All Reports

Date Issued
|
Report Number
21-01048-154
|
Topics:  Patient Safety

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 Veterans Health Administration (VHA)
Closure Date: 3/1/2023
The Veterans Integrated Service Network Director reviews the primary care provider’s care of the patient in the year prior to surgery and takes action as indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
The Charlie Norwood VA Medical Center Director ensures patient aligned care team nurses are aware of and comply with the Veterans Health Administration patient aligned care team policy including requirements for same-day access.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2023
The Charlie Norwood VA Medical Center Director ensures patient aligned care team physicians are aware of and comply with the Veterans Health Administration directive regarding communication of test results to patients including time frames and communication of associated treatment plans.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
The Charlie Norwood VA Medical Center Director ensures that surrogates are assigned for patient aligned care team nurses while they are on leave.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
The Charlie Norwood VA Medical Center Director reviews the patient’s preoperative care, including additional quality reviews, and takes action as indicated.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
The Charlie Norwood VA Medical Center Director reviews medical-surgical unit nurses’ care of the patient and takes action as warranted.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
The Charlie Norwood VA Medical Center Director evaluates the use of the Trendelenburg position in inpatient areas and provides education to all facility nursing staff on the potential risks of and indications for use.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
The Charlie Norwood VA Medical Center Director ensures that all medical-surgical unit nurses demonstrate competency to provide adequate alcohol withdrawal care and monitors for compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
The Charlie Norwood VA Medical Center Director implements controls to ensure care provided by medical-surgical unit nurses is of an acceptable quality.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
The Charlie Norwood VA Medical Center Director ensures that the Charlie Norwood VA Medical Center alcohol withdrawal treatment protocol is specific, does not conflict with physicians’ orders, and aligns with the probable onset of patients’ alcohol withdrawal symptoms.
Date Issued
|
Report Number
21-00533-157
|
Topics:  COVID-19

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 Veterans Health Administration (VHA)
Closure Date: 9/14/2023
The Under Secretary for Health reviews the processes by which COVID-19 emotional well-being resources were developed and disseminated and takes action as needed to increase and ensure Veterans Integrated Service Network and facility leadership as well as facility staff’s awareness of available resources about the potential risks and signs of burnout.
Date Issued
|
Report Number
21-00296-145
|
Topics:  Patient Safety

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 Veterans Health Administration (VHA)
Closure Date: 12/21/2022
The Director evaluates and determines any additional reasons for noncompliance and ensures the Systems Redesign Coordinator participates on the Quality Leadership Council.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Peer Review Committee recommends individual improvement actions, and clinical managers implement the committee’s recommendations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that staff complete final peer reviews within 120 calendar days from the date it is determined a peer review is required or have a written extension request approved by the Director.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Peer Review Committee submits quarterly summaries of peer review data for review by the Executive Committee of the Medical Staff.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2022
The Director evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group meets at least monthly.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2023
The Director evaluates and determines any additional reasons for noncompliance and ensures credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2023
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain all inter-facility transfers are monitored and evaluated as part of the Veterans Health Administration’s Quality Management Program.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members attend Disruptive Behavior Committee meetings.
Date Issued
|
Report Number
18-04227-91
|
Topics:  Electronic Health Records Modernization (EHRM)

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 Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 1/3/2023

We recommend that the Deputy Secretary of Defense and Deputy Secretary of Veterans Affairs review the actions of the Federal Electronic Health Record Modernization Program Office and direct the Federal Electronic Health Record Modernization Program Office to develop processes and procedures in accordance with the Federal Electronic Health Record Modernization Program Office charter and the National Defense Authorization Acts.

Date Issued
|
Report Number
21-00300-130
|
Topics:  Care Coordination ● Patient Safety

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 Veterans Health Administration (VHA)
Closure Date: 10/4/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that staff conduct a peer review for all applicable deaths that occur within 24 hours of admission.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that credentialing staff complete primary source verification of all registered nurses’ licenses at the time of initial application.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2022
The Associate Director for Patient Care Services determines any additional reasons for noncompliance and ensures nurse-to-nurse communication occurs between sending and receiving facilities.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that required members attend Disruptive Behavior Committee meetings.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2023
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Date Issued
|
Report Number
21-02125-132
|
Topics:  COVID-19

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 Veterans Health Administration (VHA)
Closure Date: 1/5/2023
Establish a realistic goal for days in storage along with a process for closely monitoring days in storage and taking corrective actions when the goal is not met.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2023
Perform a cost-benefit analysis in conjunction with VA contracting officials and the contractor to determine whether a new process can be implemented that initiates the data plan when a device is issued to the veteran or otherwise reduces unused plan costs.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 2,336,381.00
Date Issued
|
Report Number
21-02209-147
|
Topics:  Care Coordination

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 Veterans Health Administration (VHA)
Closure Date: 9/29/2022
The VA Portland Health Care System Director considers adding the requirement to document family contacts in patients’ electronic health records in Portland VA Medical Center Policy 11-11, Discharge Planning, and ensures that staff document contact with family members, including notification of discharge, when applicable.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/6/2022
The VA Portland Health Care System Director ensures a review of the Emergency Department social worker’s care coordination of the patient and takes action as warranted.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2022
The VA Portland Health Care System Director considers requiring Privacy Office staff to communicate the specific missing element(s) when returning a release of information request.
Date Issued
|
Report Number
21-00291-136
|
Topics:  Suicide Prevention ● Care Coordination

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 Veterans Health Administration (VHA)
Closure Date: 9/20/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete suicide safety plan training prior to developing suicide safety plans.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/4/2022
The Chief of Staff and Associate Director for Patient and Nursing Services evaluate and determine any additional reasons for noncompliance and make certain that all transfers are monitored and evaluated as part of VHA’s Quality Management Program.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2022
The Associate Director for Patient and Nursing Services evaluates and determines any additional reasons for noncompliance and ensures nurse-to-nurse communication occurs between sending and receiving facilities.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2022
The Chief of Staff and Associate Director for Patient and Nursing Services evaluate and determine any additional reasons for noncompliance and make certain that required members attend Disruptive Behavior Committee meetings.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/12/2023

The System Director evaluates and determines any additional reasons for noncompliance and ensures employees complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures Employee Threat Assessment Team members complete required training.
Date Issued
|
Report Number
21-01712-144
|
Topics:  Suicide Prevention ● Medical Staff Privileging Credentialing ● Mental Health

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 Veterans Health Administration (VHA)
Closure Date: 9/27/2022

The VA Pittsburgh Healthcare System Director ensures a comprehensive review of the Behavioral Health Nurse Practitioner’s assessment practices related to Patient 8’s suicide and homicide risk and Recovery Engagement and Coordination for Health – Veterans Enhanced Treatment status; and consults with the appropriate Human Resources and General Counsel Offices to determine whether personnel action is warranted and takes action, as appropriate.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2022

The VA Pittsburgh Healthcare System Director ensures a comprehensive review of the Behavioral Health Nurse Practitioner’s assessment and documentation practices including suicide risk assessments, assessment of antipsychotic medication health factors and side effects, informed consent for off-label medication use, resolution of rule-out diagnoses, and use of copy and paste, and provides training as needed.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2022

The VA Pittsburgh Healthcare System Director aligns VA Pittsburgh Healthcare System Memorandum TX-154, Use of Psychopharmacologic Agents, December 20, 2018, with leaders’ expectations for the assessment and documentation of abnormal involuntary movements and metabolic problems for patients prescribed an antipsychotic medication.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/17/2023

The VA Pittsburgh Healthcare System Director makes certain that behavioral health managers verify that all elements of the behavioral health nurse practitioner ongoing professional practice evaluation are reviewed.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2022

The VA Pittsburgh Healthcare System Director ensures a comprehensive review of managers’ oversight of behavioral health nurse practitioners’ ongoing professional practice evaluations and consults with the appropriate Human Resources and General Counsel Offices to determine whether personnel action is warranted and takes action, as appropriate.

Date Issued
|
Report Number
21-02437-120
|
Topics:  Education and Loan Guaranty

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 Veterans Benefits Administration (VBA)
Closure Date: 9/22/2022
The acting under secretary for benefits updates the School Certifying Official Handbook and considers other training aids to ensure how to calculate and report vacation breaks is clearly detailed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/22/2022
The acting under secretary for benefits develops and implements procedures for claims examiners to verify that all consecutive days are included in enrollments flagged for manual processing containing reported vacation breaks in the remarks section.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/22/2022
The acting under secretary for benefits obtains amended enrollments from school certifying officials to correct vacation break reporting errors identified during this review and take remedial action when appropriate.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/22/2022
The acting under secretary for benefits applies data analysis and record matching to identify enrollments with possible vacation break reporting errors made by school certifying officials, or processing errors by claims examiners.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/11/2023
The acting under secretary for benefits includes in the development of the new automated system fields for vacation breaks to eliminate the need for manual processing.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 624,000.00
Date Issued
|
Report Number
19-08364-140
|
Topics:  Patient Safety

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 Veterans Health Administration (VHA)
Closure Date: 9/27/2022
The Veteran Integrated Service Network 12 Director evaluates processes that affected facility supervisors’ initial efforts to identify and address facility mental health providers’ inappropriate relationships and takes actions as necessary.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2022
The VA Illiana Health Care System Director reviews the process for reporting providers to state licensing boards or state certification boards and makes appropriate changes as deemed necessary to ensure timely reporting.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2022
The VA Illiana Health Care System Director reviews Patient C’s care to determine if there was an adverse event and if so, whether institutional disclosure is warranted
Date Issued
|
Report Number
21-03916-103
|
Topics:  Community Care

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 Veterans Health Administration (VHA)
Closure Date: 12/22/2022
The director of VISN 7 ensures the Atlanta VA Health Care System develops and implements a plan for the routine proper and prompt processing of mail. That plan should include adequate staffing of the mailroom and sufficient training for mailroom personnel.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2023
The director of VISN 7 assists the Atlanta VA Health Care System in taking steps when appropriate to recoup money owed from expired checks that were identified in the mail backlog.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2023
The under secretary for health assess the negative effects of this mail backlog on veterans, community care providers, and other parties, and where possible take steps to remedy those effects.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
The under secretary for health determines if unprocessed mail backlogs exist at other VA medical facilities.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2022
The under secretary for health develops procedures and controls to make certain that medical facility personnel taking over POM on-site mail processing have the necessary resources and expertise to accomplish this work accurately and within prescribed timelines.
Date Issued
|
Report Number
21-02889-134
|
Topics:  Electronic Health Records Modernization (EHRM) ● System Development and Implementation

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 Electronic Health Record Modernization Integration Office (EHRM IO)

The executive director of the Electronic Health Record Modernization Program Management Office complies with internal guidance and ensures the development of an integrated master schedule for the Electronic Health Record Modernization program that complies with standards adopted from GAO for scheduling.

No. 2
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

The executive director of the Electronic Health Record Modernization Program Management Office takes action to improve stakeholder coordination in the development of the program schedules to ensure activities from all relevant VA entities are included.

No. 3
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

The executive director of the Electronic Health Record Modernization Program Management Office develops procedures for when and how staff should perform an initial schedule risk analysis for the program and conduct periodic updates as needed.

No. 4
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

The executive director of the Electronic Health Record Modernization Program Management Office ensures consistency between contract language and program office plans or other guidance identifying the entity or individuals responsible for developing and maintaining the program’s work breakdown structure and integrated master schedule.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 6/17/2024

The executive director of the Electronic Health Record Modernization Program Management Office evaluates the contract requirements for schedule management and modifies as needed to ensure clear roles and expectations for further development and maintenance of the program’s integrated master schedule.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 3/10/2023

The executive director of the Electronic Health Record Modernization Program Management Office complies with the Federal Acquisition Regulation and issue guidance to accept deliverables not separately priced before invoice payment.

Date Issued
|
Report Number
21-00836-124
|
Topics:  Claims and Medical Exams ● Financial Management

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 Veterans Benefits Administration (VBA)
Closure Date: 12/20/2022
The under secretary for benefits implements procedures to identify failed automated weekly death matches and demonstrate progress towards processing all failed matches.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/28/2023
The under secretary for benefits implements a process to review the social security number verification program and demonstrate progress towards ensuring the accuracy of social security numbers in VBA’s electronic systems.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/28/2023
The under secretary for benefits implements an intra-agency data-sharing process with the Veterans Health Administration and demonstrate progress in obtaining information on veterans’ deaths.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 677,385.00
Date Issued
|
Report Number
21-00294-128
|
Topics:  Patient Safety

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 Veterans Health Administration (VHA)
Closure Date: 12/21/2022
The Medical Center Director determines the reasons for noncompliance and makes certain that leaders identify adverse events as sentinel events when criteria are met.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that leaders conduct institutional disclosures for all sentinel events.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Systems Redesign Coordinator consistently participates in Veterans Integrated Service Network Systems Redesign Review Advisory Group meetings.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that the Surgical Work Group meets monthly and core members consistently attend meetings.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group analyzes efficiency and utilization metrics and evaluates critical surgical events.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2022
The Chief of Staff and Associate Director for Patient and Nursing Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/1/2023
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Date Issued
|
Report Number
21-02491-129
|
Topics:  Patient Safety ● Medical Staff Privileging Credentialing

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 Veterans Health Administration (VHA)
Closure Date: 6/1/2023
The Amarillo VA Healthcare System Director ensures Emergency Department staff follow established protocols for clinical assessment, frequency, and intervention regarding abnormal vital signs, and monitors for compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2022
The Amarillo VA Healthcare System Director completes an evaluation of the registered nurse’s failure to ensure the patient received urgent medical attention after presenting to the clinic with stroke-like symptoms and takes appropriate action as indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
The Amarillo VA Healthcare System Director reiterates expectations that patient aligned care team staff engage in respectful communications with patients and their families, and monitors patient advocate data as well as patient satisfaction survey data for evidence of compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
The Amarillo VA Healthcare System Director completes a retrospective review of critical view alerts and other quality of care elements of the subject provider for the two years immediately preceding the subject provider’s summary suspension, takes clinical and administrative actions in accordance with Veterans Health Administration guidelines, and monitors for compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
The Amarillo VA Healthcare System Director ensures patient aligned care team staff follow communication protocols and electronic health record documentation requirements, and monitors for compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/18/2023
The Veterans Integrated Service Network Director evaluates the system leaders’ actions in this case related to ongoing professional practice evaluation and focused professional practice evaluation for cause processes, focused clinical care review, and institutional disclosure; takes action related to staff training and other identified deficits, as needed; and monitors for compliance.
Date Issued
|
Report Number
21-01309-74
|
Topics:  FISMA

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)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology consistently implement an improved continuous monitoring program in accordance with the NIST Risk Management Framework. Specifically, implement an independent security control assessment process to evaluate the effectiveness of security controls prior to granting authorization decisions. (This is a repeat recommendation from prior years.)
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement improved mechanisms to ensure system stewards and Information System Security Officers follow procedures for establishing, tracking, and updating Plans of Action and Milestones for all known risks and weaknesses including those identified during security control assessments. (This is a repeat recommendation from prior years.)
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement controls to ensure that system stewards and responsible officials obtain appropriate documentation prior to closing Plans of Action and Milestones. (This is a repeat recommendation from prior years.)
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology develop mechanisms to ensure system security plans reflect current operational environments, include an accurate status of the implementation of system security controls, and all applicable security controls are properly evaluated. (This is a repeat recommendation from prior years.)
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement improved processes for reviewing and updating key security documents such as security plans, risk assessments, and interconnection agreements on an annual basis and ensure the information accurately reflects the current environment. (This is a repeat recommendation from prior years.)
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement improved processes to ensure compliance with VA password policy and security standards on domain controls, operating systems, databases, applications, and network devices. (This is a repeat recommendation from prior years.)
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement periodic 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 prior years.)
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology enable system audit logs on all critical systems and platforms and conduct centralized reviews of security violations across the enterprise. (This is a repeat recommendation from prior years.)
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Office of Personnel Security, Human Resources, and Contract Offices implement improved processes for establishing and maintaining accurate data within VA’s authoritative system of record for background investigations. (This is a modified repeat recommendation from prior years.)
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Office of Personnel Security, Human Resources, and Contract Offices strengthen processes to ensure appropriate levels of background investigations are completed for applicable VA employees and contractors. (This is a modified repeat recommendation from prior years.)
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement more 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 prior years.)
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement a more effective patch and vulnerability management program to address security deficiencies identified during our assessments of VA’s web applications, database platforms, network infrastructure, and workstations. (This is a repeat recommendation from prior years.)
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology maintain a complete and accurate security baseline configuration for all platforms and ensure all baselines are appropriately monitored for compliance with established VA security standards. (This is a repeat recommendation from prior years.)
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement improved network access controls that restrict medical devices from systems hosted on the general network. (This is a repeat recommendation from prior years.)
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology consolidate the security responsibilities for networks not managed by the Office of Information and Technology, under a common control for each site and ensure vulnerabilities are remediated in a timely manner. (This is a repeat recommendation from prior years.)
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement improved processes to ensure that all devices and platforms are evaluated using credentialed vulnerability assessments. (This is a repeat recommendation from prior years.)
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Acting Assistant Secretary for Information and Technology implement improved procedures to enforce standardized system development and change control processes that integrates information security throughout the life cycle of each system. (This is a repeat recommendation from prior years.)
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology review system boundaries, recovery priorities, system components, and system interdependencies and implement appropriate mechanisms to ensure that established system recovery objectives can be measured and met. (This is a modified repeat recommendation from prior years.)
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology ensure that contingency plans for all systems are updated to include critical inventory components and are tested in accordance with VA requirements. (This is a repeat recommendation from prior years.)
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement more effective agency-wide incident response procedures to ensure timely notification, reporting, updating, and resolution of computer security incidents in accordance with VA standards. (This is a repeat recommendation from prior years.)
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology ensure that VA’s Cybersecurity Operations Center has full access to all security incident data to facilitate an agency-wide awareness of information security events. (This is a repeat recommendation from prior years.)
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement improved safeguards to identify and prevent unauthorized vulnerability scans on VA networks. (This is a repeat recommendation from prior years.)
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement improved measures to ensure that all security controls are assessed in accordance with VA policy and that identified issues or weaknesses are adequately documented and tracked within POA&Ms. (This is a repeat recommendation from prior years.)
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology fully develop a comprehensive list of approved and unapproved software and implement continuous monitoring processes to prevent the use of prohibited software on agency devices. (This is a repeat recommendation from prior years.)
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology develop a comprehensive inventory process to identify connected hardware, software, and firmware used to support VA programs and operations. (This is a repeat recommendation from prior years.)
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement improved procedures for monitoring contractor-managed systems and services and ensure information security controls adequately protect VA sensitive systems and data. (This is a repeat recommendation from prior years.)
Date Issued
|
Report Number
20-00827-126
|
Topics:  Medical Staff Privileging Credentialing ● Patient Safety

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 Veterans Health Administration (VHA)
Closure Date: 2/23/2024

The Under Secretary for Health reviews the State Licensing Board reporting processes at the facility level to ensure compliance with Veterans Health Administration policy, identifies noncompliance, and takes action as warranted.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health ensures that the National Practitioner Data Bank facility reporting practices align with federal regulations and Veterans Health Administration policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2024

The Under Secretary for Health instructs facility directors to submit National Practitioner Data Bank reports regarding physicians and dentists consistent with Veterans Health Administration policy.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2025

The Under Secretary for Health ensures programmatic oversight of facility State Licensing Board and National Practitioner Data Bank reporting processes.