Recommendations
2056
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-00510-167 | Review of VA’s Compliance with the Payment Integrity Information Act for Fiscal Year 2023 | Review | ||
1 Reduce improper and unknown payments to below 10 percent for the Pension Program. This is a repeat recommendation from the OIG’s FY 2022 report.
Closure Date:
2 Reduce improper and unknown payments to below 10 percent for the Purchased Long-Term Services and Supports Program. This is a repeat recommendation from the OIG’s FY 2022 report.
Closure Date:
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| 23-03167-173 | System Leaders’ Response to Allegations Related to Access to Behavioral Health Care at the El Paso VA Health Care System in Texas | Hotline Healthcare Inspection | ||
1 The El Paso VA Health Care System Director ensures Behavioral Health Service policies and guidance are in alignment with federal laws and Texas and New Mexico state laws specific to the system’s emergency detention orders, and educates behavioral health licensed independent practitioners on the policies, as needed.
Closure Date:
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| 23-00110-168 | Comprehensive Healthcare Inspection of the Roseburg VA Health Care System in Oregon | Comprehensive Healthcare Inspection Program | ||
1 The Executive Director ensures staff complete root cause analyses for sentinel events.
Closure Date:
2 The Chief of Staff ensures service chiefs initiate Focused Professional Practice Evaluations for newly appointed licensed independent practitioners.
Closure Date:
3 The Chief of Staff ensures service chiefs regularly complete Ongoing Professional Practice Evaluations for licensed independent practitioners.
Closure Date:
4 The Chief of Staff ensures service chiefs consider specialty-specific data during licensed independent practitioners’ Ongoing Professional Practice Evaluations.
Closure Date:
5 The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations.
Closure Date:
6 The Chief of Staff ensures the Healthcare Delivery Council or an appropriately identified executive committee of the medical staff reviews professional practice evaluation results.
Closure Date:
7 The Veterans Integrated Service Network Chief Medical Officer oversees the healthcare system’s privileging processes.
Closure Date:
8 The Executive Director ensures staff follow the manufacturer’s recommendations for testing over-the-door alarms for sleeping rooms in the Acute Psychiatric Unit.
Closure Date:
9 The Executive Director ensures staff test panic alarms in the Acute Psychiatric Unit and document VA police response times.
Closure Date:
10 The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation the same calendar day, when logistically feasible and clinically appropriate, for all ambulatory care patients with a positive suicide risk screen.
11 The Chief of Staff ensures clinical staff notify the suicide prevention team when patients report suicidal behaviors during the Comprehensive Suicide Risk Evaluation.
12 The Chief of Staff ensures the suicide prevention coordinators conduct, track, and report a minimum of five suicide prevention outreach activities each month.
Closure Date:
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| 23-01105-69 | Federal Information Security Modernization Act Audit for Fiscal Year 2023 | Audit | ||
1 We recommended the Assistant Secretary for Information and Technology consistently implement an improved continuous monitoring program in accordance with the NIST Risk Management Framework. Specifically, implement an independent security control assessment process to evaluate the effectiveness of security controls prior to granting authorization decisions.
Closure Date:
2 We recommended the Assistant Secretary for Information and Technology implement improved mechanisms to ensure system stewards and Information System Security Officers follow procedures for establishing, tracking, and updating Plans of Action and Milestones for all known risks and weaknesses including those identified during security control assessments.
Closure Date:
3 We recommended the Assistant Secretary for Information and Technology implement controls to ensure that system stewards and responsible officials obtain appropriate documentation prior to closing Plans of Action and Milestones.
Closure Date:
4 We recommended the Assistant Secretary 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.
Closure Date:
5 We recommended the Assistant Secretary for Information and Technology implement improved processes for reviewing and updating key security documentation, including control assessments on a risk-based rotation or as needed. Such updates will ensure all required information is included and accurately reflects the current environment.
Closure Date:
6 We recommended the Assistant Secretary for Information and Technology implement improved processes to ensure compliance with VA password policy and security standards on domain controls, operating systems, databases, applications, and network devices.
Closure Date:
7 We recommended the Assistant Secretary for Information and Technology implement periodic reviews to minimize accounts and permissions in excess of required functional responsibilities, and to remove unauthorized or unnecessary accounts.
Closure Date:
8 We recommended the Assistant Secretary for Information and Technology enable system audit logs on all critical systems and platforms and conduct centralized reviews of security violations across the enterprise.
Closure Date:
9 We recommended the Office of Personnel Security, Human Resources, and Contract Offices implement improved processes for establishing and maintaining accurate investigation data within VA systems used for background investigations.
Closure Date:
10 We recommended the Office of Personnel Security, Human Resources, and Contract Offices strengthen processes to ensure appropriate levels of background investigations are completed for applicable VA employees and contractors.
Closure Date:
11 We recommended the Assistant Secretary 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.
Closure Date:
12 We recommended the Assistant Secretary for Information and Technology implement improved processes for tracking and resolving vulnerabilities that cannot be addressed within policy timeframes. Implement more effective patch and vulnerability management processes to mitigate identified security deficiencies and reduce applicable security risks.
Closure Date:
13 We recommended the Assistant Secretary for Information and Technology maintain a complete and accurate security baseline configuration for all platforms and ensure all baselines are appropriately monitored for compliance with established VA security standards.
Closure Date:
14 We recommended the Assistant Secretary for Information and Technology implement improved controls that restrict vulnerable medical devices from unnecessary access to the general network.
Closure Date:
15 We recommended the Assistant Secretary for Information and Technology enhance procedures for tracking security responsibilities for networks, devices, and components not managed by the Office of Information and Technology to ensure vulnerabilities are remediated in a timely manner.
Closure Date:
16 We recommended the Assistant Secretary for Information and Technology implement improved processes to ensure that all devices and platforms are evaluated using credentialed vulnerability assessments.
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17 We recommended the Assistant Secretary for Information and Technology implement improved procedures to enforce standardized system development and change control processes that integrates information security throughout the life cycle of each system.
Closure Date:
18 We recommended the Assistant Secretary for Information and Technology implement improved procedures to ensure that system outages and disruptions are tracked to specific system boundaries and that interdependent systems are considered for the purposes of tracking and measuring against stated system recovery time objectives.
Closure Date:
19 We recommended the Assistant Secretary for Information and Technology ensure contingency plans for all systems and applications are updated and tested in accordance with VA requirements.
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20 We recommended the Assistant Secretary for Information and Technology ensure that systems and applications are adequately logged and monitored to facilitate an agency-wide awareness of information security events.
Closure Date:
21 We recommended the Assistant Secretary for Information and Technology implement improved safeguards to identify and prevent unauthorized vulnerability scans on VA networks.
Closure Date:
22 We recommended the Assistant Secretary for Information and Technology implement improved measures to ensure that all security controls are assessed in accordance with VA policy and that identified issues or weaknesses are adequately documented and tracked within POA&Ms.
Closure Date:
23 We recommended the Assistant Secretary for Information and Technology implement improved processes to monitor for unauthorized changes to system components and the installation of prohibited software on all agency devices and platforms.
Closure Date:
24 We recommended the Assistant Secretary for Information and Technology develop a comprehensive inventory process to identify connected hardware, software, and firmware used to support VA applications and operations.
Closure Date:
25 We recommended the Assistant Secretary for Information and Technology implement improved procedures for monitoring contractor-managed systems and services and ensure information security controls adequately protect VA sensitive systems and data.
Closure Date:
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| 23-03773-169 | VA Improperly Awarded $10.8 Million in Incentives to Central Office Senior Executives | Administrative Investigation | ||
1 The Secretary of Veterans Affairs directs the assistant secretary for Human Resources and Administration/Operations, Security, and Preparedness should update Policy Notice 23-03 and Form 10017-A to address the deficiencies noted in this report, including the overly broad definitions of groups, failure to provide adequate support for high-demand skill CSIs, and lack of needs analyses for recruitment and retention.
Closure Date:
2 The Secretary of Veterans Affairs designates a responsible official to review the critical skill incentives that have been paid to any member of the Senior Executive Service (SES), SES-equivalent, or other Senior Leader (including Veterans Health Administration’s medical center directors and Veterans Integrated Service Network directors and the Veterans Benefits Administration’s regional office and district directors) for the deficiencies identified in this report and to ensure compliance with all applicable statutory criteria and VA policy, and take any corrective action needed.
Closure Date:
3 The Secretary of Veterans Affairs designates a responsible official to review any critical skill incentive payments based on a high-demand skills justification made to all nonexecutive groups of employees, if any, to ensure compliance with all applicable statutory criteria and VA policy, and take any corrective action needed.
Closure Date:
4 In consultation with the Office of General Counsel’s Ethics Specialty Team, the Secretary of Veterans Affairs or his designee takes appropriate action to determine whether individuals involved in the decision-making process for awarding CSIs had any actual or apparent conflicts of interest and develop a process to ensure all decision-makers are free from conflicts when awarding future incentives.
Closure Date:
5 The Secretary of Veterans Affairs directs the assistant secretary for Human Resources and Administration/Operations, Security, and Preparedness to revise policies regarding critical skills incentives to ensure that recommending and approving officials are accountable for their determinations that each CSI recipient meets all established criteria, and that the roles and responsibilities of a technical reviewer and human resources reviewer are clearly established.
Closure Date:
6 The Secretary of Veterans Affairs delegates to a responsible official the development of a formal concurrence process to provide reasonable assurance that a senior attorney within the Office of General Counsel (with sufficient experience and expertise to consider all relevant facts and perspectives) is accountable for providing legal advice before and during the implementation of any new authority that carries the potential for significant reputational or financial harm to VA.
Closure Date:
7 The Secretary of Veterans Affairs delegates to a responsible official a review of existing governance board policies to determine whether additional guidance is needed to define their role in reviewing proposals for implementing new pay authorities affecting senior executive compensation.
Closure Date:
8 The Secretary of Veterans Affairs takes whatever administrative actions, if any, he deems appropriate related to personnel involved in the process for granting critical skill incentives for VA central office executives based on the findings in this report.
Closure Date:
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| 23-01059-72 | Better Oversight Needed of Accessibility, Safety, and Cleanliness at Contract Facilities Offering VA Disability Exams | Review | ||
1 Formalize the executive director’s intent by requiring the submission to the OIG of a related plan and documentation of progress on implementing VA’s maintenance of an independent and updated list of contract facilities.
2 Comply with the requirements of the customer satisfaction survey contract to route exam comment cards directly between the survey vendor and veteran.
Closure Date:
3 Develop and implement formal standard operating procedures for the contract exam facility site visits detailing roles, responsibilities, objectives, and monitoring.
Closure Date:
4 Update the Medical Disability Examination Office site visit checklist to include a focus on specific ADA and OSHA criteria required by contracts with exam vendors.
Closure Date:
5 Complete a standardized training plan for staff who conduct site visits at contract exam facilities to include ADA and OSHA compliance.
Closure Date:
6 Ensure the Medical Disability Examination Office is conducting complaint-based contract facility inspections.
Closure Date:
7 Enforce contractual requirements for vendors to conduct inspections and recertify all facilities to ensure ADA and OSHA compliance.
8 Review and analyze all veteran complaints related to exam facilities received through all entities and perform complaint-based site visits or create action plans, as necessary.
Closure Date:
9 Make certain that the Medical Disability Examination Office develops a plan with the vendors to determine if each veteran seeking an exam requires accessibility arrangements prior to scheduling.
Closure Date:
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| 22-03463-60 | Delays Occurred in Some Veterans’ Benefits Claims While Awaiting Decision | Review | ||
1 Implement a plan to strengthen the National Work Queue division’s monitoring of claims awaiting decision at its own location to ensure its rules are operating as intended and make adjustments as needed.
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2 Ensure the Office of Field Operations includes the National Work Queue division’s functioning in its annual internal controls assessment and statement of assurance.
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| 23-02020-85 | Delays in Community Care Consult Processing and Scheduling at the Martinsburg VA Medical Center in West Virginia | Review | ||
1 Ensure that personal information of veterans who have passed away while waiting for community care consults to be scheduled is only shared with staff who need to know for specific work assignments.
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2 Conduct a strategic business evaluation of the community care department’s workflow processes to determine if there are alternatives that could improve consult processing and scheduling efficiency and timeliness.
Closure Date:
3 Continue to increase specialty provider availability in VA and the community for veterans assigned to the Martinsburg VA medical facility.
Closure Date:
4 Ensure that the performance plan of the chief of community care has standards related to the metrics for community care.
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| 23-00159-160 | Comprehensive Healthcare Inspection of the VA Maryland Health Care System in Baltimore | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs recommend continued privileges for licensed independent practitioners based on Ongoing Professional Practice Evaluation activities, and the Medical Executive Committee recommends them based on evaluation results.
Closure Date:
2 The Deputy Medical Center Director ensures staff post biohazard signs in applicable areas.
Closure Date:
3 The Associate Director ensures staff keep patient care areas safe and clean.
Closure Date:
4 The Assistant Director ensures staff document VA police response times for panic alarm testing in the inpatient mental health unit.
Closure Date:
5 The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in all ambulatory care settings.
Closure Date:
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| 23-00112-161 | Comprehensive Healthcare Inspection of the Harry S. Truman Memorial Veterans' Hospital in Columbia, Missouri | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs regularly complete Ongoing Professional Practice Evaluations for licensed independent practitioners.
Closure Date:
2 The Chief of Staff ensures the Clinical Executive Board reviews professional practice evaluation data for licensed independent practitioners.
Closure Date:
3 The Chief of Staff ensures service chiefs include service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.
Closure Date:
4 The Medical Center Director ensures staff follow the manufacturer’s recommendations for testing over-the-door alarms on mental health inpatient unit sleeping room doors.
Closure Date:
5 The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation the same calendar day, when logistically feasible and clinically appropriate, for all ambulatory care patients with a positive suicide risk screen.
Closure Date:
6 The Chief of Staff ensures suicide prevention coordinators conduct, track, and report a minimum of five suicide prevention outreach activities each month.
Closure Date:
7 The Chief of Staff ensures clinical staff notify the suicide prevention team when patients report suicidal behaviors during the Comprehensive Suicide Risk Evaluation.
Closure Date:
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14921