Date Issued
|
Report Number
22-01279-206
All Reports
Date Issued
|
Report Number
21-03061-209
|
Topics: Claims and Appeals
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 9/20/2023
Centralize all Camp Lejeune-related claims processing at the Louisville VA Regional Office, or implement a plan and report progress mitigating the error rate disparity between the Louisville Regional Office and other regional offices.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 9/20/2023
Conduct and report to the Office of Inspector General the results of targeted quality reviews of Camp Lejeune-related claims from all regional offices processing these claims until the accuracy rate meets or exceeds the Veterans Benefits Administration’s overall national accuracy goal for disability compensation claims.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 13,800,000.00
Date Issued
|
Report Number
21-02668-182
|
Topics: Supplies and Equipment
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/30/2024
Establish clear oversight roles and responsibilities of the program office and of regional network telehealth and medical facility leads to monitor medical facility social worker and telehealth staff compliance with the “Digital Divide Standard Operating Procedure” for conducting assessments, ordering, and scheduling.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 6/10/2024
Develop and implement a mechanism to alert the requesting clinic that a patient has a loaned device and can now be scheduled for a VA Video Connect appointment.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/23/2022
Clarify timeliness goals for the digital divide consult, and video device order placement.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/20/2023
Update the digital divide consult training to include procedure updates and ensure social workers and facility telehealth and Remote Order Entry System coordinators who process digital divide consults and video device orders complete the training and take refresher training as needed.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 6/10/2024
Implement procedures to require responsible staff to check for duplicate devices before submitting a device order consult.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 9/30/2024
Establish an alert in the Remote Order Entry System to notify the responsible staff member that a patient already has an issued device before ordering another, and initiate retrieval activities for duplicate devices.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 3/26/2024
Delegate in the “Digital Divide Standard Operating Procedure” facility staff to monitor the tablet dashboard for VA Video Connect appointment activity and device use, and clearly define regional network telehealth leads’ oversight responsibilities to ensure facilities initiate retrieval activities when warranted.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 6/10/2024
Establish an automated mechanism using the tablet dashboard to routinely identify the devices that meet retrieval priorities and also initiate retrieval of those that already meet retrieval requirements.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 3/23/2023
Augment tracking mechanisms for packages sent to patients to ensure VA receipt of the retrieval kit so that devices are accurately recorded in inventory and available for refurbishment and reissue.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 3/26/2024
Address restrictions in the refurbishment process, implement accessible and trackable reporting of devices waiting to be refurbished, and implement a structured purchasing model to guide new device purchases and maintain an appropriate inventory level.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 14,478,000.00
Date Issued
|
Report Number
21-02401-190
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 12/9/2022
Improve monitoring procedures and demonstrate progress toward ensuring all felony referrals are processed.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 8/3/2022
Update fugitive felon letters and ensure they are consistently sent with all required information.
No. 3
to Veterans Benefits Administration (VBA)
Review unprocessed felony referrals identified in this report, take corrective action as needed, and report the efforts taken to the OIG.
Date Issued
|
Report Number
22-00210-191
|
Topics: Information Technology and Security
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Office of the Secretary (SVA)
Closure Date: 5/25/2023
Designate roles and responsibilities for all program offices involved in VA’s identity, credential, and access management program.
No. 2
to Office of the Secretary (SVA)
Closure Date: 12/12/2024
Provide appropriate oversight and ensure coordination between designated program offices to implement a comprehensive identity, credential, and access management policy.
No. 3
to Information and Technology (OIT)
Closure Date: 12/12/2024
Update and publish a VA directive and handbook associated with identity and access management that includes current National Institute of Standards and Technology requirements.
No. 4
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 9/29/2025
Update and publish VA directives and handbooks associated with the Homeland Security Presidential Directive 12 Program and VA’s personnel security and suitability program as required by VA’s enterprise directives management procedures.
Date Issued
|
Report Number
21-01351-151
|
Topics: Claims and Appeals
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 6/17/2024
Implement a formal procedure to ensure all improperly created debts identified by the review team are corrected, and certify the results to the OIG.
No. 2
to Veterans Benefits Administration (VBA)
Enact a formal procedure to review all VBA compensation awards not already reviewed by the OIG that were completed since January 1, 2020, with debts due to reduced disability levels, take corrective action as appropriate, and report the results to the OIG.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 8/31/2023
Develop and demonstrate progress toward implementing a plan to update the electronic system to make employees aware of each period in which an award creates a debt.
No. 4
to Veterans Benefits Administration (VBA)
Develop a mechanism to review the effectiveness of the recommendations periodically and a process for determining what additional measures, if any, are needed.
Date Issued
|
Report Number
21-02194-198
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/7/2022
The Under Secretary for Health evaluates current guidance regarding the monitoring and reporting of medication recall adverse drug events and makes changes as necessary.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/7/2022
The Under Secretary for Health reviews vulnerabilities in the medication recall process due to variances in Veterans Health Administration medical facility processes and makes changes as necessary.
Date Issued
|
Report Number
22-01137-204
|
Topics: Electronic Health Records Modernization (EHRM)
● Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 9/28/2022
The Deputy Secretary reviews the process that led to Oracle Cerner’s failure to inform VA of the unknown queue and takes action as indicated.
No. 2
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 2/13/2023
The Deputy Secretary evaluates the unknown queue technology and mitigation process and takes action as indicated.
Date Issued
|
Report Number
21-02599-156
|
Topics: Contract Integrity
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/25/2023
Establish procedures for consistent quality assurance reviews to ensure all contract closeout requirements, such as identifying and deobligating excess funds, closing out contracts timely, and properly completing and uploading closeout documentation, are performed in accordance with the Federal Acquisition Regulation and the Veterans Health Administration procurement manual. Further, update Veterans Health Administration policies and procedures to provide guidance on conducting and documenting the reviews.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/21/2022
Assess and determine how to effectively distribute contracting officer workload and address imbalances among staff to help ensure contract closeouts are completed in accordance with the Federal Acquisition Regulation and the Veterans Health Administration procurement manual.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/21/2022
Clarify the Veterans Health Administration procurement manual to indicate when simplified acquisition procedures closeout processes are to be used and the documentation requirements for each contract closeout step.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/21/2022
Determine whether setting aside specific time weekly to focus on contract administration tasks, such as contract closeout, and using contractors to perform closeout procedures could improve contract closeout compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 12/21/2022
Ensure the contract files for the 81 sampled contracts have complete closeout documentation in accordance with the Federal Acquisition Regulation and the Veterans Health Administration procurement manual.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 4,400,000.00
Date Issued
|
Report Number
22-00722-187
|
Topics: Staffing
Date Issued
|
Report Number
21-03853-174
|
Topics: Financial Management
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/30/2022
Ensure that healthcare system finance office staff are made aware of policy requirements and that reviews are conducted on all inactive open obligations, and deobligate any identified excess funds as required by VA Financial Policy, vol. 2, chap. 5, “Obligations Policy.”
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
Ensure cardholders comply with record retention requirements as stated in VA’s Financial Policy, vol. XVI, “Charge Card Programs.”
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
Establish controls to confirm approving officials and purchase cardholders review their purchases and make sure contracting is used when it is in the best interest of the government.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 11/30/2022
Require purchase cardholders to submit a request for ratification for any unauthorized commitments identified.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 11/30/2022
Ensure quarterly purchase card audits are performed as required by the Veterans Health Administration’s standard operating procedure, “Internal Audits—Purchase Cards and Convenience Checks.”
No. 6
to Veterans Health Administration (VHA)
Closure Date: 5/19/2023
Ensure supply chain management staff implement a plan to improve data reliability within the Generic Inventory Package system.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 5/19/2023
Ensure the chief of supply chain management signs quarterly physical inventory memorandums of “A” classified items and makes them available to Veterans Integrated Service Network personnel as required in the VHA’s Directive 1761 Supply Chain Management Operations.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
Develop and implement a plan to increase inventory turnover to meet the level recommended by the Veterans Health Administration Pharmacy Benefits Management Office.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 379,439.00
Date Issued
|
Report Number
22-01637-176
|
Topics: Education and Loan Guaranty
● Information Technology and Security
Date Issued
|
Report Number
22-00180-169
Date Issued
|
Report Number
21-03080-142
|
Topics: Information Technology and Security
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Information and Technology (OIT)
Closure Date: 10/25/2022
The OIG recommends the Assistant Secretary for Information and Technology develop controls to help ensure minor applications are not misclassified as assets and undergo the appropriate security accreditation and certification process.
No. 2
to Information and Technology (OIT),Veterans Benefits Administration (VBA)
Closure Date: 8/7/2023
The OIG recommends the Assistant Secretary for Information and Technology in conjunction with the Under Secretary for Benefits, make certain that appropriate security and privacy controls are implemented during the development of information technology systems before being hosted on VA’s network.
No. 3
to Information and Technology (OIT),Veterans Benefits Administration (VBA)
The OIG recommends the Under Secretary for Benefits, in conjunction with the Assistant Secretary for Information and Technology, establish a mechanism to gain assurance that proper Office of Information Technology project management processes and protocols are followed when establishing information technology systems and applications.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 10/25/2022
The OIG recommends the Under Secretary for Benefits establish policies and procedures to ensure the Mission Accountability Support Tracker is used appropriately and does not contain unnecessary personally identifiable information.
Date Issued
|
Report Number
21-01237-127
|
Topics: Claims and Medical Exams
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 1/24/2023
Assess and modify contracts and any renewals to ensure that vendors can be heldaccountable for unsatisfactory performance by applying monetary disincentives.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 5/5/2023
Assess and modify contracts and any renewals to ensure procedures are established for vendors to correct errors identified by the Medical Disability Examination Office.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 5/5/2023
Implement procedures requiring the Medical Disability Examination Office tocommunicate exam errors to the Office of Field Operations and the regional officesand demonstrate progress in correcting the identified errors.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 8/10/2022
Implement procedures requiring the Medical Disability Examination Office toanalyze all available error data and provide systemic exam issues and error trends tovendors.
Date Issued
|
Report Number
21-02453-99
|
Topics: Information Technology and Security
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Information and Technology (OIT)
Closure Date: 6/1/2022
Implement more effective inventory management tools for all network segments.
No. 2
to Information and Technology (OIT)
Closure Date: 9/29/2022
Implement a more effective vulnerability and flaw remediation program that can accurately identify vulnerabilities and enforce flaw remediation.
No. 3
to Information and Technology (OIT)
Closure Date: 6/1/2022
Develop and implement methods to ensure delivery, receipt, and understanding of assigned roles and responsibilities for Consolidated Mail Outpatient Pharmacy activities to ensure full implementation of approved policy.
No. 4
to Information and Technology (OIT)
Closure Date: 9/25/2023
Develop and implement a disaster recovery plan and capability that will restore operations in the event of a disruption to critical operations.
No. 5
to Information and Technology (OIT)
Closure Date: 6/1/2022
Task the facility manager to change the default username and password for the security camera system.
No. 6
to Information and Technology (OIT)
Closure Date: 9/29/2022
Request the Office of Information and Technology to configure audit logging on the misconfigured devices in accordance with established baselines, policy, and procedures.
Date Issued
|
Report Number
21-01123-97
|
Topics: Information Technology and Security
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Information and Technology (OIT)
Closure Date: 8/7/2023
The assistant secretary for information and technology and chief information officer will ensure the Veterans Data Integration and Federation Enterprise Platform security objectives are all set at a categorization level of high based upon both the sensitive personal information maintained in the system and the approved risk assessment.
No. 2
to Information and Technology (OIT)
Closure Date: 8/7/2023
The assistant secretary for information and technology and chief information officer will act to reestablish the Veterans Data Integration and Federation Enterprise Platform in the Enterprise Mission Assurance Support Service to ensure appropriate security controls are implemented and the system is assessed at the high risk level.
No. 3
to Information and Technology (OIT)
Closure Date: 1/4/2023
The assistant secretary for information and technology and chief information officer will ensure the Office of Information Technology provides appropriate oversight and follows proper program management processes and protocols when establishing and monitoring security controls for IT systems.
Date Issued
|
Report Number
21-03305-139
|
Topics: Information Technology and Security
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Information and Technology (OIT)
Closure Date: 10/20/2022
Implement an effective inventory management system for all network segments.
No. 2
to Information and Technology (OIT)
Closure Date: 3/23/2023
Implement an effective vulnerability and flaw remediation program that can
accurately identify vulnerabilities and enforce flaw remediation
No. 3
to Information and Technology (OIT)
Closure Date: 6/1/2022
Develop and implement methods to ensure delivery, receipt, and understanding of assigned roles and responsibilities for local activities to ensure full implementation
of approved policy.
No. 4
to Information and Technology (OIT)
Closure Date: 6/1/2022
Implement effective configuration control processes that ensure network devices maintain standards mandated by the VA Office of Information and Technology Configuration Control Board.
No. 5
to Information and Technology (OIT)
Closure Date: 1/14/2025
Remove or disable group accounts to comply with established requirements and criteria.
No. 6
to Information and Technology (OIT)
Closure Date: 6/1/2022
Ensure employees lock devices when they are unattended.
No. 7
to Information and Technology (OIT)
Closure Date: 6/1/2022
Implement database authentication processes that comply with National Institute of
Standards and Technology standards and VA security requirements.
No. 8
to Information and Technology (OIT)
Closure Date: 10/20/2022
Implement a process to retain database logs for a period consistent with VA’s record
retention policy.
No. 9
to Information and Technology (OIT)
Closure Date: 6/1/2022
Establish a process for validating and logging the sanitization of hard drives.
No. 10
to Information and Technology (OIT)
Closure Date: 10/20/2022
Implement parking barriers that meet VA Physical Security & Resiliency Design Manual
requirements.
Date Issued
|
Report Number
21-01820-159
|
Topics: Community Care
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/3/2023
The VISN 23 Director ensures implementation and sustainment of initial and annual home visits for patients accepted into the VISN 23 home dialysis program.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/28/2023
The VISN 23 Director ensures the implementation and sustainment of quality monitoring of contracted clinical services for home dialysis.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/11/2023
The VISN 23 Director ensures that VA providers receive mammography reports from non-VA providers within the established acceptable timeframe.