All Reports

We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that employees consistently ask inpatients whether they want to discuss advance directives and that facility managers monitor compliance.

We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when inpatients request a discussion about advance directives, clinicians consistently document that the discussion occurred using only the two Veterans Health Administration standardized note titles for advance directive discussions and that facility managers monitor compliance.

We recommended the Principal Executive Director for Acquisition, Logistics, and Construction (and Chief Acquisition Officer) ensure sufficient oversight on all high-dollar value and complex acquisitions to prevent violations of acquisition regulations and VA policies.

We recommended the Principal Executive Director for Acquisition, Logistics, and Construction (and Chief Acquisition Officer) ensure critical planning actions—requirements development, market research, and independent government cost estimates are performed and provided to contracting officers, prior to developing requests for proposals.

We recommended the Principal Executive Director for Acquisition, Logistics, and Construction (and Chief Acquisition Officer) obtain pricing analysis and technical assistance, to ensure quality products and services are procured at fair and reasonable contract prices.

We recommended the Principal Executive Director for Acquisition, Logistics, and Construction (and Chief Acquisition Officer) enforce compliance with the VA policy to document all required acquisition decisions in the Electronic Contract Management System.

We recommended that the Facility Director ensure that the selection of a colorectalcancer screening method is based on a shared decision-making process between apatient and his/her provider and that the patient‘s preference is honored.

We recommended that the Facility Director define and communicate current localprocesses for obtaining screening colonoscopies.

We recommended that the VA Pacific Islands Health Care System Director continue efforts to enhance the availability of, and access to, a comprehensive network of care and services.

We recommended the Principal Executive Director of Office of Acquisition, Logistics, and Construction ensure required reconciliations of cost estimates be performed prior to releasing construction design documents for all major construction projects.

We recommended the Principal Executive Director of Office of Acquisition, Logistics, and Construction provide sufficient, adequately trained and experienced staff to ensure appropriate oversight is provided over all phases for future major construction projects.

We recommended the Principal Executive Director of the Office of Acquisition, Logistics, and Construction establish policies and procedures to ensure disputes are resolved before proceeding with projects when actual cost and schedule milestones exceed established planned thresholds.

We recommended the Principal Executive Director of the Office of Acquisition, Logistics, and Construction implement mechanisms to ensure that adequate acquisition plans for major construction projects are completed at each appropriate acquisition stage.

We recommended the Principal Executive Director of the Office of Acquisition, Logistics, and Construction ensure adequate controls are implemented and monitored to verify change requests are processed timely.

We recommended the Deputy Assistant Secretary for Acquisition and Logistics implement a mechanism to ensure proper coordination between the Veterans Affairs Acquisition Academy and Office of Logistics and Supply Chain Management when developing logistics training.

We recommended the VA Assistant Secretary for Information and Technology improve VA’s email security filtering software configuration controls to effectively flag improper transmissions of veterans’ personally identifiable information over the VA network.

We recommended the VA Assistant Secretary for Information and Technology establish Memoranda of Understandings with third party organizations that define network responsibilities, processes and procedures for handling sensitive veterans’ information, and require information security controls are implemented commensurate with VA’s information security standards.

We recommended the VA Assistant Secretary for Information and Technology evaluate whether permanent encryption controls are needed for non-VA employees who maintain VA accounts for conducting business on behalf of veterans.

We recommended the VA Assistant Secretary for Information and Technology conduct reviews of processes, procedures, and controls in place at VA regional offices that collaborate with third party organizations to ensure security of sensitive veterans’ information.

We recommended that the Interim Facility Director strengthen processes to ensure suicide prevention training is completed per Veterans Health Administration Directive 1071 and monitor compliance.

We recommended the VA Northwest Health Network management assign a local Contracting Officer¿s Representative and Information Security Officer to provide oversight of Alaska VA Healthcare System contractors.

We recommended the VA Northwest Health Network management, in conjunction with the Assistant Secretary for Information and Technology, ensure that ProCare personnel complete VA's information security awareness training and sign the Contractor Rules of Behavior.

We recommended the Assistant Secretary for Information and Technology conduct a site assessment of information security controls at the ProCare facility, to include a risk assessment to determine the extent that any sensitive veteran data may have been compromised and, if so, with appropriate corrective action, to ensure compliance with VA and Federal information security requirements.

We recommended that the System Director ensure that the care of Patient A is evaluated, including a review of computerized tomography scan orders and imaging study results, and take action if appropriate.

We recommended that the System Director consider revising the Do Not Resuscitate Policy to include re-addressing Do Not Resuscitate orders status with patients prior to any procedures in the hospital.

We recommended that the System Director ensure timely compliance with all elements of the Drug-Free Workplace Program.

We recommended that the Facility Director initiate a clinical review of this case and take appropriate actions to educate providers, if indicated.

We recommend that the Director, VBA Continental District, confer with the Offices of General Counsel (OGC), Human Resources (OHR), and Accountability Review to determine the appropriate administrative action to take, if any, against Ms. Murphy.

We recommend that the Director, VBA Continental District, review whether the privilege of credit hours and telework should be revoked and ensure that Ms. Murphy receives refresher training on VA’s policy for time and attendance, credit hours, and telework.

We recommend that the Director, VBA Continental District, confer with OGC and OHR concerning the 14 days in which Ms. Murphy was unable to fully account for her activities, determine whether she was absent without approved leave, and initiate action to recover pay she received when she was not present for duty.

We recommend that the Director, VBA Continental District, ensure that any VARO local policy for credit hours complies with VA policy and that employees use VA Form 5631 or the ETA system as the official means to record, certify, and report their time and attendance, to include any compensatory or credit hours earned or used.

We recommended the Under Secretary for Health implement an oversight process to ensure Integrated Oversight Process reviews arecompleted in accordance with established policies.

We recommended the Head of Contracting Activity, Veterans Health Administration, Service Area Office East, develop a mechanism to ensure effective coordination between acquisition personnel when transferring contracting responsibilities.

We recommended the Head of Contracting Activity, Veterans Health Administration, Service Area Office East, implement a process to ensure all acquisition personnel record contracting actions in the Electronic Contract Management System.

We recommended that the Veterans Integrated Service Network Acting Director ensure that Facility Directors reassign or redistribute primary care patients to other primary care teams as required by the Veterans Health Administration and monitor compliance.

We recommended that the Acting Veterans Integrated Service Network Director ensure that the Facility Director reviews Primary Care Management Module data and reports and takes steps to follow Veterans Health Administration guidance for primary care provider panel sizes across the system.