Recommendations
2056
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-00879-249 | VA’s Compliance with the VA Transparency & Trust Act of 2021 Semiannual Report: September 2024 | Review | ||
1 Confirm VA has resumed submitting biweekly reports and, therefore, has submitted reports from June 2023 to present as required by the VA Transparency & Trust Act of 2021.
2 Confirm that the American Rescue Plan Act of 2021 section 8002 quarterly reports are submitted to Congress within the time frame established on the Consolidated Appropriations Acts of 2022 and 2023, which is no later than 30 days after the end of each fiscal quarter.
3 Coordinate with administration and staff office chief financial officers to ensure that the finance office staff responsible for the management of open obligations know and understand VA financial policy requirements for the review of open obligations included in quarterly obligation reports.
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| 24-01170-232 | Action Needed to Ensure VA Meets Staffing and Vacancy Reporting Requirements under the MISSION Act of 2018 | Review | ||
1 Ensure that annual reports to Congress include the steps VA is taking to improve the onboard timeline for facilities for which the duration of the onboarding process exceeds the metrics laid out in the Veterans Health Administration’s time-to-hire model, or successor model, as required by section 3008(b) of the Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020.
Closure Date:
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| 23-02123-202 | Improved Oversight Is Needed to Correct VISN-Identified Deficiencies in Medical Facilities’ Supply Chain Management | Audit | ||
1 Track facilities’ supply chain personnel vacancies as part of the quality control reviews and take appropriate action.
2 Develop guidelines that define when facility supply chain management problems require additional interventions and then routinely identify them for network director action.
3 Ensure facility and network directors work with the Procurement and Logistics Office on a plan to identify resources and milestones to resolve identified supply chain management problems for identified facilities.
4 Direct the program office to develop a process to provide resources when needed to help networks and facilities resolve persistent supply chain management deficiencies, including those identified in this report.
5 Continue Procurement and Logistics Office efforts to automate tracking that will accurately capture and monitor all quality control review results, corrective action plans, and implementation of those plans.
6 Update the Procurement and Logistics Office audits of the quality control program to apply risk‑based sampling, evaluate action plan sufficiency and implementation, and use the results to continuously improve quality control review guidance and requirements.
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| 23-03278-233 | Financial Efficiency Inspection of the VA Pittsburgh Healthcare System | Financial Inspection | ||
1 Establish a plan to use VA’s cost accounting system information to identify alternative ways to reduce costs, enhance efficiency, and inform business decisions as identified by VA financial policy.
Closure Date:
2 Consider a plan to align VA Pittsburgh Healthcare System financial management practices with federal financial accounting standard practices, which could include using cost information for performance measurement, budgeting, cost control, and making economic decisions.
Closure Date:
3 Ensure requesting offices are trained to effectively communicate status of open obligations in a timely manner so healthcare system finance staff can comply with VA Financial Policy, vol. 2, chap. 5, “Obligation.” by ensuring monthly that open obligations balances are valid and should remain open or are closed in a timely manner.
Closure Date:
4 Establish an escalation process to notify the appropriate leaders if the requesting office does not provide a response to the finance office’s monthly request for status of outstanding obligations.
Closure Date:
5 Establish controls to confirm approving officials and cardholders review purchases for VA policy compliance, ensuring purchases are not being split and that strategic sourcing is pursued for ongoing or repetitive purchases.
Closure Date:
6 Ensure supply chain managers implement a plan to detect and correct data validity issues within inventory systems.
Closure Date:
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| 23-03721-180 | Follow-Up Information Security Inspection at the Southwest Consolidated Mail Order Pharmacy in Tucson, Arizona | Information Security Inspection | ||
1 Improve vulnerability management processes to ensure plans of action and milestones are created for vulnerabilities that cannot be mitigated within OIT timelines.
Closure Date:
2 Implement a more effective system life-cycle process to ensure network devices are running operating systems that are configured to approved baselines and free of vulnerabilities.
Closure Date:
3 Implement a process to verify that when employees are terminated, all their accounts are disabled.
Closure Date:
4 Ensure network segmentation controls are applied to all network segments with special-purpose systems.
Closure Date:
5 Implement a process to retain database logs for a period consistent with VA’s record retention policy.
Closure Date:
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| 22-03672-199 | A Hiring Initiative to Expand Substance Use Disorder Treatment Needed Stronger Coordination, Planning, and Oversight | Review | ||
1 Instruct the Office of Finance to review the $14 million retained by the medical centers to ensure these funds were, or will be, spent in accordance with all applicable VA policies and federal laws.
Closure Date:
2 Require the Office of Finance to strengthen controls over designated specific purpose funds so that Veterans Integrated Service Network chief financial officers can account for all the distributed funds and make certain that the funds are used for the intended purpose.
Closure Date:
3 Define the roles and responsibilities of the appropriate assistant under secretaries, program office staff, and regional and medical center staff in the implementation and monitoring of the substance use disorder hiring initiative and ensure the relative priority of the initiative is communicated; hiring progress is monitored; possible hiring challenges are addressed to the extent possible; and actions are taken as needed to meet the goals of the hiring initiative.
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| 23-02907-216 | Follow-Up Financial Efficiency Inspection of the Southeast Louisiana Veterans Health Care System in New Orleans | Financial Inspection | ||
1 Establish internal controls to help ensure the healthcare system monitors the Medical/Surgical Prime Vendor product list for updates and completes the item conversion process
Closure Date:
2 Ensure that prime vendor contract performance issues are routinely reported to the Medical Supplies Program Office and the Strategic Acquisition Center using established Veterans Health Administration reporting tools.
Closure Date:
3 In coordination with the Strategic Acquisition Center, submit ratifications for any unauthorized commitments following the Federal Acquisition Regulation.
Closure Date:
4 Ensure that the facility-level contracting officer’s representative and ordering officers are appointed and delegated properly and perform all required duties according to the scope and limitation of the designee’s authority.
Closure Date:
5 Establish internal controls to help ensure the healthcare system submits national contract requests for waiver and justifications prior to purchasing available product list items from nonmandatory procurement instruments.
6 Ensure cardholders obtain a proper prior approval and maintain segregation of duties, and ensure that cardholders and approving officials perform prompt purchase card reconciliations as required by VA financial policy.
Closure Date:
7 Develop formalized processes and controls to ensure approving officials, cardholders, and the agency contracting office review repetitive open market purchases of goods and services and obtain contracts when it is determined to be in the best interest of the government.
Closure Date:
8 In coordination with the Strategic Acquisition Center, submit a ratification for an unauthorized commitment following the Federal Acquisition Regulation.
Closure Date:
9 Develop formalized processes for monitoring and achieving efficiency targets and using available pharmacy data to make business decisions.
Closure Date:
10 Develop and implement a plan to increase inventory turnover to meet or exceed the VHA-recommended level, and complete monthly B09 reconciliations consistently to ensure discrepancies are corrected in a timely manner.
Closure Date:
11 Establish measures to improve compliance with the VA directive to avoid end-of-year pharmaceutical purchases.
Closure Date:
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| 23-01502-234 | Deficiencies in Facility Leaders’ Summary Suspension of a Provider and Patient Safety Reporting Concerns at the VA Black Hills Health Care System in Fort Meade, South Dakota | Hotline Healthcare Inspection | ||
1 The VA Black Hills Health Care System Director ensures that summary suspensions and related privileging actions are conducted in accordance with Veterans Health Administration policy, and monitors for compliance.
Closure Date:
2 The VA Black Hills Health Care System Director in conjunction with facility leaders and surgical service leaders, ensures a focused clinical care review is completed of the care provided by the subject provider according to Veterans Health Administration policy, and takes action as warranted.
Closure Date:
3 The VA Black Hills Health Care System Director, in conjunction with the National Center for Patient Safety, evaluates the patient safety event reporting processes, identifies deficiencies, and takes action as warranted to ensure compliance with entering adverse events or close calls into the Joint Patient Safety Reporting system.
Closure Date:
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| 23-03677-237 | Incorrect Use of the Baker Act at the North Florida/South Georgia Veterans Health System in Gainesville, Florida | Hotline Healthcare Inspection | ||
1 The VA North Florida/South Georgia Health System Director consults with the Office of General Counsel to ensure system and service line policies and practices related to voluntary and involuntary admissions under the Baker Act provide clear guidance and are consistent with Florida state law as allowed by federal law and Veterans Health Administration regulations.
Closure Date:
2 The VA North Florida/South Georgia Health System Director ensures that providers document their rationales for initiating involuntary examinations under the Baker Act within a patient’s electronic health record and monitors compliance.
3 The VA North Florida/South Georgia Health System Director verifies that a process is in place to provide patients who are admitted for an involuntary examination under the Baker Act with written information on their rights and monitors compliance.
Closure Date:
4 The VA North Florida/South Georgia Health System Director confirms that mental health staff document offering evidence-based therapies during treatment planning with patients diagnosed with posttraumatic stress disorder, as required by Veterans Health Administration policy, and monitors compliance.
Closure Date:
5 The VA North Florida/South Georgia Health System Director ensures that all licensed mental health staff receive annual training on the Baker Act and tracks compliance.
Closure Date:
6 The VA North Florida/South Georgia Health System Director determines if there is a need for non-mental health providers in the emergency department to complete Baker Act training and takes action as warranted.
Closure Date:
7 The VA North Florida/South Georgia Health System Director, in consultation with Veterans Health Administration’s Senior Security Officer, ensures system police, emergency department, and mental health staff follow VA policy specific to assisting staff in the prevention of patient elopements prior to an involuntary mental health evaluation and tracks compliance.
Closure Date:
8 The VA North Florida/South Georgia Health System Director develops a process to provide oversight of compliance with all elements required by state law for use of the Baker Act as permitted by federal law and Veterans Health Administration policy.
Closure Date:
9 The VA North Florida/South Georgia Health System Director, in consultation with the Office of General Counsel, determines whether Baker Act reporting by the system is required and provides clear guidance for applicable reporting processes.
Closure Date:
10 The VA North Florida/South Georgia Health System Director develops a process to ensure system policies adhere to Veterans Health Administration Directive 0999(1), medical center policy standardized template as it pertains to assignment of oversight responsibilities.
Closure Date:
11 The VA North Florida/South Georgia Health System Director directs a review of current patient advocate processes for follow-up and resolution with complainants, updates the process as warranted, and monitors compliance.
Closure Date:
12 The VA North Florida/South Georgia Health System Director considers having the patient advocate process for tracking and monitoring trends capture complaints specific to involuntary admissions for leaders’ awareness and follow-up.
Closure Date:
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| 23-01252-175 | VBA Needs to Improve Oversight of the Digital GI Bill Platform | Audit | ||
1 Establish a mechanism to monitor progress of the Digital GI Bill platform implementation under the renegotiated contract to avoid additional costs and delays.
Closure Date:
2 Communicate regularly with the Digital GI Bill platform contractor to ensure that the project’s integrated master schedule or other master scheduling plan is consistently updated to reflect all schedule changes for external dependencies.
Closure Date:
3 Develop strategies to address critical path failures to provide a clear timeline of further implementation activities.
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