Recommendations
2225
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 23-01690-31 | Without Effective Controls, Public Disability Benefits Questionnaires Continue to Pose a Significant Risk of Fraud to VA | Review | ||
1 Direct the Office of Financial Management to continue to develop a system for digitally capturing, analyzing, and monitoring public questionnaires to identify inauthentic or potentially fraudulent questionnaires and work with the Compensation Service to develop policies for reviewing and remediating any such public questionnaires identified.
Closure Date:
2 Have the Medical Disability Examination Office update the examiner certification and signature section found in public questionnaires to include that the form is being completed under the penalty of perjury and to ask examiners to list any organizations that requested they complete the examinations on the claimant’s behalf.
Closure Date:
3 Instruct the Compensation Service to provide claims processors guidance in the procedures manual on how to identify a potentially fraudulent public questionnaire, and provide the steps they should take when they suspect that a public questionnaire may be inauthentic or potentially fraudulent.
Closure Date:
4 Require the Compensation Service to inform claims processors as part of the public questionnaire review process that they have a duty to review and weigh all the evidence of record, including public questionnaires, and that they have the responsibility to assign low or no probative value if they have reason to suspect that the public questionnaire is inauthentic or potentially fraudulent.
Closure Date:
5 Direct the Veterans Benefits Administration to develop and provide training on authentication and fraud, including training related to public questionnaires, to provide claims processors with the knowledge to identify inauthentic or potentially fraudulent public questionnaires, and include what steps claims processors should take when they make that determination.
Closure Date:
| ||||
| 23-00007-45 | Comprehensive Healthcare Inspection of the Miami VA Healthcare System in Florida | Comprehensive Healthcare Inspection Program | ||
1 The Executive Director ensures staff complete peer reviews for unanticipated deaths occurring within 24 hours of admission.
Closure Date:
2 The Chief of Staff ensures service chiefs complete Ongoing Professional Practice Evaluations for licensed independent practitioners.
Closure Date:
| ||||
| 22-03165-46 | Comprehensive Healthcare Inspection of the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures providers with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.
Closure Date:
2 The Chief of Staff ensures service chiefs include service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.
Closure Date:
3 The Associate Director ensures managers maintain a safe and clean environment throughout the medical center.
Closure Date:
4 The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a positive suicide risk screen when it is clinically appropriate.
Closure Date:
| ||||
| 23-00004-37 | Comprehensive Healthcare Inspection of the W.G. (Bill) Hefner VA Medical Center in Salisbury, North Carolina | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures providers complete a Comprehensive Suicide Risk Evaluation following a positive suicide risk screen.
Closure Date:
2 The Chief of Staff ensures clinical staff notify the suicide prevention team if patients report suicidal or other self-directed violent behaviors that occurred in the 12 months preceding the Comprehensive Suicide Risk Evaluation.
Closure Date:
3 The Chief of Staff ensures leaders appoint one full-time suicide prevention coordinator to each community-based outpatient clinic that serves at least 10,000 unique veterans annually.
Closure Date:
4 The Chief of Staff ensures the Suicide Prevention Program Manager reports suicide-related events monthly to mental health leaders and quality management staff.
Closure Date:
| ||||
| 22-02934-208 | VA Should Validate Contractor Energy Baseline and Savings Estimates and Ensure Payments Are Legally Compliant | Audit | ||
1 Develop specific policy and procedures to ensure the contractor’s investment grade audit, which includes the contractor’s energy baseline and cost savings estimates, are witnessed and validated per Federal Energy Management Program guidelines.
Closure Date:
2 Publish criteria for payments for energy savings performance contracts to ensure compliance with federal law and Department of Energy Federal Energy Management Program guidance.
Closure Date:
3 Develop procedures to ensure contracting officer’s representatives or other contracting officer designees have independently witnessed and validated the contractor’s energy baseline and savings estimates prior to negotiating energy savings performance contracts’ guaranteed savings amounts.
Closure Date:
4 Develop oversight procedures to ensure documentation that demonstrates the contractor’s energy baseline and energy savings estimates were witnessed and validated is maintained in the official contracting records.
Closure Date:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $68,000,000
Total: $68,000,000
| ||||
| 22-00410-197 | VA Needs to Conduct Seismic Evaluations on Critical and Essential Buildings to Effectively Prioritize Program Funds | Audit | ||
1 The executive director of VA’s Office of Construction and Facilities Management should confirm seismic evaluations are done for all critical and essential buildings in high and very high seismic zones immediately to ensure they meet life, safety, and occupancy performance standards
2 The executive director of the Office of Construction and Facilities Management should review the Capital Asset Inventory and work with Veterans Health Administration Office of Capital Asset Management, Veterans Integrated Service Network capital asset managers, and VA medical facility engineers to update and correct inaccurate seismic data in the Capital Asset Inventory.
Closure Date:
3 The executive director of the Office of Construction and Facilities Management should submit change requests to the Capital Asset Inventory so that critical and essential designations are visible to medical center engineers and Veterans Integrated Service Network capital asset managers.
Closure Date:
4 The executive director of the Office of Asset Enterprise Management should ensure facilities and Veterans Integrated Service Networks review critical and essential designations as part of their annual certifications of the Capital Asset Inventory.
Closure Date:
| ||||
| 22-02739-210 | Significant Deficiencies Found in VA’s Denver Logistics Center Inventory Management Operations and Systems | Audit | ||
1 Implement oversight, monitoring, and quality assurance mechanisms that routinely ensure all goods received by the Denver Logistics Center are accurately and promptly recorded in the inventory management system at the time of receipt.
Closure Date:
2 Properly record all apnea stock in the inventory management system.
Closure Date:
3 Ensure Denver Logistics Center management routinely assess the appropriateness of manual adjustments to the inventory system and document the findings and causes, review trends in error codes, and develop action plans to minimize inaccuracies in future physical counts.
Closure Date:
4 Strengthen controls over inventory adjustments to ensure the accountable officer or designee reviews and approves supply variances above an established threshold.
Closure Date:
5 Establish and implement policy that clearly defines roles and responsibilities for Denver Logistics Center logistics and warehouse employees, separates duties to avoid conflicts of interest, and enhances the quality assurance function.
Closure Date:
6 Establish and implement formal policies and procedures specific for inventory management operations at the Denver Logistics Center, to include cycle counts, regular inventory audits, adjustments and forecasting demand, safety levels, reordering, and tools to allow for automated scanning.
Closure Date:
7 Develop and deliver formal training to logistics and warehouse staff on inventory management policies, procedures, and tools.
Closure Date:
8 Implement routine reporting of all Denver Logistics Center inventory adjustments to the National Acquisition Center and the Office of Acquisition, Logistics, and Construction.
Closure Date:
9 Ensure the Denver Logistics Center staff complete reports of survey for adjustments to inventory in accordance with VA logistics management policy, and communicate such information to the National Acquisition Center.
Closure Date:
10 Address the physical security issues identified and develop, implement, and provide initial and recurring training and guidance to Denver Logistics Center’s logistics, distribution, and contract staff on proper physical security controls and procedures, including the proper disposal of personally identifiable information.
Closure Date:
11 Conduct an independent, comprehensive, and multiyear financial audit that includes wall-to-wall inventory assessments of the Denver Logistics Center.
Closure Date:
12 Transfer the stewardship and responsibility for Denver Logistics Center systems to the Office of Information and Technology.
Closure Date:
13 In collaboration with the Office of Information and Technology, establish information system controls for user access, segregation of duties designations, permission access, and privilege access for the inventory management systems and data.
Closure Date:
14 Establish and perform routine reviews of the access levels for users with direct access to the inventory management systems and ensure that access is limited to those who have a defined business purpose.
Closure Date:
15 In collaboration with the Office of Information and Technology, ensure the Denver Logistics Center meets physical access, security, and contingency planning requirements for its information management systems.
Closure Date:
16 Establish a connection for Denver Logistics Center inventory data to VA’s Corporate Data Warehouse.
Closure Date:
17 In collaboration with the Office of Information and Technology, ensure the information technology system application does not bypass internal control restrictions, has a complete audit trail, and does not introduce errors in the information system.
Closure Date:
18 Ensure the Denver Logistics Center develops and maintains comprehensive documentation of the information system to support operations and train information resource management staff.
Closure Date:
19 Ensure security documentation accurately supports the proper controls are implemented, tested, and representative of the system security.
Closure Date:
| ||||
| 21-03102-201 | The Office of Integrated Veteran Care Needs to Improve Community Dialysis Oversight and Develop a Strategy to Align Future Contracts with the MISSION Act | Audit | ||
1 Clarify guidance to ensure it includes local dialysis contract options and specifically defines when they should be used.
Closure Date:
2 Establish roles and responsibilities to ensure dialysis coordinators follow required procedures when referring veterans to dialysis care in the community.
Closure Date:
3 Develop and implement a plan to regularly examine and validate dialysis provider information in the Provider Profile Management System for accuracy and completeness.
Closure Date:
4 Develop and implement a strategy to ensure that any new dialysis service contracts follow the John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 payment rate requirements.
Closure Date:
| ||||
| 21-01445-30 | Greater Compliance with Policies Needed Related to the Management of Emergent Care for Patients Presenting with Acute Sexual Assault | National Healthcare Review | ||
1 The Under Secretary for Health makes certain the Veterans Health Administration complies with requirements that all acute sexual assault victim-survivors are offered prophylaxis for sexually transmitted infection when clinically indicated and monitors compliance.
Closure Date:
2 The Under Secretary for Health verifies compliance with Veterans Health Administration requirements that all acute sexual assault victim-survivors are offered prophylaxis for pregnancy when clinically indicated and monitors compliance.
Closure Date:
3 The Under Secretary for Health ensures all sexual assault victim-survivors are offered mental health resources, either directly through Veterans Health Administration or through the community and monitors compliance.
Closure Date:
4 The Under Secretary for Health ensures compliance with Veterans Health Administration requirements for documentation of signature informed consent for forensic examinations conducted by staff at Veterans Health Administration facilities and monitors compliance.
Closure Date:
5 The Under Secretary for Health coordinates with VA Office of Security and Law Enforcement to provide direction that facility policy or guidance include facility and jurisdiction-specific information necessary for frontline staff to act in accordance with jurisdiction and Veterans Health Administration requirements for VA police responding to sexual assaults.
Closure Date:
6 The Under Secretary for Health ensures Veterans Health Administration’s policy specifies the required elements to include in Veterans Health Administration facilities’ policies or guidance on acute sexual assault, including jurisdiction-specific requirements, and considers an online national policy with an appendix containing each facility’s supplemental information.
Closure Date:
7 The Under Secretary for Health makes certain that facility level management of acute sexual assault policy or guidance is updated to incorporate information on facility-specific resources and jurisdictional requirements as warranted, and educates staff as needed.
Closure Date:
8 The Under Secretary for Health ensures that VA Police Chiefs review facility policy and guidance for police responding to sexual assaults and update to incorporate information on facility-specific resources and processes, including jurisdictional requirements, as warranted, and educates facility police officers as needed.
Closure Date:
| ||||
| 22-04037-32 | Comprehensive Healthcare Inspection of the VA Providence Healthcare System in Rhode Island | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures providers with equivalent specialized training and similar privileges complete Focused Professional Practice Evaluations for licensed independent practitioners.
Closure Date:
2 The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same calendar day, when it is clinically appropriate, following a positive suicide risk screen.
Closure Date:
| ||||
15770