All Reports

Quality and Coordination of a Patient’s Care at the VA Eastern Colorado Health Care System, Denver, Colorado
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18-01455-108

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: 7/9/2020
The VA Eastern Colorado Health Care System Director confirms that providers who perform patients’ clinical histories complete medication reconciliation to include non-VA medications.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2019
The VA Eastern Colorado Health Care System Director confirms that healthcare providers further evaluate patients when indicators of infection are present, including rising white blood cell counts, and that providers take action as appropriate.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2019
The VA Eastern Colorado Health Care System Director ensures that patient care teams verify that resources needed upon discharge, including family assistance, are available and meets patients’ needs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2020
The VA Eastern Colorado Health Care System Director strengthens processes and documentation that is consistent with Veterans Health Administration Directive 1140.11 when elderly patients are transitioning in care.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2020
The VA Eastern Colorado Health Care System Director conducts a review of the interdisciplinary discharge planning team notes and patient discharge orders to identify and correct provider to patient communication deficiencies, and if deficiencies are noted, develop action plans to rectify the communication and mitigation issues identified.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2019
The VA Eastern Colorado Health Care System Director verifies that outpatient podiatry scheduling practices align with Veterans Health Administration and VA Eastern Colorado Health Care System podiatry scheduling policies and takes action as necessary.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2019
The VA Eastern Colorado Health Care System Director verifies that Wound Care Clinic practice aligns with VA Eastern Colorado Health Care System policy and takes action as necessary.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2019
The VA Eastern Colorado Health Care System Director ensures that a review is conducted of podiatry resident supervision and develop and implement corrective action plans with timelines and oversight of podiatry residency program as necessary.
Review of Hepatitis C Virus Care within the Veterans Health Administration
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17-05297-85

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2019
The Under Secretary for Health ensures that patients with confirmed positive chronic hepatitis C infection have provider documentation to address treatment considerations entered in their EHRs.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2019
The Under Secretary for Health ensures that providers obtain posttreatment hepatitis C RNA tests to evaluate patient response to DAA treatment in alignment with VA National Viral Hepatitis Program Guidelines.
Federal Information Security Modernization Act Audit for Fiscal Year 2018
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18-02127-64

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology consistently implement the agency-wide risk management governance structure, along with mechanisms to identify, monitor, and manage risks across the enterprise. (This is a modified repeat recommendation from prior years.)
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology implement mechanisms to ensure sufficient supporting documentation is captured to justify closure of Plans of Action and Milestones. (This is a repeat recommendation from prior years.)
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology implement improved processes to ensure that all identified weaknesses are incorporated into the Governance Risk and Compliance tool in a timely manner, and corresponding Plans of Action and Milestones are developed to track corrective actions and remediation. (This is arepeat recommendation from prior years.)
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology implement clear roles, responsibilities, and accountability for developing, maintaining, completing, and reporting on Plans of Action and Milestones. (This is a repeat recommendation from prioryears.)
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge 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. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology implement improved processes for reviewing and updating key security documents such as security plans and security control assessments on an annual basis and ensure the information accurately reflects the current environment. (This is a modified repeat recommendation from prior years.)
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended 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 prioryears.)
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge 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 repeatrecommendation from prior years.)
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge 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. 10
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology fully implement two-factor authentication to the extent feasible for all user accounts throughout the agency. (This is a modified repeat recommendation from prior years.)
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge 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: 3/31/2020
We recommended the Executive in Charge 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: 3/31/2020
We recommended the Executive in Charge for Information and Technology maintain a complete and accurate security baseline configuration for all platforms and ensure all baselines are appropriately implemented 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: 3/31/2020
We recommended the Executive in Charge for Information and Technology implement improved network access controls to restrict medical devices from the general network and ensure that databases, file shares, and management devices, are adequately secured prior to connecting to VA’s network. (This is a modified repeat recommendation from prior years.)
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology consolidate thesecurity 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: 3/31/2020
We recommended the Executive in Charge 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: 3/31/2020
We recommended the Executive in Charge for Information and Technology implement improved procedures to enforce a standardized system development and change control framework that integrates information security throughout the life cycle of each system. (Thisis a repeat recommendation from prior years.)
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology implement improved processes for ensuring that backup data is adequately secured in accordance with organizational policy. (This is a repeat recommendation from prior years.)
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology implement improved processes for the review of system outages and disruptions for contingency plan improvements in accordance with defined policy. (This is a modified repeat recommendationfrom prior years.)
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology identify all external network interconnections and implement improved processes for monitoring VA networks, systems, and connections for unauthorized activity. (This is a repeatrecommendation from prior years.)
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology implement more effective agency-wide incident response procedures to ensure timely reporting, updating, and resolution of computer security incidents in accordance with VA standards. (This is arepeat recommendation from prior years.)
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology ensure that VA’s Cybersecurity Operations Center has full access to all security incident data to facilitate anagency-wide awareness of information security events. (This is a repeat recommendationfrom prior years.)
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology implement improved safeguards to identify and prevent unauthorized vulnerability scans on VA networks. (This is a modified repeat recommendation from prior years.)
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge 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 amodified repeat recommendation from prior years.)
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge 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 modified repeat recommendationfrom prior years.)
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology implement improved procedures for overseeing contractor-managed systems and ensure information security controls adequately protect VA sensitive systems and data. (This is a modified repeat recommendation from prior years.)
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology implement mechanisms for updating their systems inventory, including contractor-managed systems and interfaces, and provide this information in accordance with Federal reporting requirements. (This is a repeat recommendation from prior years.)
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology ensure appropriate levels of background investigations be completed for all personnel in a timely manner, implement processes to monitor and ensure timely reinvestigations on all applicable employees and contractors, and monitor the status of the requested investigations.
Delayed Radiology Test Reporting at the Dwight D. Eisenhower VA Medical Center, Leavenworth, Kansas (VA Eastern Kansas Health Care System)
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18-00980-84

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2019
The VA Eastern Kansas Health Care System Director ensures providers communicate abnormal test results to patients and update the VA Eastern Kansas Health Care System policy in accordance with Veterans Health Administration Directive 1088 and monitors for compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2019
The VA Eastern Kansas Health Care System Director ensures radiologists receive training for the national diagnostic codes and the software that triggers view alerts.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/15/2019
The VA Eastern Kansas Health Care System Director ensures that peer reviews are initiated in accordance with Veterans Health Administration Directive 2010-025 and monitors for compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2019
The VA Eastern Kansas Health Care System Director ensures that an administrative investigation of the primary care provider involved in the patient’s care is conducted in accordance with VA Handbook 0700 and takes any action necessary.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2019
The VA Eastern Kansas Health Care System Director considers initiating an institutional disclosure consistent with Veterans Health Administration Directive 1004.08 and takes action as necessary.
Delays in Processing Community-Based Patient Care at the Orlando VA Medical Center, Florida
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18-01766-78

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/8/2019
The Orlando VA Medical Center Director ensures that the nurse practitioner referenced in this report has appropriate competencies to perform current duties.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2019
The Orlando VA Medical Center Directoridentifies and implements a reliable tool for coordinating the non-VA care coordination process and monitors the tool for consistency.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/8/2019
The Orlando VA Medical Center Directorconducts a compliance review of the clinically indicated dates used by providers referring patients to Integrated Health Service to determine adherence to Veterans Health Administration Directive 1232 (1), Consult Processes and Procedures, and implements a plan for improvement, if warranted.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/8/2019
The Orlando VA Medical Center Directorensures that non-VA care coordination appointments are scheduled within 30 days of the clinically indicated date and monitors performance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2019
TheOrlando VA Medical Center Director conducts a review of Integrated Health Services workload demand and available staff and takes action, as appropriate, to ensure staffing allows for consults to be acted upon within Veterans Health Administration consult timeliness standards.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2019
The Orlando VA Medical Center Director implements a process for measuring the timeliness of approvals for requests for additional services and monitors compliance.
Medication Management, Dispensing, and Administration Deficiencies at the VA Maryland Health Care System, Perry Point, Maryland
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17-05742-66

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2020
The Veterans Integrated Service Network Director ensures evaluation of inaccuracies and risks involved with use of bulk bottles of controlled liquid solutions, takes actions as needed to reduce risks, and monitors effectiveness of actions taken.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2019
The VA Maryland Health Care System Director ensures the interdisciplinary review of unit dose and multi-dose oxycodone solution dispensing and administration, takes actions as appropriate, and monitors effectiveness of actions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2019
The VA Maryland Health Care System Director consults with the Office of Chief Counsel regarding whether an institutional disclosure is appropriate for this patient’s death and takes actions as needed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/8/2019
The VA Maryland Health Care System Director conducts a quality review of the patient’s death and takes actions as needed.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/8/2019
The VA Maryland Health Care System Director ensures that nursing staff follow facility policy in the hiring of nurses.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2020
The VA Maryland Health Care System Director ensures evaluation and revision as needed of facility nurse competency processes on the hospice unit for high-alert medications and monitors effectiveness of actions taken.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2020
The VA Maryland Health Care System Director evaluates the care provided to other patients by the nurse who administered the potential overdose for other possible practice issues.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2019
The VA Maryland Health Care System Director ensures evaluation by nursing leaders to determine the need for reporting the nurse who administered the potential overdose to the State Licensing Board and takes steps as appropriate.
Lost Opportunities for Efficiencies and Savings During Data Center Consolidation
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16-04396-44

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/30/2019
The Assistant Secretary for Information and Technology consults with the Office of Management and Budget for additional guidance on determining whether servers the Office of Information Technology excluded from inventories were subject to the Data Center Optimization Initiative guidance in its June 2017 policy memo, Data Center Development Freeze.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 7/1/2019
The Assistant Secretary for Information and Technology ensures the facility Chief Information Officers effectively communicate Data Center Optimization Initiative requirements to all staff responsible for VA data centers.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 7/1/2019
The Assistant Secretary for Information and Technology develops a mechanism for validating the accuracy and completeness of reported data center information to the Office of Information and Technology National Data Center Program team.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/30/2019
The Assistant Secretary for Information and Technology establishes a process to facilitate a VA-wide inventory of data centers, including those outside the direct control and ownership of the Office of Information Technology.
No. 5
Not Implemented Recommendation Image, X character'
to Information and Technology (OIT)
Closure Date: 1/30/2019
The Assistant Secretary for Information and Technology ensures VA’s Data Center Optimization Initiative strategic plan is complete and includes a timeline for achieving OMB’s cost savings targets, data center closures targets, and optimization performance metrics for energy metering and power usage effectiveness.
Falsification of Blood Pressure Readings at the Danville Community Based Outpatient Clinic, Salem, VA
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18-05410-62

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/30/2019
The Salem VA Medical Center Director ensures that patients impacted by blood pressurefalsifications are evaluated and receive follow-up as clinically indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/6/2019
The Salem VA Medical Center Director develops processes to ensure the integrity of VeteransHealth Administration Support Service Center data that supports performance metrics.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/6/2019
The Salem VA Medical Center Director directs the development of policies and proceduresthat ensure compliance with clinical quality reporting requirements as outlined in the Danvillecommunity based outpatient clinic contract.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/6/2019
The Salem VA Medical Center Director evaluates the adequacy of the Chief of Staff’s andChief of Primary Care’s responsiveness to the VA Office of Inspector General’s concerns andtakes action as appropriate.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/30/2019
The Salem VA Medical Center Director ensures the Contracting Officer’s Representativereceives the necessary training to fulfill all required functions and oversight responsibilities.
Comprehensive Healthcare Inspection Program Review of the Washington DC VA Medical Center
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17-01757-50

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2021
The Facility Director ensures that recommended actions from peer reviews and root cause analyses are implemented and monitored for improvement.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2019
The Chief of Staff ensures that assigned staff complete at least 75 percent of all inpatient admissions and continued stay reviews and monitors the staff’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2021
The Chief of Staff ensures an interdisciplinary Facility group reviews utilization management data and monitors the group’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2019
The Facility Director ensures that the Patient Safety Manager provides feedback of root cause analysis results to the reporting individuals or departments and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2021
The Chief of Staff ensures that Focused and Ongoing Professional Practice Evaluations are completed, and that the Professional Standards Board reviews these evaluations in considering whether to continue provider privileges, and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/25/2021
The Associate Director ensures that safety and infection prevention processes are in place at construction sites and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2020
The Associate Director for Patient Care Services ensures that nursing staff dispose of expired or unsealed supplies and monitors the staff’s compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2021
The Associate Director ensures that a safe and clean environment is maintained throughout the Facility and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2020
The Associate Director ensures all applicable equipment is inspected and identified as safe for patient use and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2019
The Associate Director ensures the mental health seclusion room flooring provides cushioning.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2020
The Associate Director ensures the furniture in the mental health seclusion room is limited to an appropriate style bed and monitors for compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2021
The Facility Director ensures that all deficiencies identified on the Annual Physical Security Survey are addressed or corrected and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2019
The Facility Director ensures that electronic access for performing or monitoring controlled substance balance adjustments is limited to appropriate staff and monitors compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2019
The Facility Director ensures that the duties of the Controlled Substance Coordinator and Alternate Controlled Substance Coordinator are included in the employees’ position description or functional statement.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The Facility Director ensures that a reconciliation of controlled substance return to pharmacy stock is performed during controlled substance inspections and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2020
The Chief of Staff ensures that the geriatric evaluation performance improvement activities are reviewed by the appropriate leadership board and monitors compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2019
The Associate Director for Patient Care Services ensures that all registered nurses involved in the insertion and/or management of central lines receive the required central line-associated bloodstream infection and infection prevention education and monitors compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2019
The Facility Director ensures the Chief of Health Information Management facilitate the timely scanning of clinical reports into the electronic health record and monitors compliance.
Alleged Clinical and Administrative Concerns Involving a Wound Care Provider in Veterans Integrated Service Network 21
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18-05264-58

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/21/2019
The System Director ensures completion of evaluations of Patients B and C to determine whether opportunities for more timely diagnosis of deep vein thrombosis existed, and takes action if indicated.
Mismanagement of the VA Executive Protection Division
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17-03499-20

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 7/21/2020
The Acting Assistant Secretary for Human Resources and Administration ensures that the VA Police Service publishes written operational policies and procedures designed to regulate essential functions of the Executive Protection Division, including threat assessment processes, motorcade operations, security drills, equipment maintenance, use of personal protective gear, and other topics deemed appropriate after consultation with executive protection experts.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 5/10/2021
The Acting Assistant Secretary for Human Resources and Administration makes certain that an adequate threat assessment is developed and kept current for each principal secured by the Executive Protection Division.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 6/20/2019
The Acting Assistant Secretary for Human Resources and Administration, along with the Director of the Office of Security and Law Enforcement and the Director of Police Service, reviews the U.S. Secret Service recommendation made to VA in April 2017 about shift scheduling and either implements the recommendation or thoroughly documents the reasons for non-implementation.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 7/21/2020
The Acting Assistant Secretary for Human Resources and Administration confers with the VA Offices of General Counsel and Accountability and Whistleblower Protection to ensure that bills of collection are issued to agents identified as receiving improper payments of overtime or travel reimbursement and to determine the appropriate administrative action to take, if any, against agents and supervisors who submitted or approved falsified time cards.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 1/16/2020
The Acting Assistant Secretary for Human Resources and Administration consults with the Offices of General Counsel and Accountability and Whistleblower Protection to determine the appropriate administrative action to take, if any, against personnel involved with the nonsecure transmission of the former VA Secretary’s anticipated movements to individuals external to VA who had no need to know.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 1/16/2020
The Acting Assistant Secretary for Human Resources and Administration ensures that the Executive Protection Division institutes procedures to report and appropriately address security lapses, such as those described in this report, and holds agents accountable for individual conduct that contributes to such lapses.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 8/10/2021
The Acting Assistant Secretary for Human Resources and Administration establishes written procedures for documenting the review and approval of employee overtime within the Executive Protection Division and ensures compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 8/10/2021
The Acting Assistant Secretary for Human Resources and Administration assesses and takes remedial action, if necessary, to make certain that Executive Protection Division staff use parking and transit benefits in accordance with VA policy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 9/27/2021
The Acting Assistant Secretary for Human Resources and Administration confers with the Offices of General Counsel and Accountability and Whistleblower Protection to determine whether any agents inappropriately accepted transit benefits while using VA parking spaces, and if so, determine the appropriate administrative action to take, if any.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 8/10/2021
The Acting Assistant Secretary for Human Resources and Administration works with the Offices of General Counsel and Accountability and Whistleblower Protection to institute procedures for an ombudsman or similar function that will enable the Executive Protection Division agents to address management disputes without needing to involve the VA Secretary.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 1/16/2020
The Acting Assistant Secretary for Human Resources and Administration consults with the Office of General Counsel to confirm that the Executive Protection Division and the Office of Secretary have written policies and procedures reasonably designed to ensure that the principal under protection receives a thorough orientation to the appropriate uses of the Division’s services.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 8/10/2021
The Acting Assistant Secretary for Human Resources and Administration consults with the Offices of General Counsel and Accountability and Whistleblower Protection to provide adequate mechanisms and training for all staff within the Office of Operations, Security, and Preparedness, including the Executive Protection Division, that ensure allegations of perceived misconduct by the VA Secretary can be appropriately addressed without the threat of retaliation.
Concerns Related to the Management of a Patient’s Medication at Three VA Medical Centers and Inaccurate Response to a Congressional Inquiry at the VA Illiana Health Care System, Danville, Illinois
|
18-02056-54

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2019
The Orlando VA Medical Center Director evaluates the care of the subject patient with respect to the patient’s cardiac complaints and takes action, as appropriate, including clinical disclosure.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2019
The Orlando VA Medical Center Director verifies staff compliance with Veterans Health Administration policies related to patient notification of electrocardiogram test results and follow-up as clinically indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2019
The Richard L. Roudebush VA Medical Center Director evaluates the care of the subject patient with respect to the patient’s cardiac complaints and takes action, as appropriate, including clinical disclosure.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2019
The Richard L. Roudebush VA Medical Center Director verifies staff compliance with Veterans Health Administration policies related to patient notification of medication blood level test results and follow-up as clinically indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2019
The VA Illiana Health Care System Director evaluates the care of the subject patient with respect to the patient’s cardiac complaints and takes action, as appropriate, including clinical disclosure.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2019
The VA Illiana Health Care System Director strengthens processes for effective clinical consultation and follow-up between mental health and collaborating primary care providers.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2019
The VA Illiana Health Care System Director strengthens the processes for congressional inquiry response to ensure response timeliness, clinical information accuracy, and records retention, as required.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2019
The VA Illiana Health Care System Director evaluates staff actions and approval processes in the preparation of the letter to Senator Donnelly, and takes appropriate administrative action, if indicated.
Comprehensive Healthcare Inspection Program Review of the Marion VA Medical Center, Illinois
|
18-01155-48

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2019
The Chief of Staff ensures service chiefs collect Ongoing Professional Practice Evaluation data utilizing assessments by providers with similar training and privileges and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2019
The Associate Director ensures Police Service regularly tests panic alarm testing and addresses identified deficiencies at the Harrisburg Community Based Outpatient Clinic and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2019
The Associate Director ensures that the Emergency Operations Plan is reviewed annually by the Emergency Management Committee and approved by executive leadership and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2019
The Facility Director ensures that all deficiencies identified on the Annual Physical Security Survey are corrected and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2019
The Facility Director ensures controlled substances inspectors verify a corresponding sealed evidence bag containing drug(s) for each medication held for destruction at the Evansville Health Care Center and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2019
The Associate Director for Patient Care Services ensures that all registered nurses involved in managing central lines receive the required central line-associated bloodstream infection prevention education and monitors compliance.
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