Open Recommendations

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

The VA Southern Nevada Healthcare System Director ensures that clinical service chiefs take action to address concerns substantiated in factfindings, and that all patient safety concerns identified in factfindings are reviewed and addressed.

The VA Southern Nevada Healthcare System Director evaluates the need for additional factfinders, and takes action as warranted.

The VA Southern Nevada Healthcare System Director ensures that clinical service chiefs take action timely when aware of patient safety concerns.

The VA Southern Nevada Healthcare System Director reviews the information outlined in this report, determines the need to initiate the state licensing board reporting process, and takes action as warranted.

The VA Southern Nevada Healthcare System Director requires clinical service chiefs and credentialing and privileging managers to receive education on the completion of provider exit review forms and that, when supervisory staff contact credentialing and privileging staff for initiation of the state licensing board reporting process, a process is in place to ensure the message is clear and received.

The VA Southern Nevada Healthcare System Director ensures that clinical service chiefs and staff are educated on the need and process for submitting Joint Patient Safety Reporting reports upon awareness of patient safety events in accordance with facility policy.

The VA Southern Nevada Healthcare System Director educates the Chief of Staff on the need to complete management reviews when warranted, ensures that a review occurs of the dental hygienist’s care of Patient C, and ensures disclosure is provided if warranted.

The VA Southern Nevada Healthcare System Director makes certain that the Chief of Staff utilizes high reliability organization principles and establishes a process for the communication of pervasive concerns regarding a provider’s care.

Update and maintain a complete Critical Software Inventory that staff may utilize to fulfill their responsibilities and provide transparency and tracking.

Create or update guidance to implement policies and procedures to guide and govern supply chain risk management activities related to attestations.

Ensure all responsible staff receive appropriate training on attestation roles and responsibilities.

Update PBGC's process documentation to properly align with OMB requirements for software producers who cannot attest to adhering to the secure software development practices within their attestations and ensure PBGC effectively follows this process.

Contact OMB to obtain additional guidance to determine if an exception, waiver, or if the Corporation should discontinue the use of software for outstanding attestations.

Incorporate Office of Strategic Infrastructure LMD representatives with property expertise
into the programs and projects at the contract’s onset to ensure procurement officials receive
sufficient support.

Review Artemis-related contracts that are not delegated to DCMA for contractor-held property
management to determine whether NASA can leverage the delegations already in place to
consolidate government property administration tasks.

District leaders and the Detroit, Escanaba, and Cincinnati Vet Center Directors collaborate with the supporting VA medical facility to determine reasons for noncompliance with staff participation on the mental health executive council, take action as indicated, and monitor compliance.

District leaders and the Fort Wayne, Escanaba, and Cincinnati Vet Center Directors determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented, and monitor compliance.

District leaders and the Detroit and Escanaba Vet Center Directors determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.

District leaders and the Fort Wayne, Detroit, Escanaba, and Cincinnati Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.

District leaders and Escanaba Vet Center Director determine reasons for noncompliance with annual fire or safety inspections, ensure completion, and monitor compliance.

District leaders and the Fort Wayne, Detroit, and Escanaba Vet Center Directors determine reasons for noncompliance with having an annual risk and vulnerability assessment completed by VA police or local law enforcement, ensure completion, and monitor compliance.

District leaders and the Cincinnati Vet Center Director determine reasons for noncompliance with annual automated external defibrillator servicing by VA medical center biomedical engineering, ensure completion, and monitor compliance.

District leaders and the Detroit and Escanaba Vet Center Directors determine reasons for noncompliance with having a current emergency and crisis plan that includes required components, ensure completion, and monitor compliance.