All Reports

Delay in Diagnosis and Treatment for a Patient with a New Lung Mass at the Hampton VA Medical Center in Virginia
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22-02800-225

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Hampton VA Medical Center Director assesses the current use of care coordination agreements between the Patient Aligned Care Team and specialty care services, and determines if there would be benefit in developing agreements where they do not currently exist.
No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Hampton VA Medical Center Director, in conjunction with the Radiology Department chief, reviews the Radiology Department standard operating procedures and scheduling processes, identifies deficiencies, and ensures compliance with Veterans Health Administration policies.
No. 3
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to Veterans Health Administration (VHA)
The Hampton VA Medical Center Director, in conjunction with the Primary Care Service chief, reviews the Patient Aligned Care Team processes, identifies deficiencies, and ensures compliance with Veterans Health Administration Patient Aligned Care Team requirements, including scheduling huddles, follow-up of Emergency Department patient discharges, and communication with and coordination of specialty care.
No. 4
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to Veterans Health Administration (VHA)
The Hampton VA Medical Center Director, in conjunction with the Primary Care Service chief, reviews the Patient Aligned Care Team pain management and referral processes, identifies deficiencies, and takes action as warranted.
No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Hampton VA Medical Center Director, in consultation with a subject matter expert from the National Program Office for Oncology, reviews the facility cancer registry program, identifies deficiencies, and ensures compliance with Veterans Health Administration requirements, including the need for a qualified cancer registrar and entry of all cancer cases in the registry.
No. 6
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to Veterans Health Administration (VHA)
The Hampton VA Medical Center Director reviews the completed root cause analysis in order to ensure its completeness, and take action if warranted.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Hampton VA Medical Center Director reviews the institutional disclosure made to the patient’s family and completes any required items not addressed, including providing the patient’s family with information about potential compensation from the Veterans Benefits Administration and under the Federal Tort Claims Act.
Comprehensive Healthcare Inspection of the Gulf Coast Veterans Health Care System in Biloxi, Mississippi
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22-00074-218

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The System Director evaluates and determines any additional reasons for noncompliance and ensures leaders follow their defined governance structure.
No. 2
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to Veterans Health Administration (VHA)
The Chief of Staff determines any additional reasons for noncompliance and ensures leaders use service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.
No. 3
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to Veterans Health Administration (VHA)
The Chief of Staff determines any additional reasons for noncompliance and ensures service chiefs maintain Ongoing Professional Practice Evaluation data in licensed independent practitioners’ privileging folders.
No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with equivalent specialized training and similar privileges complete professional practice evaluations of licensed independent practitioners.
No. 5
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to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Executive Committee of the Medical Staff reviews the service chiefs’ recommendations along with clinical competence information when making privileging recommendations for licensed independent practitioners.
No. 6
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to Veterans Health Administration (VHA)
The System Director determines any additional reasons for noncompliance and ensures staff maintain a clean and safe environment.
Review of Veterans Health Administration’s Multi-Tiered Patient Safety Program
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22-02377-217

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Assistant Under Secretary for Health for Quality and Patient Safety establishes facility patient safety program oversight requirements for patient safety officers to include minimum frequency and volume of oversight activities and expectations for follow-up when patient safety program deficiencies are identified.
No. 2
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to Veterans Health Administration (VHA)
The National Center for Patient Safety Executive Director evaluates the National Center for Patient Safety quarterly reports, includes an analysis of patient safety data in the reports, and establishes a mechanism for National Center for Patient Safety, in conjunction with Veteran Integrated Service Networks, to direct interventions to promote improvements when facility patient safety program requirements are not met or if deemed necessary to enhance patient safety programs.
No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health evaluates barriers to communication between third-party administrators and patient safety officers and takes action as needed to resolve barriers.
No. 4
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to Veterans Health Administration (VHA)
The Assistant Under Secretary for Health for Quality and Patient Safety evaluates barriers that limit engagement between Veteran Integrated Service Network and facility directors and patient safety officers and patient safety managers.
No. 5
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to Veterans Health Administration (VHA)
The National Center for Patient Safety Executive Director develops a patient safety program staffing configuration for patient safety managers to include facility complexity and patient safety program requirements with recurring reassessment and revision based on requirement changes.
No. 6
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to Veterans Health Administration (VHA)
The National Center for Patient Safety Executive Director establishes staffing guidance for Veteran Integrated Service Network patient safety programs to include facility complexity and workload from other assigned responsibilities to ensure prioritization of patient safety officer oversight and support of facility patient safety programs.
No. 7
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to Veterans Health Administration (VHA)
The National Center for Patient Safety Executive Director establishes processes to evaluate factors contributing to patient safety managers and patient safety officers’ burnout, including patient safety manager turnover, and implements actions as needed to address burnout.
No. 8
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to Veterans Health Administration (VHA)
The National Center for Patient Safety Executive Director evaluates patient safety manager and patient safety officer training and implements standardized formalized training with requirements for newly appointed patient safety managers and newly appointed patient safety officers to include time frames and completion.
No. 9
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to Veterans Health Administration (VHA)
The National Center for Patient Safety Executive Director establishes standardized continuing education requirements to meet the training needs for patient safety managers and patient safety officers.
Inspection of Information Security at the VA Dublin Healthcare System in Georgia
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23-01138-203

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Information and Technology (OIT)
Improve vulnerability management processes to ensure system changes occur within organization timelines.
No. 2
Open Recommendation Image, Square
to Information and Technology (OIT)
Develop and approve an authorization to operate for the special-purpose systems.
No. 3
Open Recommendation Image, Square
to Information and Technology (OIT)
Include system personnel during the security categorization process to ensure that all necessary information types are considered when determining the security categorization for special-purpose systems.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Review the list of unauthorized software and remediate or remove unneeded software at the facility.
No. 5
Open Recommendation Image, Square
to Information and Technology (OIT)
Implement the appropriate physical security controls to restrict and monitor access to the facility, its server room, communication closets, and generators.
No. 6
Open Recommendation Image, Square
to Information and Technology (OIT)
Implement and monitor emergency power and uninterruptible power supplies that support information technology resources.
No. 7
Open Recommendation Image, Square
to Information and Technology (OIT)
Validate that appropriate physical and environmental security measures are implemented and functioning as intended.
VA Should Strengthen Enterprise Cloud Security and Privacy Controls
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22-03525-195

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Information and Technology (OIT)
The assistant secretary for information technology develop a timeline for updating the security and privacy guidance to reflect the latest revisions to the National Institute of Standards and Technology Special Publication 800-53, Security and Privacy Controls for Federal Information Systems and Organizations, and address identified weaknesses with personally identifiable information and supply chain management.
No. 2
Open Recommendation Image, Square
to Information and Technology (OIT)
The assistant secretary for information technology eEstablish a mechanism to ensure continuous monitoring of VA Enterprise Cloud systems to include having and testing contingency, incident response, and disaster recovery plans and conducting scanning as required.
No. 3
Open Recommendation Image, Square
to Information and Technology (OIT)
The assistant secretary for information and technology ensure VA Directive and Handbook 6517 are updated to reflect the revised National Institute of Standards and Technology requirements.
No. 4
Open Recommendation Image, Square
to Information and Technology (OIT)
The assistant secretary for information and technology continue to improve criteria and processes for submitting claims for recoupment of service credits.
No. 5
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to Information and Technology (OIT)
The assistant secretary for information and technology assign roles and responsibilities for submitting claims for service credits and monitoring outcomes.
Comprehensive Healthcare Inspection of the VA Northern California Health Care System in Mather
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22-00063-220

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs document professional practice evaluation results in practitioners’ profiles and report them to the Executive Committee of the Medical Staff Credentialing and Privileging.
No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures services chiefs base reprivileging recommendations on service-specific Ongoing Professional Practice Evaluation data.
No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The System Director evaluates and determines any additional reasons for noncompliance and ensures staff document VA Police response times to panic alarm testing in the inpatient mental health unit.
No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The System Director evaluates and determines any additional reasons for noncompliance and ensures staff keep patient care areas clean and maintain furnishings and equipment in good working order.
No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The System Director evaluates and determines any additional reasons for noncompliance and ensures staff test over-the-door alarms for inpatient mental health unit sleeping rooms as required.
No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The System Director evaluates and determines any additional reasons for noncompliance and ensures staff properly store and secure medications.
No. 7
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to Veterans Health Administration (VHA)
The System Director evaluates and determines additional reasons for noncompliance and ensures staff conduct timely follow-up for intermediate, high-acute, or chronic risk-for-suicide patients who are discharged home from the Emergency Department.
Inspection of Information Security at the VA El Paso Healthcare System in Texas
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23-01179-204

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Information and Technology (OIT)
Implement a more effective vulnerability management program to address security deficiencies identified during the inspection.
No. 2
Open Recommendation Image, Square
to Information and Technology (OIT)
Ensure vulnerabilities are remediated within OIT’s established time frames.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Ensure that physical access for the data center and communication rooms are reviewed on a quarterly basis.
No. 4
Open Recommendation Image, Square
to Information and Technology (OIT)
Ensure physical access controls are implemented for communication rooms.
No. 5
Open Recommendation Image, Square
to Information and Technology (OIT)
Ensure a video surveillance system is operational and monitored for the data center.
No. 6
Open Recommendation Image, Square
to Information and Technology (OIT)
Ensure communication rooms with infrastructure equipment have adequate environmental controls.
No. 7
Open Recommendation Image, Square
to Information and Technology (OIT)
Ensure water detection sensors are implemented in the data center.
No. 8
Open Recommendation Image, Square
to Information and Technology (OIT)
Test the emergency power bypass during annual uninterruptible power supply testing and document results.
Comprehensive Healthcare Inspection of the Corporal Michael J. Crescenz VA Medical Center in Philadelphia, Pennsylvania
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22-00071-216

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Director evaluates and determines any additional reasons for noncompliance and ensures staff complete an individual root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.
No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Chief of Staff determines the reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.
No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures service chiefs recommend reprivileging based, in part, on Ongoing Professional Practice Evaluation data.
No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs report Focused Professional Practice Evaluation results to the Medical Executive Board.
No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Board reviews Ongoing Professional Practice Evaluation results and documents its review when making reprivileging recommendations to the Director.
No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Director determines the reasons for noncompliance and ensures staff conduct environment of care inspections at the required frequency.
No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Director determines any additional reasons for noncompliance and ensures staff maintain a clean and safe environment.
No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Director determines any additional reasons for noncompliance and ensures staff maintain a safe environment in the inpatient mental health unit.
No. 9
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Associate Director for Patient/Nursing Services determines the reasons for noncompliance and ensures only authorized personnel have access to medication and supply rooms.
Oversight Could Be Strengthened for Non-VA Healthcare Providers Who Prescribe Opioids to Veterans
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22-00414-113

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Clarify roles and responsibilities of the Office of Integrated Veteran Care and third-party administrators with respect to ensuring non-VA providers receive and certify they have reviewed Opioid Safety Initiative guidelines in accordance with the John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 and collaborate with the contracting office to modify the contracts as appropriate.
No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Ensure the Office of Integrated Veteran Care strengthens controls to monitor the third-party administrators to ensure non-VA providers’ completion of the VA Opioid Safety Initiative training module.
No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Ensure the Office of Integrated Veteran Care strengthens controls to monitor the third-party administrators to ensure non-VA providers’ completion of required prescription drug monitoring program queries
Review of VHA’s Oversight of Community Care Providers’ Opioid Prescribing at the Eastern Kansas Health Care System in Topeka and Leavenworth
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22-02017-224

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health collaborates with the region 2 third-party administrator to ensure that community care providers submit documentation of care to the Veterans Health Administration including treatments provided specific to opioid risk mitigation (urine drug screening, prescription drug monitoring program checks) and all prescriptions, to include urgently/emergently prescribed opioids and utine/maintenance opioid prescriptions.
No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The VA Eastern Kansas Health Care System Director ensures system providers document evidence of Opioid Safety Initiative risk-mitigation strategies for patients who are on long-term opioids, as required by Veterans Health Administration policy.
No. 3
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to Veterans Health Administration (VHA)
The Under Secretary for Health develops and implements action requiring community care network providers to document evidence of application of Opioid Safety Initiative risk mitigation strategies when treating a veteran to whom they have rescribed opioids, and monitor compliance as part of their Community Provider Opioid Prescribing Practice reviews.
No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health develops and implements action requiring community care network providers to conduct and document completion of state prescription drug monitoring program queries consistent with VHA policy, prior to prescribing controlled substances, regardless of whether the prescriptions are urgent, emergent, routine or maintenance prescriptions and monitor compliance as part of their Community Provider Opioid Prescribing Practice reviews.
No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health considers issuing formal guidance to all Veterans Health Administration pharmacy staff regarding best practices for conducting state prescription drug monitoring program queries upon receipt of controlled substance prescriptions from community care network providers.
No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health develops and implements a process to oversee compliance of VHA’s medication reconciliation process for patients receiving care in the community who are prescribed opioids to include recording of the prescriptions in the non-VA medication section of the medication profile.
No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health considers options and implements a process for including non VA medications prescribed by community care providers in the data populating the opioid safety tools.
No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The VA Eastern Kansas Health Care System Director ensures that medications known to system staff are entered into the patient’s medication profile in the electronic health record.
No. 9
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The VA Heartland Network Director ensures the Veterans Integrated Service Network Community Care Oversight Council conducts oversight of community care network providers’ opioid prescribing practices and reports results through the Opioid Prescribing Community Providers’ SharePoint site.
No. 10
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The VA Heartland Network Director confirms that the VA Eastern Kansas Health Care System has a local process outlining expectations, roles, and responsibilities for completing reviews of community care network provider’s opioid prescribing practices and that the process is shared with system staff, initiated, and monitored.
No. 11
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The VA Eastern Kansas Health Care System Director continues efforts to recruit and hire staff to fill vacant pain management positions.
No. 12
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health consults with the Office for Integrated Veteran Care to determine the value of including a review of community care network provider documentation for evidence of prescription drug monitoring program queries as a required element in VA’s Guidance for Community Provider Opioid Prescribing Practices Review.
No. 13
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to Veterans Health Administration (VHA)
The VA Eastern Kansas Health Care System Director ensures system staff and leaders are educated on the processes to report patient safety concerns involving community care network providers.
Improvements Needed for VBA’s Claims Automation Project
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22-02936-175

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Benefits Administration (VBA)
Implement technology improvements and demonstrate progress to ensure the accuracy and completeness of information on the hypertension summary sheet.
No. 2
Open Recommendation Image, Square
to Veterans Benefits Administration (VBA)
Implement a process to communicate any change in policy, procedure, or the claims processing manual associated with all automated diagnostic codes between the Office of Automated Benefits Delivery, the Office of Policy and Oversight, the Office of Field Operations, and Compensation Service to ensure guidance is clear and consistent for all claims processors.
No. 3
Open Recommendation Image, Square
to Veterans Benefits Administration (VBA)
Implement an improved quality assurance process and monitor the results to ensure the accuracy of hypertension summary sheets and final decisions.
No. 4
Open Recommendation Image, Square
to Veterans Benefits Administration (VBA)
Create or amend metrics to compare the timeliness of claims processing using automation tools versus the traditional process.
Comprehensive Healthcare Inspection of the Michael E. DeBakey VA Medical Center in Houston, Texas
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22-00238-213

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Director evaluates and determines any additional reasons for noncompliance and ensures leaders conduct institutional disclosures for applicable sentinel events.
No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.
No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Deputy Director evaluates and determines any additional reasons for noncompliance and ensures staff keep furnishings and equipment safe and in good repair.
Comprehensive Healthcare Inspection Program Summary Report: Evaluation of Medication Management in Veterans Health Administration Facilities
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23-01177-215

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensure providers counsel patients who have the potential to become pregnant on the risks and benefits of teratogenic medications prior to prescribing them and document this counseling in the electronic health record.
VA’s Governance of Its Personnel Suitability Program for Medical Facilities Continues to Need Improvement
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21-03718-189

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Establish robust oversight of the personnel suitability program within responsible office(s) that includes verifying background investigations are initiated and adjudicated within prescribed timelines and that documentation is filed as required.
No. 2
Open Recommendation Image, Square
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Reimplement the monitoring program specifically required by VA Handbook 0710 as part of VA’s oversight efforts, or an appropriate equivalent, to identify and prevent systemic weaknesses in the personnel suitability program.
No. 3
Open Recommendation Image, Square
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Assess program resources and allocate staff as needed to prioritize oversight of the personnel suitability program within responsible office(s).
No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Establish a plan to implement the updated staffing metrics for the Veterans Health Administration’s suitability function and consider using available hiring flexibilities.
No. 5
Open Recommendation Image, Square
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Incorporate formal data-testing procedures (and data-matching as appropriate) of HR Smart and the VA Centralized Adjudication Background Investigation System (or any replacement systems) into the monitoring program discussed in recommendation 2.
No. 6
Open Recommendation Image, Square
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Develop and execute a plan to collect, maintain, and access sufficient and appropriate data through a single system to support the tracking of background investigations from initiation to adjudication.
No. 7
Open Recommendation Image, Square
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Establish a plan to ensure that future systems support the functionality needed to effectively oversee and manage the background investigation process, including addressing limitations identified in the current systems and incorporating the fields necessary to track timeliness metrics.
Inspection of Information Security at the VA Beckley Healthcare System in West Virginia
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23-00089-144

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
The assistant secretary for information and technology and chief information officer implement a process to minimize the Information Central Analytics and Metrics Platform data reliability issues.
No. 2
Open Recommendation Image, Square
to Information and Technology (OIT)
The assistant secretary for information and technology and chief information officer improve vulnerability management processes to ensure system changes occur within organization timelines.
No. 3
Open Recommendation Image, Square
to Information and Technology (OIT)
The assistant secretary for information and technology and chief information officer develop and approve an authorization to operate for the special-purpose system.
No. 4
Open Recommendation Image, Square
to Information and Technology (OIT)
The assistant secretary for information and technology and chief information officer include system personnel during the security categorization process to ensure that all necessary information types are considered when determining the security categorization for special-purpose systems.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
The assistant secretary for information and technology and chief information officer implement improved mechanisms to ensure system stewards are creating plans of action and milestones for all controls that have not been implemented or assessed.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
The assistant secretary for information and technology and chief information officer ensure network segmentation controls are applied to all network segments with special-purpose systems.
No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The VA medical center director install uninterruptible power supplies to eliminate single points of electrical failure supporting the facility.
No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The VA medical center director ensure that hot and cold aisles in computer rooms, and electric and data cables are installed in accordance with VA standards.
No. 9
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The VA medical center director validate that appropriate physical and environmental security measures are implemented and functioning as intended.
No. 10
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The VA medical center director implement media sanitization methods in accordance with VA policy requirements.
Manufacturers Failed to Make Some Drugs Available to Government Agencies at a Discount as Required
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22-01624-143

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Acquisitions, Logistics, and Construction (OALC),Veterans Health Administration (VHA)
Issue guidance clarifying that allergens are exempt from the public law and include how the determination was reached.
No. 2
Open Recommendation Image, Square
to Acquisitions, Logistics, and Construction (OALC),Veterans Health Administration (VHA)
Formalize and communicate the process for manufacturers to request exemptions.
No. 3
Open Recommendation Image, Square
to Acquisitions, Logistics, and Construction (OALC),Veterans Health Administration (VHA)
Formalize the internal process for granting exemptions.
No. 4
Open Recommendation Image, Square
to Acquisitions, Logistics, and Construction (OALC),Veterans Health Administration (VHA)
Establish a procedure for monitoring covered drugs identified in this report as not commercially sold.
No. 5
Open Recommendation Image, Square
to Acquisitions, Logistics, and Construction (OALC),Veterans Health Administration (VHA)
Develop a procedure to monitor covered drugs identified in this report as newly launched to ensure they have an established ceiling price, and make certain they are made available on the Federal Supply Schedule at the end of the 75-day period.
No. 6
Open Recommendation Image, Square
to Acquisitions, Logistics, and Construction (OALC),Veterans Health Administration (VHA)
Request that noncompliant manufacturers identified by the Office of Inspector General conduct a self-audit and submit their findings for remediation.
No. 7
Open Recommendation Image, Square
to Acquisitions, Logistics, and Construction (OALC),Veterans Health Administration (VHA)
Engage with the Food and Drug Administration to ensure that when manufacturers request new national drug codes, they are made aware of the public law requirements.
No. 8
Open Recommendation Image, Square
to Acquisitions, Logistics, and Construction (OALC)
Require contracting staff at the National Acquisition Center to conduct a covered drug check for all of a manufacturer’s drugs when any pharmaceutical Federal Supply Schedule proposal or product addition modification is submitted.
Total Monetary Impact of All Recommendations
Open: $ 28,100,000.00
Closed: $ 0.00
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