All Reports

Inpatient Mental Health Clinical Operations Concerns at the Phoenix VA Health Care System, Arizona
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17-02629-119

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2020
The Phoenix VA Health Care System Director verifies that clinicians document clinical justification for the continued use of restraints and debriefing sessions according to Veterans Health Administration and Phoenix VA Health Care System policy requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2019
The Phoenix VA Health Care System Director makes certain that the Phoenix VA Health Care Patient Safety Observer policy is followed, and compliance is monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2019
The Phoenix VA Health Care System, Director ensures that inpatient mental health unit nurse staffing methodology is conducted as required by Nurse Staffing Methodology for Veterans Health Administration Nursing Personnel Directive.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2020
The Phoenix VA Health Care System, Director confirms that mental health staff receive mandated training at required intervals including training for patients with dementia as appropriate, and compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2019
The Phoenix VA Health Care System Director verifies that the inpatient mental health unit is cleaned on a regular basis and compliance is monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2020
The Phoenix VA Health Care System Director ensures that the environment on the inpatient mental health unit is a home-like therapeutic setting as required by Veterans Health Administration Inpatient Mental Health Services Handbook.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2019
The Phoenix VA Health Care System Director ensures that Phoenix VA Health Care System staff enter complaints into the Patient Advocate Tracking System consistent with current Veterans Health Administration Patient Advocacy Program and facility policies and compliance is monitored.
Staffing, Quality of Care, Supplies, and Care Coordination Concerns at the VA Loma Linda Healthcare System, California
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17-02186-114

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2020
The VA Loma Linda Healthcare System Director defines goals, implements measures, and monitors outcomes to improve the flow of patients throughout the hospital, including the Emergency Department, inpatient medical and surgical units, mental health units, and the Community Living Center.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/24/2020
The VA Loma Linda Healthcare System Director conducts a review to evaluate the accuracy of data entered in Emergency Department Integration Software and takes action to ensure that the data collection tool may be used for operational improvement.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2020
The VA Loma Linda Healthcare System Director ensures that patients admitted to a unit where there is no bed available receive the same level of care that is provided in the unit to which they are assigned.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/24/2020
The VA Loma Linda Healthcare System Director ensures that bed closures are reported to the Veterans Integrated Service Network as required by VA Loma Linda Healthcare System policy.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2020
The VA Loma Linda Healthcare System Director evaluates the care of patients with sepsis in the Emergency Department, identifies opportunities for improvement, and takes actions to improve care.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/24/2020
The VA Loma Linda Healthcare System Director evaluates the response time of psychiatrists consulted for the care of mental health patients in the Emergency Department and takes action if required.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/15/2019
The VA Loma Linda Healthcare System Director conducts an evaluation of Patient C’s 2016 coordination of care, discharge planning, and transfer of care, including but not limited to, conferring with the Director of the Robley Rex Veterans Affairs Medical Center, Louisville, Kentucky, and takes action as necessary.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2020
The VA Loma Linda Healthcare System evaluates, develops, and implements processes for veterans who have anticipated or unexpected medical needs coordinated by their preferred medical facility and an alternate medical facility.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/15/2019
The VA Loma Linda Healthcare System Director evaluates and ensures that root cause analyses are completed in accordance with Veterans Health Administration directives.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The VA Loma Linda Healthcare System Director reviews the care of the two fall patients with injuries discussed in this report, adheres to Veterans Health Administration policies, and takes action as appropriate.
Improper Coding and Unnecessary Overtime at the Central Texas Veterans Health Care System
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18-03159-74

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2019
The Central Texas Veterans Health Care System Director ensures all psychologists are properly trained on coding.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2019
The Central Texas Veterans Health Care System Director instructs the Chief of Psychology to review care provider coding accuracy in routine evaluations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2019
The Central Texas Veterans Health Care System Director makes certain the Chief of Health Information Management performs annual reviews of provider coding as specified in VHA policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2019
The Central Texas Veterans Health Care System Director confirms that the Chief and Assistant Chief of Medical Administration Service, along with the Compliance Officer, provide adequate oversight of the Health Information Management provider coding reviews.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2019
The Central Texas Veterans Health Care System Director ensures clinic hours are sufficiently scheduled to maximize direct patient care and to achieve targeted productivity.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2019
The Central Texas Veterans Health Care System Director makes certain that all telehealth clinics follow VHA’s scheduling policies by using the approved electronic scheduling system and assigns properly trained telehealth schedulers.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2019
The Central Texas Veterans Health Care System Director oversees proper disposal of the paper planner and secures patient information.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2019
The Central Texas Veterans Health Care System Director makes certain the Chief of Psychology determines, before authorizing overtime, whether the requested services could be performed during normal working hours.
Expendable Inventory Management System: Oversight of Migration from Catamaran to the Generic Inventory Package
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17-05246-98

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/31/2019
The Executive in Charge, Office of the Under Secretary for Health, implements controls to ensure VA medical centers comply with policy to accurately annotate distribution of supply items.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2020
The Executive in Charge, Office of the Under Secretary for Health, implements controls to ensure VA medical centers comply with policy to make supply logs available, include all required elements, and are used by VA medical center staff.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2021
The Executive in Charge, Office of the Under Secretary for Health, strengthens procedures for VA medical centers to sufficiently conduct and document physical inventory results and retain documentation as required by VHA policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2021
The Executive in Charge, Office of the Under Secretary for Health, strengthens controls at VA medical centers to ensure supplies are consistently secured.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2021
The Executive in Charge, Office of the Under Secretary for Health, ensures VA medical centers affix barcode labels for all expendable supplies at the locations where the inventory items are stored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2021
The Executive in Charge, Office of the Under Secretary for Health, strengthens procedures for the Veteran Integrated Service Network Quality Control Review process, ensuring a thorough review is conducted and action plans are developed and executed to address identified deficiencies at the VAMCs. In addition, update the Quality Control Review document regarding VA medical center security, access requirements, and improper distribution of supplies.
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

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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
|
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

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: 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.
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