All Reports

Excess Purchase of Surgical Supplies and Improper Purchase Card Transactions at the New Orleans VA Medical Center in Louisiana
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20-00395-224
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Topics:  Supplies and Equipment ● Purchase Cards

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2022
The OIG recommended the Southeast Louisiana Veterans Health Care System director account for the disposition of just over $125,000 in unaccounted for supplies in accordance with VA policies.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2022
The OIG recommended the Southeast Louisiana Veterans Health Care System director determine if any administrative action should be taken on just over $675,000 in unaccounted-for supplies listed in the report of survey.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/28/2022
The OIG recommended the Southeast Louisiana Veterans Health Care System director ensure Federal Acquisition Regulation violations that resulted when purchase cards were used to acquire the approximately $1.9 million of supplies are reported to the Financial Services Center, and appropriate remedies, discipline, or penalties are taken in accordance with VA Financial Policy, Volume XVI.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/28/2022
The OIG recommended the Southeast Louisiana Veterans Health Care System director request the Veterans Health Administration’s head of contract activity ratify the approximately $1.9 million of identified split purchases.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2022
The OIG recommended the Southeast Louisiana Veterans Health Care System director ensure appropriate medical center employees coordinate with and obtain guidance from National Purchase Card Program staff when they are uncertain if they are properly using government purchase cards.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2022
The OIG recommended the Southeast Louisiana Veterans Health Care System director ensure leased operating room equipment is returned to the contractor as soon as possible if there are no plans to use that operating room for at least one year.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 3,145,291.00
Failure to Locate Missing Veteran Found Dead at a Facility on the Bedford VA Hospital Campus
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20-03465-243
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Topics:  VA Police

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The under secretary for health makes certain that policies and procedures are developed to require VA police, and other VHA staff as appropriate, to conduct searches for all persons who are reported missing on medical center campuses.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 8/31/2022
The executive director of the Office of Security and Law Enforcement updates VA Handbook 0730 with revisions clarifying VA police responsibilities with respect to searching for persons who are reported missing on VA property.
No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The assistant under secretary for health for operations, in consultation with the VA chief security officer, requires VA police chiefs at medical centers to obtain approval from the facility associate director or the medical center director prior to excluding a building or area of the medical center’s campus from regular patrols, and, if the building or area is subject to an enhanced-use lease, confirms with the Office of Enterprise Asset Management and the Office of General Counsel that the exclusion is not in conflict with the terms of the lease.
No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
For all medical centers that have property subject to enhanced-use leases, the assistant under secretary for health for operations, in consultation with the VA chief security officer, requires the medical center director or the director’s designee to meet with the assigned oversight monitor at the Office of Asset Enterprise Management, the designated local site monitor, and a representative of the Office of General Counsel at least annually—or sooner if there is a change of lease terms or facility leadership—to discuss the terms of the enhanced-use leases and the lessee’s and VA’s responsibilities with respect to the leased properties.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Asset Enterprise Management (OAEM)
Closure Date: 1/28/2022
The executive director of the Office of Asset Enterprise Management includes a copy of the lease and VA Handbook 7454 with the designation memorandum sent to newly appointed lease site monitors.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Asset Enterprise Management (OAEM)
Closure Date: 4/11/2023
The executive director of the Office of Asset Enterprise Management, in conjunction with the Office of General Counsel, reviews all active enhanced-use leases to determine whether any involve portions of buildings also occupied by VA, and, if so, whether they are clear regarding the maintenance and security obligations.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Asset Enterprise Management (OAEM)
Closure Date: 4/11/2023
The executive director of the Office of Asset Enterprise Management modifies its existing Annual Oversight Compliance Certificate policies to include a review of VA’s performance with respect to any services VA is required to provide under the terms of enhanced-use leases.
Blue Water Navy Outreach Requirements Were Met, but Claims Processing and Procedures Could Improve
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20-03938-208
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Topics:  Claims and Appeals

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/2/2021
The OIG recommendated the under secretary for benefits develop and distribute procedures for when the ship locator tool provides results based on deck log coordinates for unlikely locations of herbicide exposure.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/7/2022
The OIG recommended the under secretary for benefits determine and execute additional actions to ensure employees processing Blue Water Navy claims understand how to accurately evaluate and decide herbicide-related medical conditions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/27/2021
The OIG recommended the undersecretary for benefits implement a plan for centralized regional offices to conduct local reviews on the accuracy of rating decisions involving herbicide-related medical conditions that will mitigate error trends identified.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 37,200,000.00
Improvements Still Needed in Processing Military Sexual Trauma Claims
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20-00041-163
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Topics:  Military Sexual Trauma

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/22/2022
Establish and implement a formal procedure to ensure all processing errors on claims identified by the review team are corrected and report the results to the OIG.
No. 2
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 4/30/2025

Develop, implement, and monitor a written plan to address continuing military sexual trauma claims processing deficiencies identified by the review team, including reassessing previously decided claims when appropriate, and report the results to the OIG.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2023
Strengthen controls to effectively implement and promote compliance with 2018 OIG report recommendations related to military sexual trauma claims.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2023
Develop, implement, and monitor a written plan that requires the Compensation Service and the Office of Field Operations to strengthen communication, oversight, and accountability of military sexual trauma claims processing.
Contracted Residence Programs Need Stronger Monitoring to Ensure Veterans Experiencing Homelessness Receive Services
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19-08267-147
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Topics:  Clinical Care Services Operations

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2022
Establish control mechanisms at the Veterans Integrated Service Network and Contracted Residential Services program levels to ensure Contracted Residential Services staff at medical facilities comply with Veterans Health Administration Handbook 1162.09 requirements for monitoring and documentation.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2022
Direct Network Contracting Offices to establish controls to verify contracting officers meet with contracting officer’s representatives on at least a quarterly basis to evaluate contractor performance and document the meetings.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/14/2022
Direct Network Contracting Offices for all Contracted Residential Services contracts to ensure contracting officers include quality assurance surveillance plans and promptly issue letters of delegation to staff who have been nominated to be contracting officer’s representatives.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2022
Update Veterans Health Administration Handbook 1162.09 to incorporate unannounced site visits to the extent possible during annual inspections and quarterly evaluations.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2022
Update Veterans Health Administration Handbook 1162.09 to include guidance on paying for veteran absences and make certain these requirements are reflected in contracts and surveillance plans.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 35,300,000.00
VBA’s Fiduciary Program Needs to Improve the Timeliness of Determinations and Reimbursements of Misused Funds
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20-00433-168
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Topics:  Claims and Fiduciary
Related Media: Video

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/21/2021
The OIG recommended the under secretary for benefits implement a mechanism for ensuring negligence determinations subsequent to December 31, 2017, are completed promptly and monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/6/2022
The OIG recommended the under secretary for benefits implement a mechanism for ensuring reimbursements subsequent to December 31, 2017, are completed promptly and monitor compliance.
Adaptive Sports Grants Management Needs Improvement
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20-01807-173
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Topics:  Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2024

The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director develop standard operating procedures for all processes related to managing the adaptive sports grants program.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director develop and train current staff and identify and hire staff specialized in grants management.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/30/2024

The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director establish and execute a plan to evaluate risks posed by grant applicants before awarding grants, in accordance with VA financial policy.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2024

The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director establish procedures to ensure the timely reimbursement of grant recipient expenses.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2024

The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director establish grant closeout procedures that include communicating timelines with the grant recipients, documentation requirements for proper grant closeout, availability of grant funds, and a process to approve modification and extension requests.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2024

The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director act to ensure all adaptive sports grants are closed out on time.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2024

The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director determine, in coordination with VA’s Office of Finance and Office of General Counsel, whether a Purpose Statute violation occurred, whether account adjustments need to be made, whether Antideficiency Act violations occurred, and report any Purpose Statute and Antideficiency Act violations.

Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 247,000.00
VBA Overpaid Veterans Due to Delays in Reducing Compensation Benefits
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20-03229-155

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/18/2021
Establish, document, and implement a workload management strategy to distribute and process proposals to reduce benefits that minimizes delays and excessive payments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/18/2021
Develop, document, and implement a formal procedure to routinely monitor the workload management strategy to ensure it minimizes delays and excessive payments.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 348,000,000.00
Inadequate Financial Controls and Payments Related to VA-Affiliated Nonprofit Corporations
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20-03704-165
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Topics:  Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2022
Establish procedures at all facilities with affiliated nonprofit corporations to help ensure VA medical center Research and Development Budget Office staff review nonprofit corporation invoice documentation and confirm services were performed before approving payment.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2022
Establish procedures for Research and Development Budget Office supervisors at all the VA medical centers with affiliated nonprofit corporations that ensure periodic reviews are conducted of invoices authorized for payment, confirming that staff verified services were performed before approving payments.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/15/2022
Ensure the Nonprofit Program Office invoice review procedures incorporate verification that affiliated nonprofit corporations include evidence that services were provided with invoices submitted to VA.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 17,900,000.00
Unreliable Information Technology Infrastructure Cost Estimates for the Electronic Health Record Modernization Program
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20-03185-151
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Topics:  Electronic Health Records Modernization (EHRM) ● System Development and Implementation

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 11/9/2022

Ensure an independent cost estimate is performed for program life-cycle cost estimates related to information technology infrastructure costs.

No. 2
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

Reassess the cost estimate for Electronic Health Record Modernization program-related information technology infrastructure and refine as needed to comply with VA’s cost-estimating standards. 

No. 3
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

Develop procedures for cost-estimating staff that align with VA cost-estimating guidance.

No. 4
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

Ensure costs for all information technology infrastructure upgrades funded by the Office of Information and Technology and the Veterans Health Administration or other sources needed to support the Electronic

No. 5
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

Formalize agreements with the Office of Information and Technology and the Veterans Health Administration identifying the expected contributions from each entity toward information technology infrastructure upgrades in support of the Electronic Health Record Modernization program.

No. 6
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

Establish procedures that identify when life-cycle cost estimates should be updated and ensure those updated estimates are disclosed in the program’s congressionally mandated reports.

VHA Made Inaccurate Payments to Part-Time Physicians on Adjustable Work Schedules
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20-01646-139
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Topics:  Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2025

Ensure payroll personnel complete overdue reconciliations of part-time physicians on adjustable work schedule agreements and take any necessary actions to address overpayments and underpayments.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Establish oversight procedures to make certain that part-time physicians submit and validate their subsidiary time sheets and that supervisors promptly certify the time sheets.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/5/2024

Train newly assigned payroll personnel on agreement reconciliation procedures and develop follow-up procedures to prevent missed reconciliations because of staff turnover.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2024

Implement procedures to confirm service chiefs conduct quarterly reviews of all adjustable work hour agreements that include identifying physicians with significant variances from the agreements or indicators that the cap on part-time hours is likely to be exceeded and taking corrective actions.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2024

Document oversight procedures for monitoring and validating compliance with the requirements of the part-time physician on adjustable work schedules program.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2025

Direct the program office, in coordination with the VA Office of General Counsel, to determine whether medical centers committed Antideficiency Act violations by not correcting underpayments and preventing physicians from working above the annual limit of 1,820 hours.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Establish oversight procedures for monitoring and validating their medical centers’ compliance with the requirements of the part-time physician on adjustable work schedules program.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 2/8/2022
Complete overdue reconciliations of part-time physicians on adjustable work schedule agreements and take any necessary actions to address overpayments and underpayments.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 2/8/2022
Document oversight procedures for monitoring and validating that all reconciliations and payment corrections are completed when agreements expire or are terminated.
Total Monetary Impact of All Recommendations
Open: $ 16,600,000.00
Closed: $ 0.00
Inadequate Oversight of Contractors’ Personal Identity Verification Cards Puts Veterans’ Sensitive Information and Facility Security at Risk
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20-00345-77
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Topics:  Contract Integrity

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to ensure contracting officers obtain and maintain evidence of contractor-provided lists of all personal identity verification cards issued to contractor employees.
No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to ensure contracting officers maintain evidence documenting personal identity verification cards were returned to the issuing or designated office when the cards were no longer required and prior to closing the contract.
No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to evaluate the role of contracting officer’s representatives in the personal identity verification card process for contractor employees and assess whether updates to their letter of delegation and standard operating procedures are necessary.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/3/2023
The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to establish policies and procedures outlining specific supervisory responsibilities for contracting officer oversight in accordance with the Government Accountability Office Standards for Internal Controls in the Federal Government.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2025

The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to assess the contract completion statement template to determine whether to include the contractor-related personal identity verification card requirements.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to establish procedures within the Procurement Audit Office for periodic reviews of contract files to determine compliance with the personal identity verification card requirements established in the Federal Acquisition Regulation and the Veterans Health Administration procurement manual. Further, require the results of these reviews to be reported to senior management to help determine whether corrective actions are required.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2025

The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to determine whether existing or planned systems can have the functionality to allow management to effectively and routinely monitor contractor employee personal identity verification cards or whether a new system should be established.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to assess whether contracting officers should be required to include the contractor-provided list as an explicit requirement in all Veterans Health Administration contracts that require issuance of personal identity verification cards to contractor employees.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2025

The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to establish procedures to ensure contracting officers include Federal Acquisition Regulation clause 52.204-9, “Personal Identity Verification of Contractor Personnel,” in contracts when required.

No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2025

The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to consider directing contracting officers to delay final payment to contractors on future contracts until all personal identity verification cards have been returned.

Deficiencies in Emergency Preparedness for Veterans Health Administration Telemental Health Care at VA Clinic Locations Prior to the Pandemic
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19-09808-171
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Topics:  Mental Health ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/18/2022
The Under Secretary for Health ensures the Office of Connected Care Telehealth Services and the Office of Mental Health and Suicide Prevention collaborate to develop a consistent process for facility implementation of telehealth emergency plans tailored for telehealth care and the patient-clinic locations that are inclusive of procedures addressing mental health and medical emergencies and technological disruptions during telemental health care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/18/2022
The Under Secretary for Health verifies the Office of Connected Care Telehealth Services reviews and implements oversight of telehealth emergency plan processes to include expectations for updating and monitoring.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/8/2022
The Under Secretary for Health confirms the Office of Connected Care Telehealth Services develops consistent processes for healthcare systems to define and communicate individual telehealth staff responsibilities during telehealth emergencies, specific to the patient-clinic locations.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/8/2022
The Under Secretary for Health ensures the Office of Connected Care Telehealth Services has a consistent process for healthcare systems to develop, maintain and communicate accurate, patient-clinic location specific telehealth emergency contact information to all telehealth staff, to include remote providers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/2/2022
The Under Secretary for Health collaborates with the Office of Connected Care Telehealth Services to develop a streamlined process to report patient safety events specific to telehealth that clearly identifies the setting and specific service line to allow tracking, trending, and monitoring.
Veterans Cemetery Grants Program Did Not Always Award Grants to Cemeteries Correctly and Hold States to Standards
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20-00176-125

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 11/4/2021
The OIG recommended the under secretary for memorial affairs develop controls to ensure state grants are prioritized and awarded in accordance with the Code of Federal Regulations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 11/4/2021
The OIG recommended the under secretary for memorial affairs develop and implement written policies and procedures for grant prioritization.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 11/15/2022
The OIG recommended the under secretary for memorial affairs evaluate all current national headstone and niche cover contracts for appropriate penalties and clauses for timeliness and quality issues and enforce and amend those contracts as necessary.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 5/11/2022
The OIG recommended the under secretary for memorial affairs direct the Improvement and Compliance Service to assign levels of importance to standards and measures used for compliance reviews and test the inscription accuracy of all gravesites sampled.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 2/7/2024

The OIG recommended the under secretary for memorial affairs require all state and tribal cemeteries to submit certified condition and operations performance assessments annually.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 5/11/2022
The OIG recommended the under secretary for memorial affairs ensure representatives from all state and tribal cemeteries are provided opportunities to participate in National Cemetery Administration standards training via remote training options and monitor all training to ensure adequate participation.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 11/4/2021
The OIG recommended the under secretary for memorial affairs continue to seek an increase in cemetery grant funding in excess of $45 million
No. 8
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 11/4/2021
The OIG recommended the under secretary for memorial affairs ensure that the Improvement and Compliance Service follows up with Hawaiian cemeteries after action plans are submitted to ensure deficiencies are corrected.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 11/4/2021
The OIG recommended the under secretary for memorial affairs implement controls to ensure cemeteries that receive provisionally compliant or noncompliant scores during reviews are followed up with on a fixed and regular basis until sufficient corrective action plans are submitted.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 3/4/2024

The OIG recommended the under secretary for memorial affairs use accountability measures in the Code of Federal Regulations when appropriate if grantees do not take adequate steps to correct significant long standing deficiencies.

No. 11
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 8/16/2023
The OIG recommended the under secretary for memorial affairs work with the State of Hawaii Office of Veterans’ Services to conduct an extensive assessment of all eight Hawaii state veterans cemeteries, including organizational oversight and operations, staffing needs (including training), gravesite marker accuracy, and grounds conditions.
VHA Needs More Reliable Data to Better Monitor the Timeliness of Emergency Care
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20-01141-145
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Topics:  Appointment Scheduling and Wait Times

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/15/2022
The OIG recommended the under secretary for health ensure Baltimore VA Medical Center leaders reevaluate their corrective action plan and adjust as needed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/15/2022
The OIG recommended the under secretary for health make certain relevant staff receive appropriate training on recording wait times in the software.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2022
The OIG recommended the under secretary for health strengthen reliability reviews of Emergency Department Integration Software data to mitigate the risk of inaccurate records.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2023
The OIG recommended the under secretary for health establish routine oversight responsibilities for Veterans Integrated Service Network and facility leaders of emergency departments’ efforts to improve the reliability of their emergency department data.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/15/2022
The OIG recommended the under secretary for health improve the monitoring of data for patients with the highest Emergency Severity Index levels of one or two receiving emergency care services.
Improvements Needed in Adding Non-VA Medical Records to Veterans’ Electronic Health Records
|
19-08658-153
|
Topics:  Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/8/2023
Ensure facilities create and implement standard operating procedures that clearly define all Health Information Management and community care staff responsibilities and the procedures for accurately scanning, importing, and indexing non-VA medical records.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/8/2023
Require facility directors ensure that Health Information Management leaders provide or formally delegate training, quality checks, and quality assurance monitoring for community care staff responsible for medical record management.
Stronger Financial Management Practices Are Needed at VA's Maryland Health Care System
|
19-07719-113
|
Topics:  Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2024

The OIG recommended the Maryland Health Care System director implement internal controls for healthcare system staff to submit and document approvals for all equipment requests in the Enterprise Equipment Request Portal before ordering and paying for equipment.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/14/2022
The OIG recommended the Maryland Health Care System director implement a control requiring staff to justify the waiver of any healthcare system approvals ordinarily required to purchase equipment in the Enterprise Equipment Request Portal.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/11/2022
The OIG recommended the Maryland Health Care System director inform the deputy under secretary for health for operations and management for procurement and logistics of the internal control weakness in the Enterprise Equipment Request Portal and request a response regarding whether corrective action is necessary.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2021
The OIG recommended the Maryland Health Care System director require the logistics service to develop a plan for working with the prime vendor to ensure historical and current estimated supply data are timely, accurate, and meet healthcare system supply requirements.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2021
The OIG recommended the Maryland Health Care System director ensure the logistics service implements a plan to monitor for and correct unit conversion factor errors consistently and promptly.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2024

The OIG recommended the Maryland Health Care System director establish processes and controls for cardholders to comply with the record retention requirements in the Federal Acquisition Regulation and VA’s Financial Policy, Volume XVI, “Charge Card Program.”

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2023
The OIG recommended the Maryland Health Care System director ensure all staff are provided clear guidance on overtime approval and payment policies and procedures that meet VA requirements.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/8/2023
The OIG recommended the Maryland Health Care System director implement policies and procedures for supervisors to effectively monitor overtime worked and maintain documentation required to support related payments.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 5,552,000.00
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