All Reports

Healthcare Inspection – Substandard Care of a Lupus Patient at the Albany CBOC and Carl Vinson VA Medical Center, Dublin, Georgia
|
14-00467-202

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2014
We recommended that the Facility Director develop a system to ensure appropriate follow-up on Non-VA care consults.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2014
We recommended that the Facility Director ensure that managers and peer reviewers follow policies for conducting and completing peer reviews.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2014
We recommended that the Facility Director evaluate the VA care provided to the patient summarized in this report and confer with Regional Counsel regarding the need for possible disclosure.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2014
We recommended that the Facility Director and the Chief of Staff ensure that an individual patient's clinical complexity is considered when assigning a primary care provider.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Hampton VA Medical Center, Hampton, Virginia
|
14-00908-194

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2014
We recommended that the parent facility include staff at the Albemarle CBOC in required education, training, planning, and participation in annual disaster exercises.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2015
We recommended that the parent facility's Emergency Management Committee evaluate the Albemarle CBOC's emergency preparedness activities, participation in annual disaster exercises, and staff training/education relating to emergency preparedness requirements.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2015
We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2015
We recommended that CBOC/Primary Care Clinic staff provide education and counseling for patients with positive alcohol screens and drinking levels above National Institute on Alcohol Abuse and Alcoholism guidelines.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2015
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing training and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2015
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2015
We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2015
We recommended that staff provide medication counseling/education as required.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Wilmington VA Medical Center, Wilmington, Delaware
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14-00235-195

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/15/2014

We recommended that a panic alarm system is installed at the Cape May County CBOC.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/26/2014

We recommended that managers ensure that personally identifiable information is protected by securing laboratory specimens.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/26/2014

We recommended processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Kent County CBOC.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/26/2014

We recommended that the parent facility document Emergency Management Plan-specific training completed for the Cape May County CBOC clinical providers.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2015

We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2015

We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2015

We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2016

We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.

No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/15/2014

We recommended that the facility medication reconciliation policy complies with VHA policy.

No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/26/2014

We recommended that the Chief of Staff consistently ensure that all Designated Women’s Health Providers are designated with the Women’s Health indicator in the Primary Care Management Module.

Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Eastern Kansas Health Care System, Topeka, Kansas
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14-00914-190

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2016
We recommended that external signage clearly identifies the building as a VA CBOC at the Garnett CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/23/2015
We recommended that fire drills are performed every 12 months at the Garnett CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/23/2015
We recommended that the door to the examination room designated for women veterans is equipped with an electronic or manual lock at the Garnett CBOC.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/23/2015
We recommended processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Garnett CBOC.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2014
We recommended that the information technology server closets at the Chanute and Fort Scott CBOCs are maintained according to information technology safety and security standards.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2015
We recommended that managers conduct environment of care rounds semi-annually at the Garnett CBOC.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2015
We recommended that the parent facility include staff at the Chanute, Fort Scott, and Garnett CBOCs in required education, training, planning, and participation in annual disaster exercises.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/23/2015
We recommended that the parent facility’s Emergency Management Committee evaluate the Chanute, Fort Scott, and Garnett CBOCs’ emergency preparedness activities, participation in annual disaster exercises, and staff training/education relating to emergency preparedness requirements.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2016
We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/23/2015
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Southern Oregon Rehabilitation Center and Clinics, White City, Oregon
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14-00911-193

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the information technology server closet at the Grants Pass CBOC is maintained according to information technology safety and security standards.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that CBOC/Primary Care Clinic staff provide education and counseling for patients with positive alcohol screens and drinking alcohol above National Institute on Alcohol Abuse and Alcoholism limits.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment or are evaluated by a specialty provider within 2 weeks of the screening.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed or modified.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that staff document the evaluation of patients’ level of understanding for the medication education.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at South Texas Veterans Health Care System, San Antonio, Texas
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14-00912-192

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2014
We recommended that external signage clearly identifies the building as a VA CBOC at the Beeville CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/30/2014
We recommended that managers maintain clean carpets at the Frank M. Tejeda Satellite CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/29/2015
We recommended that all identified environment of care deficiencies at the Beeville and San Antonio Primary Care Network CBOCs are reported to and tracked by the parent facility's Environment of Care Committee until resolution.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2014
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/29/2015
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/29/2015
We recommended that staff document the evaluation of patient's level of understanding for the flouroquinolone medication education.
Healthcare Inspection - Medication Management Issues in a High Risk Patient, Tuscaloosa VAMC, Tuscaloosa, Alabama
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13-02665-197

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/11/2015
We recommended that the Facility Director ensure that providers comply with local policies related to opioid therapy in patients with chronic pain.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2015
We recommended that the Facility Director ensure that all patients who are prescribed methadone are educated about potential adverse effects and warned about interactions with other over-the-counter, prescribed, and/or illicit drugs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2015
We recommended that the Facility Director develop a system to ensure communication and coordination of care, particularly for patients who receive routine and ongoing care from multiple providers.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2015
We recommended that the Facility Director ensure that Suicide Prevention staff follow policies regarding communication and coordination of care for patients on the High Risk for Suicide list.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2015
We recommended that the Facility Director ensure that clinical reviews and root cause analyses comply with Veterans Health Administration and local policies.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2015
We recommended that the Facility Director evaluate the care of the patient summarized in this report and confer with Regional Counsel regarding the need for possible disclosure.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2015
We recommended that the Facility Director ensure access to interdisciplinary pain management care for chronic pain patients who do not respond to standard medical treatment.
Inspection of VA Regional Office New York, NY
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14-00383-171

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/31/2014
We recommend the New York VA Regional Office Director implement a plan to ensure timely and appropriate action on reminder notifications for medical reexaminations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
We recommend the New York VA Regional Office Director develop and implement a plan to review for accuracy the 320 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate actions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/31/2014
We recommend the New York VA Regional Office Director develop and implement a plan to ensure staff comply with VBA and local second-signature requirements for traumatic brain injury claims
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/31/2014
We recommend that the New York VA Regional Office Director implement a plan to ensure staff comply with VARO policy requiring evaluation of higher-level special monthly compensation claims by staff assigned to the Special Operations team.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/31/2014
We recommend the New York VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefit reductions to minimize improper payments to veterans.
Healthcare Inspection - Quality of Care and Staffing Concerns, Salem VA Medical Center, Salem, Virginia
|
13-03604-198

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2014
We recommended that the Facility Director continue to monitor and address increases in post-operative infection rates and take appropriate corrective actions when indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/3/2015
We recommended that the Facility Director evaluate the admission process from the emergency department and monitor inter-unit transfer patterns, and take corrective actions as indicated.
Healthcare Inspection – Follow-Up of Mental Health Inpatient Unit and Outpatient Contract Programs, Atlanta VA Medical Center, Decatur, Georgia
|
12-03869-187

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2015
We recommended that the Facility Director ensure that a standardized and facility-wide repository be developed and implemented to monitor patients referred to community service boards.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2015
We recommended that the Facility Director strengthen processes to ensure that patients are tracked for follow-up beyond the first contracted mental health care appointment.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2015
We recommended that the Facility Director strengthen communication between the facility and the community service boards to better integrate and coordinate medical and mental health aspects of patient care.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Huntington VA Medical Center, Huntington, West Virginia
|
14-00905-182

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/8/2015
We recommended that processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Prestonsburg CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2014
We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2015
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2014
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2014
We recommended that staff consistently provide written medication information as required.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2014
We recommended that staff provide medication counseling/education as required. VA OIG
Combined Assessment Program Summary Report – Evaluation of the Controlled Substances Inspection Program at Veterans Health Administration Facilities
|
14-01785-184

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that pharmacy physical security surveys are conducted and identified deficiencies are corrected and that compliance is monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that quarterly controlled substances inspection trend reports of identified discrepancies, problematic trends, and potential areas for improvement are completed and provided to facility Directors.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that monthly inspections of all non-pharmacy controlled substances areas are conducted and that compliance is monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health ensures that VHA defines in policy acceptable reasons for missed controlled substances area inspections and provides guidance regarding Controlled Substances Coordinator performance of monthly inspections.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors validate 2 transfers of controlled substances from one storage area to another area, reconcile 1 day’s dispensing from the pharmacy to each automated unit, and verify electronic or written orders for 5 randomly selected dispensing activities.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors perform quarterly physical counts of the emergency drug cache and monthly verifications of seals and that compliance is monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors validate completion of all required drug destruction activities.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors validate accountability for all prescription pads stored in the pharmacy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors conducting outpatient pharmacy inspections verify written prescriptions for 10 percent of (or a maximum of 50) schedule II drugs dispensed.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors receive annual training regarding problematic issues identified through external surveys and other quality control measures.
Inspection of the VA Regional Office, Reno, Nevada
|
13-04324-170

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/6/2014
We recommend the Reno VA Regional Office Director implement a plan to ensure timely and appropriate action on reminder notifications for medical reexaminations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/16/2015
We recommend the Reno VA Regional Office Director conduct a review of the 275 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/6/2014
We recommend the Reno VA Regional Office Director ensure required staff receive refresher training on how to identify insufficient traumatic brain injury medical examination reports and return them to the appropriate VA medical facilities for correction.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/6/2014
We recommend the Reno VA Regional Office Director conduct training on the proper processing of special monthly compensation and ancillary benefits claims and implement a plan to assess the effectiveness of that training.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/6/2014
We recommend the Reno VA Regional Office Director develop and implement a plan to ensure adequate and continuous oversight is provided for the timely completion of the annual Systematic Analyses of Operations schedule and the required 11 Systematic Analyses of Operations.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/6/2014
We recommend the Reno VA Regional Office Director ensure that staff assigned to complete Systematic Analyses of Operations receive training on Veterans Benefits Administration policy regarding the purpose and requirements for completing Systematic Analyses of Operations.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/6/2014
We recommend the Reno VA Regional Office Director amend the workload management plan to ensure oversight and prioritization of benefit reduction cases.
Healthcare Inspection – Alleged Preventive Maintenance Inspection Deficiencies, Northern Arizona VA Health Care System, Prescott, Arizona
|
13-04592-179

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2014
We recommended that the System Director initiate actions to address medical equipment with expired preventive maintenance inspections, that processes be strengthened to identify and track deficiencies to closure, and that compliance is monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2014
We recommended that the System Director assess staffing in the Biomedical Engineering Department and take appropriate actions to meet the workload requirements.
Follow-up Audit of VBA's 100 Percent Disability Evaluations
|
14-01686-185

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
We recommend the Under Secretary for Benefits ensure regional office staff take the appropriate action to review and process the records of all veterans with a temporary 100 percent disability evaluation within 180 days of the veteran’s inclusion on the TRAP report or the veteran’s scheduled exam.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
We recommend the Under Secretary for Benefits ensure regional offices transfer from the Records Management Center all claims folders with temporary 100 percent disability evaluations to the regional office of jurisdiction.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 222,600,000.00
Audit of VBA’s Management of Concurrent VA and Military Drill Pay Compensation
|
13-02129-177

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/6/2017
We recommended the Under Secretary for Benefits take measures to ensure drill pay offsets identified after fiscal year 2012 are timely processed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/6/2017
We recommended the Under Secretary for Benefits ensure fiscal years 2011 and 2012 drill pay offsets are processed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/5/2017
We recommended the Under Secretary for Benefits modify existing information technology systems to more effectively monitor, track, and report on drill pay offset activities.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/23/2015
We recommended the Under Secretary for Benefits update the cost-benefit analysis regularly and use it to prioritize the processing of drill pay offsets.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/5/2014
We recommended the Under Secretary for Benefits require Systematic Analysis of Operations be completed annually for drill pay matching activities.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 623,100,000.00
VA's Federal Information Security Management Act Audit for Fiscal Year 2013
|
13-01391-72

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology fully develop and implement an agency-wide risk management governance structure, along with mechanisms to identify, monitor, and manage risks across the enterprise. (This is a repeat recommendation from last year.)
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement mechanisms to ensure sufficient supporting documentation is captured in the central database to justify closure of Plans of Action and Milestones. (This is a repeat recommendation from last year.)
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology define and implement clear roles and responsibilities for developing, maintaining, completing, and reporting Plans of Action and Milestones. (This is a repeat recommendation from last year.)
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement mechanisms to ensure Plans of Action and Milestones are updated to accurately reflect current status information. (This is a repeat recommendation from last year.)
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology develop mechanisms to ensure system security plans reflect current operational environments, including accurate system interconnection and ownership information. (This is a repeat recommendation from last year.)
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement improved processes for updating key security documents such as risk assessments, security impact analyses, and security self-assessments on at least an annual basis and ensure all required information accurately reflects the current environment and new risks in accordance with Federal standards. (This is a new recommendation.)
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement mechanisms to enforce VA password policies and standards on all operating systems, databases, applications, and network devices. (This is a repeat recommendation from last year.)
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement periodic access reviews to minimize access by system users with incompatible roles, permissions in excess of required functional responsibilities, and unauthorized accounts. (This is a repeat recommendation from last year.)
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology enable system audit logs and conduct centralized reviews of security violations on mission-critical systems. (This is a repeat recommendation from last year.)
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement mechanisms to ensure all remote access computers have updated security patches and antivirus definitions prior to connecting to VA information systems. (This is a repeat recommendation from last year.)
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement two-factor authentication for remote access throughout the agency. (This is a repeat recommendation from last year.)
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology develop and implement policies and procedures for restricting privileged remote access from foreign countries that may pose a significant security risk to VA systems. (This is a new recommendation.)
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement effective automated mechanisms to continuously identify and remediate security deficiencies on VA’s network infrastructure, database platforms, and Web application servers. (This is a repeat recommendation from last year.)
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement a patch and vulnerability management program to address security deficiencies identified during our assessments of VA’s Web applications, database platforms, network infrastructure, and work stations. (This is a modified repeat recommendation from last year.)
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement standard security configuration baselines for all VA operating systems, databases, applications, and network devices. (This is a repeat recommendation from last year.)
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement procedures to enforce a system development and change control framework that integrates information security throughout the life cycle of each system. (This is a repeat recommendation from last year.)
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement processes to ensure information system contingency plans are updated with the required information and lessons learned are communicated to senior management. (This is a repeat recommendation from last year.)
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology develop and implement a process for ensuring the encryption of backup data prior to transferring the data offsite. (This is a new recommendation.)
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology ensure that agreements for alternate processing sites have been established that define the roles and responsibilities for alternate locations in the event of a disaster. (This is a new recommendation.)
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology review change management procedures to ensure that any changes to system procedures are appropriately tested, validated, documented and approved. (This is a repeat recommendation from last year.)
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology fully implement an automated 24-hour security event and incident correlation solution to monitor security for all systems interconnections, database security events, and mission-critical platforms supporting VA programs and operations. (This is a repeat recommendation from last year.)
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology identify all external network interconnections and ensure appropriate Interconnection Security Agreements and Memoranda of Understanding are in place to govern them. (This is a repeat recommendation from last year.)
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement more effective agency-wide incident response procedures to ensure timely resolution of computer security incidents in accordance with VA set standards. (This is a repeat recommendation from last year.)
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology provide the OIG with timely and formal notifications of network intrusions and system compromises in accordance with FISMA. (This is a new recommendation.)
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology develop a listing of approved software and implement continuous monitoring processes to identify and prevent the use of unauthorized application software, hardware and system configurations on its networks. (This is a modified repeat recommendation from last year.)
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology develop a comprehensive software inventory process to identify major and minor software applications used to support VA programs and operations. (This is a modified repeat recommendation from last year.)
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Acting Assistant Secretary for Information and Technology develop procedures to integrate information security costs into the capital planning process while ensuring traceability of Plans of Action and Milestones remediation costs to appropriate capital planning budget documents. (This is a repeat recommendation from last year.)
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement procedures for overseeing contractor-managed cloud-based systems, ensuring OIG access to those systems, and ensuring information security controls adequately protect VA sensitive systems and data. (This is a modified repeat recommendation from last year.)
No. 29
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement mechanisms for updating the Federal Information Security Management Act systems inventory, including contractor-managed systems and interfaces, and annually review the systems inventory for accuracy. (This is a repeat recommendation from last year.)
No. 30
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement mechanisms to ensure all users with VA network access participate in and complete required VA-sponsored security awareness training. (This is a repeat recommendation from last year.)
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