Recommendations
2055
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 10-04045-124 | Audit of VBA's Liquidation Appraisal Oversight in the Cleveland and Phoenix Regional Loan Centers | Audit | ||
1 We recommended the Under Secretary for Benefits revise Loan Guaranty Service policies and procedures to include more specific criteria for evaluating appraisal comparable property selections and sales price adjustments.
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2 We recommended the Under Secretary for Benefits implement an automated appraisal review system to evaluate every liquidation appraisal.
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3 We recommended the Under Secretary for Benefits fully implement all defined elements of the Loan Guaranty Service Risk Management Program.
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4 We recommended the Under Secretary for Benefits revise the performance plan of the appropriate Loan Guaranty Service manager to ensure accountability for accomplishment of specific Risk Management Program requirements.
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| 12-02525-291 | Administrative Investigation of the FY 2011 Human Resources Conferences in Orlando, Florida | Administrative Investigation | ||
1 We recommended the VA Secretary take the appropriate action against Mr. Sepúlveda.
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2 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Ms. Muellerweiss and ensure that action is taken.
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3 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Ms. Deanes and ensure that action is taken.
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4 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Dr. McMahan and ensure that action is taken.
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5 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Mr. Barritt and ensure that action is taken.
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6 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Ms. Dudley and ensure that action is taken.
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7 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Ms. Thomas and ensure that action is taken.
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8 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Mr. Gingrich and ensure that action is taken.
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9 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Dr. McMahan and ensure that action is taken.
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10 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Ms. Coke and ensure that action is taken.
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11 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Mr. Pleso and ensure that action is taken.
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12 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Ms. McIntosh-Moore and ensure that action is taken.
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13 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Ms. Wakeley and ensure that action is taken.
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14 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Ms. Dudley and ensure that action is taken.
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15 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Mr. Barritt and ensure that action is taken.
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16 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Ms. Caruso and ensure that action is taken.
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17 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Mr. Gardner and ensure that action is taken.
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18 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Mr. Pierce and ensure that action is taken.
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19 We recommended the VA Secretary establish a policy that VA will no longer solicit lodging accommodation upgrades as part of contracts.
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20 We recommended the VA Secretary modify VA procedures to include a requirement for a detailed spend plan to ensure cost estimates are reasonable.
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21 We recommended the VA Secretary implement policy to ensure conference managers obtain subsequent authorization from the Chief of Staff or the Deputy Secretary once they determine estimated costs have been exceeded or other major changes occur.
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22 We recommended the VA Secretary require an after-action report be provided to the Chief of Staff or the Deputy Secretary identifying planned-versus-actual costs, including justifications for significant differences.
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23 We recommended the VA Secretary issue policy outlining requirements for authorizing, justifying, and conducting pre-planning site visits for conferences.
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24 We recommended the VA Secretary establish requirements to support major conferences with contracting officers and other support resources to ensure conferences and the supporting acquisitions are planned and managed in accordance with applicable regulations.
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25 We recommended the VA Secretary establish budgetary controls to ensure centralized accounting for individual conference expenditures.
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26 We recommended the VA Secretary ensure conference budgets are authorized and monitored to ensure appropriate expenditures.
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27 We recommended the VA Secretary establish controls to ensure senior officials exercise their responsibility and accountability for prudent management of conference funds.
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28 We recommended the VA Secretary require travelers and approvers to comply with the requirement to not incur hotel taxes in states which offer tax exemption to the Government.
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29 We recommended the VA Secretary require conference planning committees to identify, by name, individuals needed onsite for conference support before or after the conference and that this designation be provided to the traveler for inclusion in their travel receipts.
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30 We recommended the VA Secretary require travelers and approving officials to comply with the requirement to include a cost comparison when choosing to use a privately owned vehicle instead of a government contracted mode of transportation.
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31 We recommended the VA Secretary develop a process to track and monitor the use of interagency agreements.
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32 We recommended the VA Secretary establish a mechanism to modify existing high-risk interagency agreements and ensure that all future interagency agreements account for costs associated with each single conference event.
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33 We recommended the VA Secretary establish a process to obtain detailed vendor invoice information to support tracking and validation of costs associated with interagency agreements.
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34 We recommended the VA Secretary require that all VA program offices (Administrations, Boards, Centers, and Offices) that plan meetings, conferences, or events involving more than 50 staff identify and clearly state all event requirements to minimize contract modifications.
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35 We recommended the VA Secretary develop a mechanism to ensure that commitments, expenditures, and combined liabilities exceeding $25,000 receive a legal and technical review.
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36 We recommended the VA Secretary ensure a Price Negotiation Memorandum be used to document negotiated agreements to minimize the possibility of future claims against the Government and to obtain a clear understanding from the contractor that all costs have been fully considered.
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37 We recommended the VA Secretary ensure contracting officers designate and authorize in writing a Contracting Officer's Representative on all contracts and orders other than those that are firm-fixed-price and for firm-fixed-price contracts as appropriate.
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38 We recommended the VA Secretary ensure that only authorized contracting personnel make commitments or changes that affect price, quality, quantity, delivery, or other terms and conditions of a contract.
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39 We recommended the VA Secretary ensure contract modifications are completed timely.
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40 We recommended the VA Secretary establish oversight mechanisms to eliminate excessive and wasteful conference expenditures of public funds.
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41 We recommended the VA Secretary ensure contracting officers document the results of all contract actions in VA's Electronic Contract Management System.
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42 We recommended the VA Secretary take action to ratify any legal agreements made by VA employees where there was no previous authority to commit payments for goods and/or services with the Marriott.
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43 We recommended the VA Secretary establish an effective cost system for credit card purchases that appropriately assigns costs to individual major VA events.
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44 We recommended the VA Secretary ensure purchase card approvers are trained on proper oversight of purchase card transactions.
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45 We recommended the VA Secretary ensure VA Learning University personnel with acquisition support responsibilities have valid warrants and that the warrants match their purchase authorization.
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46 We recommended the VA Secretary issue guidance regarding the proper procedures for transferring warrants within VA organizations.
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47 We recommended the VA Secretary ensure VA Learning University employees are trained on purchase card policies related to splitting purchases.
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48 We recommended the VA Secretary ensure supervisors have the required documentation prior to approving purchase card transactions.
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49 We recommended the VA Secretary require the Department to accomplish a special review of purchase card transactions made in support of VA Learning University conferences.
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| 12-00165-277 | Review of Alleged Delays in VA Contractor Background Investigations | Audit | ||
1 We recommend that the Assistant Secretary for Operations, Security, and Preparedness implement improved policies, procedures, and practices to reduce the backlog of contractor background investigations and educate appropriate personnel on VA's personnel security requirements and contractor on-boarding processes.
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2 We recommend that the Assistant Secretary for Operations, Security, and Preparedness, in conjunction with the Assistant Secretary for Information Technology, implement a central case management system to automate the background investigation process and effectively monitor VA contractor status and associated contract costs during the background investigation process.
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| 12-00375-290 | Review of the Enhanced Use Lease between the Department of Veterans Affairs and Veterans Development, LLC | Audit | ||
1 We recommend that the Under Secretary for Health develop a long range plan that addresses the significant space shortages at Wade Park caused by the EUL for the Brecksville division.
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2 We recommend that the Under Secretary for Health in coordination with the VAMC Cleveland Director, ensure the VAMC employees comply with the Privacy Act and other confidentiality statutes such as HIPAA and 38 U.S.C. § 7332, VHA Handbooks, and the Cleveland VAMC privacy policies, by appropriately safeguarding VA employees' PII and veterans' PHI.
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3 We recommend that the Under Secretary for Health in coordination with the VAMC Cleveland Director, ensure the VAMC employees receive training on records management and the provisions of applicable Records Management Retention schedules.
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4 We recommend that the Executive in Charge for the Office of Management and Chief Financial Officer and VA’s General Counsel convene an independent group to determine the appropriateness and the legal sufficiency of the Brecksville EUL and service agreements contained in the EUL, particularly in light of the indictment of Michael Forlani and the suspension of VetDev and other entities identified in the indictment, and take appropriate action to include long and short term plans, including the renegotiation of the terms and conditions of the agreements for the administration building and the parking garage.
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5 We recommend that the Executive in Charge for the Office of Management and Chief Financial Officer and VA’s General Counsel make a referral to the VA’s Procurement Executive for a determination whether any of the service agreements constitute an unauthorized commitment and, if so, take appropriate action to rectify the problem.
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6 We recommend that the Executive in Charge for the Office of Management and Chief Financial Officer and VA’s General Counsel immediately determine what services VOA is actually performing and which services VA employees are performing and what services, if any, VA needs from VOA. Consideration should be given to simply leasing the existing space, with VA employees providing all the services, or relocating the domiciliary.
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7 We recommend that the Executive in Charge for the Office of Management and Chief Financial Officer and VA's General Counsel issue a bill of collection to VetDev to recoup the VA determined value of the overbilling relating to the failure to provide security services.
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8 We recommend that the Executive in Charge for the Office of Management and Chief Financial Officer take immediate steps to identify the security requirements for the administration building, parking, and domiciliary space and develop a plan of action to ensure the safety and security of VA employees, veterans, and their families.
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9 We recommend that the Under Secretary for Health, the Executive in Charge for the Office of Management and Chief Financial Officer, and VA's General Counsel do not execute any amendments to the current EUL or the service agreements to add additional space or services without review and approval by an independent third party. We recommend that any additional requirements for space by the Wade Park VAMC be reviewed and approved in advance by VHA's Chief Procurement Executive to ensure the legitimacy of the requirements, including the area of consideration.
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| 11-01406-247 | Healthcare Inspection Evaluation of Community Based Outpatient Clinics Fiscal Year 2011 | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers ensure that each CBOC has a Women’s Health Liaison who collaborates with the parent facility’s Women Veterans Program Manager on women’s health issues.
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2 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers ensure that all breast imaging and mammography results are linked to the appropriate radiology mammogram or breast study order.
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3 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers Ensure that each medical center has a local policy for STFB consults.
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4 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers Ensure that practitioners document a justification for the use of STFB care in the medical record, specifically at urban CBOCs.
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5 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers Ensure there is documentation in the medical record that the patient received written notification STFB consult approval, specifically at urban CBOCs.
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6 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers ensure that each CBOC has a plan that defines how MH emergencies that require a higher level of care are addressed.
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7 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers ensure patient care staff members at CBOCs have ongoing competency assessments validated for identified core competencies.
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8 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers ensure that auditory privacy is maintained during the check-in process.
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9 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers ensure that all PII is secured and protected.
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10 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers network space vulnerabilities in accordance with VA policy.
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11 We recommended that the Under Secretary for Health, in conjunction with the VISN and facility senior managers review the invoice validation process to consider creating a standardized billable roster report to improve oversight and accuracy of billable patient lists, thereby reducing man hours currently performing those duties and potential overpayments.
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12 We recommended that the Under Secretary for Health, in conjunction with the VISN and facility senior managers strengthen the oversight of the contract acquisition process to ensure that adequate planning occurs and that proper approvals are documented in the contract management system [eCMS] in accordance with VHA Directives.
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13 We recommended that the Under Secretary for Health, in conjunction with the VISN and facility senior managers ensure that MH services for contract CBOCs are addressed in a separate contract or within the primary care contract.
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| 10-03166-75 | Audit of VA Regional Offices' Appeals Management Processes | Audit | ||
1 We recommended the Under Secretary for Benefits identify and request the staffing resources needed to meet Veterans Benefits Administration’s processing goals and conduct de novo reviews on all appeals.
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2 We recommended the Under Secretary for Benefits revise productivity standards for decision review officers assigned to appeal processing to limit credit to actions that progress the appeal such as Notices of Disagreement, issuance of Statements/Supplemental Statements of the Case, conducting requested hearings, and certification of appeals.
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3 We recommended the Under Secretary for Benefits implement criteria requiring appeals staff to initiate a review or development for Notices of Disagreement and certified appeals within 60 days of receipt.
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4 We recommended the Under Secretary for Benefits revise current policy to require de novo reviews on all appeals.
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5 We recommended the Under Secretary for Benefits develop and implement a plan to provide adequate oversight to ensure staff record Notices of Disagreement into the Veterans Appeals Control and Locator System.
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6 We recommended the Under Secretary for Benefits establish a mechanism to ensure VA Regional Offices¿ staff take appropriate action to complete the appeal and provide a decision on the 145 appeals that were not processed.
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| 11-04081-142 | Audit of VA’s Duty Station Assignments | Audit | ||
1 The Assistant Secretary for Human Resources and Administration develop training for human resources personnel responsible for coding duty stations in the automated system to ensure they understand how to designate employee duty stations as well as the implications of virtual assignments.
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2 The Assistant Secretary for Human Resources and Administration issue policy requiring that at least annually, managers are notified of their employees' duty station assignments and validate the assignments.
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3 The Assistant Secretary for Human Resources and Administration establish an oversight mechanism to ensure that at least annually, managers are notified of their employees¿ duty station assignments and validate the assignments.
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4 The Assistant Secretary for Human Resources and Administration establish a mechanism to notify all VA employees at least annually of the definition of duty station, as well as the implications of virtual assignments on locality pay.
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5 The Assistant Secretary for Human Resources and Administration establish a control mechanism to provide annual notification to supervisors regarding the requirement to submit a Request for Personnel Action, Standard Form 52, if an employee¿s duty station changes.
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6 The Assistant Secretary for Human Resources and Administration provide guidance to human resources personnel regarding processing corrective actions when employees have received inaccurate locality pay, which will help ensure that recoupment efforts are appropriate.
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7 The General Counsel take action to recoup overpayments as appropriate, in accordance with VA guidance.
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8 The Assistant Secretary for Information and Technology take action to recoup overpayments as appropriate, in accordance with VA guidance.
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9 The Executive Director for the Office of Acquisition, Logistics, and Construction take action to recoup overpayments as appropriate, in accordance with VA guidance.
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| 11-00312-127 | Audit of VHA’s Prosthetics Supply Inventory Management | Audit | ||
1 We recommended the Under Secretary for Health require VA medical centers to conduct comprehensive physical inventories of stocked prosthetic supplies, adjust Prosthetics Inventory Package and Generic Inventory Package quantities on hand to match physical inventory quantities, and begin eliminating identified excess inventories and purchasing supplies to avoid identified shortages.
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2 We recommended the Under Secretary for Health collaborate with the VA Office of Information and Technology to develop a detailed plan of the steps needed to replace Prosthetics Inventory Package and Generic Inventory Package with a comprehensive modern inventory system, including milestones for deliverables and a methodology for tracking progress.
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3 We recommended the Under Secretary for Health establish a mechanism to ensure VA medical center prosthetic supply inventory managers receive the training required by the Veterans Health Administration's Inventory Management Handbook.
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4 We recommended the Under Secretary for Health collaborate with the Executive Director, Office of Acquisition, Logistics, and Construction, to develop a VA Acquisition Academy curriculum and certification program for prosthetic supply inventory managers that includes training on the inventory management practices and techniques discussed in this report.
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5 We recommended the Under Secretary for Health revise the Veterans Health Administration's Inventory Management Handbook to require at least one prosthetic supply inventory manager from each VA medical center to attend VA's Acquisition Academy's Supply Chain Management School and become Certified VA Supply Chain Managers.
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6 We recommended the Under Secretary for Health establish a mechanism to identify surgical device implants stored in VA medical center inventories, perform cost/benefit analyses of using consignment agreements to procure identified surgical device implants, and when determined to be cost effective, establish surgical device implant consignment agreements.
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7 We recommended the Under Secretary for Health discontinue using the metric of comparing prosthetic excess supply inventory and budgets and establish a mechanism to ensure VA medical centers submit the prosthetic inventory performance metrics required by the Veterans Health Administration's Inventory Management Handbook.
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8 We recommend the Under Secretary for Health include performance measurement information on VA medical centers' management of prosthetic supplies in the monthly compliance report and distribute the reports in accordance with Inventory Management Handbook requirements.
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9 We recommended the Under Secretary for Health establish policies and procedures requiring Veterans Integrated Service Network Prosthetic Representatives to conduct cyclical reviews at VA medical centers within their jurisdiction to evaluate prosthetic supply inventory management practices and provide a comprehensive written report detailing the evaluation results to the Prosthetic and Sensory Aids Service Central Office and Veterans Integrated Service Network and VA medical center directors.
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10 We recommended the Under Secretary for Health revise the Veterans Health Administration's Inventory Management Handbook to address inadequacies related to exempting Prosthetic and Sensory Aids Service; complying with maximum stock level requirements; establishing normal, reorder, and emergency stock levels; and recording supply receipt and usage in automated inventory systems timely.
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| 11-00733-95 | Audit of VA’s Internal Controls Over the Use of Disability Benefits Questionnaires | Audit | ||
1 We recommend the Under Secretary for Benefits develop internal controls within the disability benefits questionnaire process that will reduce the risk of fraud, such as notifying veterans and physicians that submitted information is subject to verification.
2 We recommend the Under Secretary for Benefits develop front-end controls for the disability benefits questionnaire process to verify the identity and credentials of private physicians who submit completed disability benefits questionnaires, including those entered into the Fast Track Claims Processing System.
3 We recommend the Under Secretary for Benefits develop a plan to measure compliance with the guidance contained in Fast Letter 11-36 pertaining to tracking claims where a disability benefits questionnaire was received as medical evidence.
4 We recommend the Under Secretary for Benefits develop controls to electronically capture information contained on completed disability benefits questionnaires.
5 We recommend the Under Secretary for Benefits update the policy manual with information on the disability benefits questionnaire process, to include procedures for verifying information on completed disability benefits questionnaires and tracking and monitoring completed disability benefits questionnaires.
6 We recommend the Under Secretary for Benefits take steps to improve quality assurance reviews by focusing reviews on disability benefits questionnaires that pose an increased risk of fraud.
7 We recommend the Under Secretary for Benefits establish control mechanisms to ensure that potential cases of fraud identified during the quality assurance review process are immediately forwarded to the Office of Inspector General.
8 We recommend the Under Secretary for Health identify key components of disability benefits questionnaires that should be reviewed as part of the Disability Examination Management Office’s quality assurance review process.
9 We recommend the Under Secretary for Health modify the process used to select claims reviewed by the Disability Examination Management Office’s quality assurance staff.
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| 11-01295-232 | Combined Assessment Program Review of the Birmingham VA Medical Center, Birmingham, Alabama | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that QM data is consistently analyzed and that corrective actions are evaluated for effectiveness.
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2 We recommended that the designated UM Ad-Hoc Committee reviews UM data and that the facility approves the case exemptions for Physician UM Advisor review.
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3 We recommended that PR data summaries include all required elements and that the PRC monitor closure of issues identified or referred for follow-up to other venues.
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4 We recommended that ongoing FPPE be completed within the defined 12-month period and that monitoring data be maintained in the physicians¿ profiles.
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5 We recommended that adequate competency data be maintained in all physicians' profiles.
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6 We recommended that processes be strengthened to ensure that all violent incidents involving patients are discussed at the DBC.
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7 We recommended that annual bloodborne pathogens training and N95 respirator fit testing be completed and that compliance be monitored.
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8 We recommended that processes be strengthened to ensure that all components of written AD notification are provided to patients and that notification is documented in the medical record.
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14917