staff input.

The Syracuse VA Medical Center Director evaluates facility contract processes and takes action to ensure leaders maintain adequate oversight of contracting milestones.

The Syracuse VA Medical Center Director evaluates the communication of established contingency plans and ensures alignment with high reliability organization principles.

The Syracuse VA Medical Center Director ensures the monitoring and evaluation of patient transfers according to Veterans Health Administration Directive 1094(1) and takes action as warranted.

The Syracuse VA Medical Center Director ensures annual procedural complexity designation infrastructure reviews are completed accurately and ensures administrative actions are performed as required.

The New York/New Jersey VA Healthcare Network Director evaluates fiscal year 2026 procedural complexity designation infrastructure reviews for all Veterans Integrated Service New York/New Jersey VA Health Care Network facilities and takes action to ensure reviews are accurate and deficiencies are addressed as required.

The Under Secretary for Health ensures a timeliness expectation for infrastructure waiver submissions pursuant to Veterans Health Administration Directive 1220(1).

The Under Secretary for Health clarifies the requirements for suicide risk and intervention training for audiologists and delineates responsibility for ensuring training is completed as required.

The Under Secretary for Health evaluates the definition of healthcare provider for the purposes of suicide risk and intervention training.

The Under Secretary for Health evaluates the accuracy of suicide risk and intervention training assignment, consistent with Veterans Health Administration policy, for all healthcare providers.

The Under Secretary for Health ensures audiology staff complete suicide risk identification screening as required.

The Under Secretary for Health evaluates oversight of and barriers to mental health integration in audiology services and takes action as appropriate.

Enforce procedures for Veterans Health Administration human resources officials to monitor employee service obligations and initiate a debt notice when an employee breaches that agreement, if warranted.

Identify and review active incentives of Veterans Health Administration employees who transferred within or left VA and take action, if appropriate.

Establish enhanced internal controls to ensure compliance with the law on recruitment, relocation, and retention incentives and take appropriate action when an employee with an active service obligation transfers within the Veterans Health Administration.

Complete the evaluation of the incentives awarded to the employees identified in this report who may not have fulfilled their service obligations, determine whether a debt was incurred, and take any appropriate action.