Date Issued
|
Report Number
20-03814-64
All Reports
Date Issued
|
Report Number
20-03086-70
|
Topics: Healthcare Infrastructure
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/21/2024
Develop and execute a project management plan to evaluate and correct Veterans Health Information Systems and Technology Architecture address data used to mail first-party billing statements.
No. 2
to Veterans Health Administration (VHA)
Establish controls to periodically review and reconcile Veterans Health Information Systems and Technology Architecture address data used to mail first-party billing statements.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/7/2025
Improve policies detailing roles, responsibilities, and procedures for remediating returned billing statements and steps for flagging and updating outdated billing addresses
Date Issued
|
Report Number
21-03260-60
Date Issued
|
Report Number
21-00497-46
|
Topics: COVID-19
● Community Care
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/14/2023
Develop guidelines requiring supervisors to use VHA systems to monitor documentation of efforts to contact patients to schedule an appointment and to take corrective action as appropriate.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/21/2023
Establish a tool to monitor whether clinicians are properly indicating the appropriateness of alternative forms of care and whether staff offered them to patients when clinically appropriate.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/14/2022
Reassess the frequency of and approach to its training for scheduling community care consults to VHA facilities as revisions are made to the various tools.
Date Issued
|
Report Number
20-00552-30
|
Topics: Financial Management
● Supplies and Equipment
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/21/2022
Update the Electronic Catalog Ordering Guide with additional guidance to clarify the requirement to consider Federal Supply Schedule contracts before ordering medical supplies and equipment through the Defense Logistics Agency’s Electronic Catalog and monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/31/2023
Establish a process to monitor orders through the Defense Logistics Agency’s Electronic Catalog to identify recurring acquisitions that could be purchased through other contract vehicles at a lower price.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/31/2023
Require a justification for every order through the Defense Logistics Agency’s Electronic Catalog if a Federal Supply Schedule contract is available.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/28/2024
Correct and monitor compliance with the Rule of Two diagram in the Electronic Catalog Ordering Guide.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/28/2024
Establish a process to ensure appropriate documentation and audits of orders in accordance with the Electronic Catalog Ordering Guide.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 1/31/2023
Conduct and document annual reviews as required in the interagency agreement.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 4,420,878.00
Date Issued
|
Report Number
20-03351-08
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/28/2024
The OIG recommended that the acting under secretary for health perform additional analyses to ensure materially accurate specialty care workload data are used to implement the Asset and Infrastructure Review Commission recommendations.
Date Issued
|
Report Number
19-07812-29
|
Topics: Supplies and Equipment
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/16/2021
The OIG recommended that the under secretary for health implement comprehensive guidance for staff who schedule home oxygen consults that includes processes for working with patients who do not or are unable to attend scheduled reevaluations, and for determining how and when to discontinue home oxygen services when appropriate.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/16/2021
The OIG recommended that the under secretary for health update guidance to include any exceptions to the scheduling time frame based on the type of home oxygen services patients are prescribed.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/26/2023
The OIG recommended that the under secretary for health update policy to assign oversight responsibility for ensuring the number of home or telehealth visits outlined in guidance is conducted.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 7/28/2023
The OIG recommended that the under secretary for health require the network contracting offices to provide oversight so that (1) contracting officers ensure vendor performance evaluations and quality assurance reports are completed and documented in the electronic contract management system, and (2) contracting officers comply with requirements when designating contracting officer’s
representatives.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 7/28/2023
The OIG recommended that the under secretary for health clearly communicate processes or tools that staff should use to achieve the contract monitoring requirements outlined in the Federal Acquisition Regulation.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 11/4/2022
The OIG recommended that the under secretary for health ensure facilities in Veterans Integrated Service Network 7 review orders that were paid for home oxygen services without an awarded contract and submit a request for ratification to the head of the contracting activity for any unauthorized commitments.
Date Issued
|
Report Number
21-00942-16
|
Topics: Financial Management
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/31/2022
The OIG recommended the director of the Eastern Oklahoma VA Health Care System ensure finance office staff are made aware of policy requirements and reviews are conducted on all open obligations as required by VA Financial Policies and Procedures, vol. 2, chap. 5, “Obligations Policy,” January 2018.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/25/2022
The OIG recommended the director of contracting for Network Contracting Office 19, VA Rocky Mountain Network, develop checks on the successful completion of quarterly audits of the purchase card program as required by the Veterans Health Administration’s standard operating procedure, “Internal Audits—Purchase Cards and Convenience Checks.”
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/31/2022
The OIG recommended the director of the Eastern Oklahoma VA Health Care System establish controls to confirm approving officials and purchase cardholders review their purchases and make sure contracting is used when it is in the best interests of the government.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/25/2022
The OIG recommended the director of the Eastern Oklahoma VA Health Care System ensure cardholders comply with record retention requirements as stated in VA’s Financial Policy, vol. XVI, “Charge Card Program.”
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The OIG recommended the director of the Eastern Oklahoma VA Health Care System develop measures to confirm completed VA Form 0242 submissions are accurate and updated for all cardholders.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/25/2022
The OIG recommended the director of the Eastern Oklahoma VA Health Care System develop formalized processes for achieving identified efficiency targets and use available pharmacy data to make business decisions.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 8/25/2022
The OIG recommended the director of the Eastern Oklahoma VA Health Care System develop and implement a plan to increase inventory turnover closer to the VHA recommended level.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 8/25/2022
The OIG recommended the director of the Eastern Oklahoma VA Health Care System develop and implement a plan to complete facility based inventory audits of noncontrolled drug line items in compliance with VHA policy.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The OIG recommended the director of the Eastern Oklahoma VA Health Care System establish measures to improve compliance with the nonformulary request process.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 95,000.00
Date Issued
|
Report Number
19-09592-262
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Office of Enterprise Integration (OEI)
Closure Date: 4/26/2023
The OIG recommended the assistant secretary for the Office of Enterprise Integration designate a senior accountable official or program office for the full scope of benefits and services provided on behalf of deceased veterans whose remains are unclaimed. This official or office should be charged with ensuring that VA’s benefits and services for unclaimed veterans comply with applicable federal enterprise risk management and internal control standards.
No. 2
to Office of Enterprise Integration (OEI)
Closure Date: 12/13/2022
The OIG recommended the assistant secretary for the Office of Enterprise Integration conduct a program evaluation of all VA benefits and services for deceased veterans whose remains are unclaimed in compliance with applicable laws and VA regulations. This evaluation should consider the extent to which existing law requires VA to conduct outreach on behalf of deceased veterans whose remains are unclaimed. This evaluation should also ensure the benefits and services are assigned to the appropriate VA program offices and the offices are given authority to administer these programs.
No. 3
to Office of Enterprise Integration (OEI)
Closure Date: 10/15/2024
The OIG recommended the assistant secretary for the Office of Enterprise Integration coordinate and implement data sharing agreements with other agencies or organizations with records of deceased veterans whose remains are unclaimed or veterans not included in VA databases.
No. 4
to Office of Enterprise Integration (OEI)
Closure Date: 1/25/2023
The OIG recommended the assistant secretary for the Office of Enterprise Integration determine eligibility and take action to facilitate dignified burials for these persons with unclaimed remains whose records the OIG referred to VA.
No. 5
to Office of Enterprise Integration (OEI)
Closure Date: 10/31/2022
The OIG recommended the assistant secretary for the Office of Enterprise Integration develop a comprehensive estimate of the number of deceased veterans whose remains are unclaimed awaiting burial, including those held at locations other than funeral homes.
No. 6
to Office of Management (OM)
Closure Date: 8/10/2023
The OIG recommended the assistant secretary for management and chief financial officer implement controls for payments made to individual payees or other entities on behalf of deceased veterans whose remains are unclaimed that can be cross referenced across current VA payment systems and ensure that staff involved with issuing payments are trained in the correct use of these controls.
No. 7
to Veterans Benefits Administration (VBA)
Closure Date: 8/3/2022
The OIG recommended the under secretary for benefits implement monitoring mechanisms, procedures, and recurring training for VA regional office directors on their responsibilities for facilitating burials for deceased veterans whose remains are unclaimed.
No. 8
to Veterans Benefits Administration (VBA)
Closure Date: 8/3/2022
The OIG recommended the under secretary for benefits require points of contact for indigent and unclaimed veterans outreach to regularly complete the outreach functions listed in VA Manual 27 1, chapter 11. VBA should ensure points of contact receive recurring training in these tasks and implement ongoing compliance activities.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 8/10/2023
The OIG recommended the under secretary for health direct VHA leadership to assess the extent to which personnel in the former VHA Office of Operations and Management and the VHA Office of Member Services were not performing required oversight activities and take appropriate action.
No. 10
to National Cemetery Administration (NCA)
Closure Date: 8/3/2022
The OIG recommended the under secretary for memorial affairs
implement system indicators in NCA systems to show when veterans’ remains are unclaimed without relying on a manually updated spreadsheet. These system indicators should enable tracking mechanisms to ensure required follow ups are performed on completed burial eligibility determinations without a scheduled interment and identify repeat burial eligibility requests.
No. 11
to National Cemetery Administration (NCA)
Closure Date: 1/25/2023
The OIG recommended the under secretary for memorial affairs
in coordination with the Secretary’s Center for Strategic Partnerships, assess options for providing a suitable casket or urn to a deceased veteran whose remains are unclaimed rather than a monetary reimbursement.
Date Issued
|
Report Number
20-04219-07
|
Topics: Claims and Appeals
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 11/16/2022
Review all active high-risk special monthly compensation housebound cases, render new decisions as appropriate, ensure the corrective actions were taken, and conduct a documented quality review of corrective actions.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 11/16/2022
Implement a plan to conduct ongoing periodic reviews of completed active high-risk special monthly compensation housebound cases, render new decisions as appropriate, ensure the corrective actions were taken, and conduct a documented quality review of corrective actions.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 11/16/2022
Update the special monthly compensation housebound training to include guidance on and examples of statutory, housebound in fact, individual unemployability, and extraschedular criteria, and monitor the effectiveness of the training.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 7/27/2022
Create a system enhancement to limit the statutory special monthly compensation housebound validation warning to trigger only when statutory housebound criteria are met but not addressed.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 5/23/2022
Create a system enhancement to prohibit rating veterans service representatives from bypassing statutory housebound validation warnings without taking action or providing justification.
No. 6
to Veterans Benefits Administration (VBA)
Closure Date: 10/25/2023
Correct all processing errors on cases identified by the review team and report the results to the OIG.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 136,000,000.00
Date Issued
|
Report Number
20-01099-249
|
Topics: Community Care
● Financial Management
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/17/2023
Ensure the Office of Community Care implements automated payment system controls to reject non VA claims that exceed the number of authorized visits or cutoff dates or includes treatment codes that deviate from established standards for care.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 6/3/2022
Ensure the Office of Community Care conducts ongoing payment system audits to identify and minimize improper payments of unauthorized claims.
No. 3
to Veterans Health Administration (VHA)
Direct the Health Information Management program office in coordination with the Office of Community Care and facility chiefs of staff to ensure facilities are conducting post payment audits of billed acupuncture and chiropractic services to verify non VA providers are properly supporting their claims and to develop processes for corrective actions based on audit results.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/12/2022
Ensure the Office of Community Care and the Health Information Management program office, in coordination with the offices of Acupuncture and Chiropractic services, make any current and future continuing education material related to documenting acupuncture and chiropractic services available to non VA providers.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/13/2023
Direct facility chiefs of staff to require those authorized to approve non VA care to document review of prior care before approving additional services.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 1/13/2023
Instruct facility chiefs of staff to require VA providers to document their clinical justification for additional care requested by a veteran.
Total Monetary Impact of All Recommendations
Open: $ 341,700,000.00
Closed: $ 0.00
Date Issued
|
Report Number
21-01807-251
|
Topics: Community Care
● Financial Management
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Direct the Health Information Management program office, in coordination with the Office of Community Care and facility chiefs of staff, to ensure facilities are conducting post payment audits of billed evaluation and management services to verify non VA providers are properly supporting their claims, including a focus on providers who frequently bill high level evaluation and management services and/or submit charges during periods when global surgery packages are in effect, and develop processes for corrective actions based on audit results.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/19/2022
Ensure the Office of Community Care and the Health Information Management program office make any current and future continuing education material related to documenting evaluation and management services available to non VA providers.
Total Monetary Impact of All Recommendations
Open: $ 59,600,000.00
Closed: $ 0.00
Date Issued
|
Report Number
21-00913-267
|
Topics: COVID-19
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/12/2022
The OIG recommended the under secretary for health develop processes for verifying facility data entered on the Pharmacy Benefits Management Services’ SharePoint website (or any subsequent data collection tool) for vaccine supply and usage.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/25/2022
The OIG recommended the under secretary for health develop a process to monitor the use of tools that have been fielded to standardize data entry for vaccine doses administered by VA medical facilities and clinics to minimize data entry errors, including the Computerized Patient Record System’s clinical reminder, the Occupational Health Record-keeping System 2.0’s guided data entry guidance, and reports that can be used to identify data entry errors in these systems, or in any subsequent systems that VA uses to collect data on vaccinations.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/25/2022
The OIG recommended the under secretary for health make sure that the Power BI dashboard data are reliable, accurate, and complete, and capture all vaccine data more accurately for VA medical facilities in the same healthcare system.
Date Issued
|
Report Number
20-01324-215
|
Topics: System Development and Implementation
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
Director of the Office of Acquisitions, Logistics, and Construction: Ensure the VA Logistics Redesign office revisits its Defense Medical Logistics Standard Support system oversight and deployment processes to align them with VA’s acquisition program management framework requirements.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
Director of the Office of Acquisitions, Logistics, and Construction: Develop processes to better identify unmet high-priority business requirements and post-deployment challenges at the Captain James A. Lovell Health Care Center and future sites and to make certain that solutions are developed and implemented.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
Director of the Office of Acquisitions, Logistics, and Construction: Properly staff the VA Logistics Redesign office with personnel who possess the appropriate subject matter expertise and employ measures to improve continuity in the project management team that oversees the Defense Medical Logistics Standard Support system’s implementation.
Date Issued
|
Report Number
21-00434-233
|
Topics: Appointment Scheduling and Wait Times
● Electronic Health Records Modernization (EHRM)
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)
Closure Date: 12/21/2022
Continue to make improvements to the scheduling training as needed to address feedback from schedulers.
No. 2
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)
Closure Date: 6/22/2023
Require that some schedulers from each clinic fully test the scheduling capabilities of their clinics, solicit feedback from the schedulers to identify system or process issues, and make improvements as needed
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/2/2024
Issue guidance to facility staff on which date fields in the new system schedulers should use to measure patient wait times.
No. 4
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)
Closure Date: 10/27/2022
Develop a mechanism to track and then monitor all tickets related to the new scheduling system, and then ensure the Office of Electronic Health Record Modernization evaluates whether Cerner effectively resolved the tickets within the timeliness metrics established in the contract.
No. 5
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)
Closure Date: 10/27/2022
Develop a strategy to identify and resolve additional scheduling issues in a timely manner as the Office of Electronic Health Record Modernization deploys the new electronic health record at future facilities.
No. 6
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)
Closure Date: 7/14/2023
Develop a mechanism to assess whether facility employees accurately scheduled patient appointments in the new scheduling system, and then ensure facility leaders conduct routine scheduling audits.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 3/13/2024
Evaluate whether patients received care within the time frames directed by Veterans Health Administration policy when scheduled through the new system.
No. 8
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 10/27/2022
Provide guidance to schedulers to consistently address system limitations until problems are resolved.
Date Issued
|
Report Number
20-02908-21
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 1/4/2023
The Executive Director of the Office of Construction and Facilities Management determines whether conducting special reviews should be conducted by the Quality Assurance Service, and if so, establishes policy or procedures to govern this type of work, including standardized processes for communicating and tracking the implementation of recommendations.
Date Issued
|
Report Number
20-03898-236
|
Topics: Claims and Fiduciary
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 6/3/2022
The OIG recommended the under secretary for benefits update the Veterans Benefits Administration’s adjudication procedures manual section related to notices of proposed adverse action to ensure automated notices align with the Veterans Affairs regulation, which requires material facts and detailed reasons for the proposed decision.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 6/3/2022
The OIG recommended the under secretary for benefits amend the language of the automated notices of proposed adverse action to include all material facts and detailed reasons for the proposed decision.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 3/1/2023
The OIG recommended the under secretary for benefits review all automatically completed fiscal year 2020 pension reductions based on Social Security cost of living adjustments to ensure regulations and procedures were followed, including consideration of supplementary medical insurance premiums and all evidence submitted by the beneficiary.
Date Issued
|
Report Number
21-01357-271
|
Topics: Staffing
Date Issued
|
Report Number
20-01802-234
|
Topics: Financial Management
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/19/2023
Coordinate with appropriate officials, including the VA Office of General Counsel, and determine if 38 U.S.C. § 1703(i) and other reimbursement practices cited in this report apply to the reimbursement rates medical facilities should pay for prosthetic and orthotic items provided by vendors. If they do apply, develop and issue guidance requiring medical facilities to adhere to them; if they do not apply, develop and issue guidance on steps medical facilities need to take to ensure they purchase prosthetic and orthotic items at reasonable prices.
No. 2
to Veterans Health Administration (VHA)
Develop and implement effective procedures to monitor prosthetic spending to make sure medical facilities reimburse vendors at reasonable prices for all prosthetic and orthotic items in accordance with updated pricing policies and processes.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/19/2023
Coordinate with appropriate officials such as the Prosthetic and Sensory Aids Service executive director and the executive director, Rehabilitation and Prosthetics Service, to establish a formal oversight structure that defines the roles and responsibilities of those charged with providing oversight of the prosthetics program, rescind handbooks that reflect an outdated oversight structure, and communicate updated oversight expectations to the Veterans Integrated Service Networks to promote consistent program oversight.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 11/9/2023
Resolve National Prosthetics Patient Database limitations and establish requirements to routinely monitor medical facilities’ input of data to improve accuracy.
Total Monetary Impact of All Recommendations
Open: $ 20,000,000.00
Closed: $ 0.00
Date Issued
|
Report Number
21-00044-219