OIG Seal
Department of Veterans Affairs, Office of Inspector General
Michael J. Missal, Inspector General

OIG Reports

| 18-02127-64 | Summary | Report

Recommendations (11)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

We recommended the Executive in Charge for Information and Technology consistentlyimplement the agency-wide risk management governance structure, along with mechanismsto identify, monitor, and manage risks across the enterprise. (This is a modified repeatrecommendation from prior years.)

No. 2   to Veterans Health Administration (VHA)

We recommended the Executive in Charge for Information and Technology implementmechanisms to ensure sufficient supporting documentation is captured to justify closure ofPlans of Action and Milestones. (This is a repeat recommendation from prior years.)

No. 3   to Veterans Health Administration (VHA)

We recommended the Executive in Charge for Information and Technology implementimproved processes to ensure that all identified weaknesses are incorporated into theGovernance Risk and Compliance tool in a timely manner, and corresponding Plans ofAction and Milestones are developed to track corrective actions and remediation. (This is arepeat recommendation from prior years.)

No. 4   to Veterans Health Administration (VHA)

We recommended the Executive in Charge for Information and Technology implement clearroles, responsibilities, and accountability for developing, maintaining, completing, andreporting on Plans of Action and Milestones. (This is a repeat recommendation from prioryears.)

No. 5   to Veterans Health Administration (VHA)

We recommended the Executive in Charge for Information and Technology developmechanisms to ensure system security plans reflect current operational environments,include an accurate status of the implementation of system security controls, and allapplicable security controls are properly evaluated. (This is a repeat recommendation fromprior years.)

No. 6   to Veterans Health Administration (VHA)

We recommended the Executive in Charge for Information and Technology implementimproved 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   to Veterans Health Administration (VHA)

We recommended the Executive in Charge for Information and Technology implementmechanisms 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   to Veterans Health Administration (VHA)

We recommended the Executive in Charge for Information and Technology implementperiodic reviews to minimize access by system users with incompatible roles, permissions inexcess of required functional responsibilities, and unauthorized accounts. (This is a repeatrecommendation from prior years.)

No. 9   to Veterans Health Administration (VHA)

We recommended the Executive in Charge for Information and Technology enable systemaudit logs on all critical systems and platforms and conduct centralized reviews of securityviolations across the enterprise. (This is a repeat recommendation from prior years.)

No. 10   to Veterans Health Administration (VHA)

We recommended the Executive in Charge for Information and Technology fully implementtwo-factor authentication to the extent feasible for all user accounts throughout the agency.(This is a modified repeat recommendation from prior years.)

No. 11   to Veterans Health Administration (VHA)

We recommended the Executive in Charge for Information and Technology implement moreeffective automated mechanisms to continuously identify and remediate securitydeficiencies on VA’s network infrastructure, database platforms, and web applicationservers. (This is a repeat recommendation from prior years.)

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-00980-84 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

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   to Veterans Health Administration (VHA)

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   to Veterans Health Administration (VHA)

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   to Veterans Health Administration (VHA)

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   to Veterans Health Administration (VHA)

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.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-01766-78 | Summary | Report

Recommendations (6)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Orlando VA Medical Center Director ensures that the nurse practitioner referenced in this report has appropriate competencies to perform current duties.

No. 2   to Veterans Health Administration (VHA)

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   to Veterans Health Administration (VHA)

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   to Veterans Health Administration (VHA)

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   to Veterans Health Administration (VHA)

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   to Veterans Health Administration (VHA)

The Orlando VA Medical Center Director implements a process for measuring the timeliness of approvals for requests for additional services and monitors compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 17-05742-66 | Summary | Report

Recommendations (8)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

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   to Veterans Health Administration (VHA)

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   to Veterans Health Administration (VHA)

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   to Veterans Health Administration (VHA)

The VA Maryland Health Care System Director conducts a quality review of the patient’s death and takes actions as needed.

No. 5   to Veterans Health Administration (VHA)

The VA Maryland Health Care System Director ensures that nursing staff follow facility policy in the hiring of nurses.

No. 6   to Veterans Health Administration (VHA)

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   to Veterans Health Administration (VHA)

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   to Veterans Health Administration (VHA)

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.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 16-04396-44 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Office of Information and Technology (OIT)

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   to Office of Information and Technology (OIT)

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   to Office of Information and Technology (OIT)

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   to Office of Information and Technology (OIT)

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   to Office of Information and Technology (OIT)

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.

Not Implemented for the Following Reason:

The recommendation is unresolved because, at issuance, VA disagreed with the OIG’s finding or recommendation, and/or the OIG found the VA’s proposed corrective action plan unacceptable.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-05410-62 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Salem VA Medical Center Director ensures that patients impacted by blood pressurefalsifications are evaluated and receive follow-up as clinically indicated.

No. 2   to Veterans Health Administration (VHA)

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   to Veterans Health Administration (VHA)

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   to Veterans Health Administration (VHA)

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   to Veterans Health Administration (VHA)

The Salem VA Medical Center Director ensures the Contracting Officer’s Representativereceives the necessary training to fulfill all required functions and oversight responsibilities.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 17-01757-50 | Summary | Report

Recommendations (18)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Facility Director ensures that recommended actions from peer reviews and root cause analyses are implemented and monitored for improvement.

No. 2   to Veterans Health Administration (VHA)

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   to Veterans Health Administration (VHA)

The Chief of Staff ensures an interdisciplinary Facility group reviews utilization management data and monitors the group’s compliance.

No. 4   to Veterans Health Administration (VHA)

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   to Veterans Health Administration (VHA)

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   to Veterans Health Administration (VHA)

The Associate Director ensures that safety and infection prevention processes are in place at construction sites and monitors compliance.

No. 7   to Veterans Health Administration (VHA)

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   to Veterans Health Administration (VHA)

The Associate Director ensures that a safe and clean environment is maintained throughout the Facility and monitors compliance.

No. 9   to Veterans Health Administration (VHA)

The Associate Director ensures all applicable equipment is inspected and identified as safe for patient use and monitors compliance.

No. 10   to Veterans Health Administration (VHA)

The Associate Director ensures the mental health seclusion room flooring provides cushioning.

No. 11   to Veterans Health Administration (VHA)

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   to Veterans Health Administration (VHA)

The Facility Director ensures that all deficiencies identified on the Annual Physical Security Survey are addressed or corrected and monitors compliance.

No. 13   to Veterans Health Administration (VHA)

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   to Veterans Health Administration (VHA)

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   to Veterans Health Administration (VHA)

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   to Veterans Health Administration (VHA)

The Chief of Staff ensures that the geriatric evaluation performance improvement activities are reviewed by the appropriate leadership board and monitors compliance.

No. 17   to Veterans Health Administration (VHA)

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   to Veterans Health Administration (VHA)

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.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-05264-58 | Summary | Report

Recommendations (1)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

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.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

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