All Reports

Joint Audit of the Department of Defense and the Department of Veterans Affairs Efforts to Achieve Electronic Health Record System Interoperability
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18-04227-91
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Topics:  Electronic Health Records Modernization (EHRM)

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 1/3/2023

We recommend that the Deputy Secretary of Defense and Deputy Secretary of Veterans Affairs review the actions of the Federal Electronic Health Record Modernization Program Office and direct the Federal Electronic Health Record Modernization Program Office to develop processes and procedures in accordance with the Federal Electronic Health Record Modernization Program Office charter and the National Defense Authorization Acts.

Additional Actions Can Help Prevent Benefits Payments from Being Sent to Deceased Veterans
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21-00836-124
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Topics:  Claims and Medical Exams ● Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/20/2022
The under secretary for benefits implements procedures to identify failed automated weekly death matches and demonstrate progress towards processing all failed matches.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/28/2023
The under secretary for benefits implements a process to review the social security number verification program and demonstrate progress towards ensuring the accuracy of social security numbers in VBA’s electronic systems.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/28/2023
The under secretary for benefits implements an intra-agency data-sharing process with the Veterans Health Administration and demonstrate progress in obtaining information on veterans’ deaths.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 677,385.00
Federal Information Security Modernization Act Audit for Fiscal Year 2021
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21-01309-74
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Topics:  FISMA

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology consistently implement an improved continuous monitoring program in accordance with the NIST Risk Management Framework. Specifically, implement an independent security control assessment process to evaluate the effectiveness of security controls prior to granting authorization decisions. (This is a repeat recommendation from prior years.)
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement improved mechanisms to ensure system stewards and Information System Security Officers follow procedures for establishing, tracking, and updating Plans of Action and Milestones for all known risks and weaknesses including those identified during security control assessments. (This is a repeat recommendation from prior years.)
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement controls to ensure that system stewards and responsible officials obtain appropriate documentation prior to closing Plans of Action and Milestones. (This is a repeat recommendation from prior years.)
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology develop mechanisms to ensure system security plans reflect current operational environments, include an accurate status of the implementation of system security controls, and all applicable security controls are properly evaluated. (This is a repeat recommendation from prior years.)
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement improved processes for reviewing and updating key security documents such as security plans, risk assessments, and interconnection agreements on an annual basis and ensure the information accurately reflects the current environment. (This is a repeat recommendation from prior years.)
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement improved processes to ensure compliance with VA password policy and security standards on domain controls, operating systems, databases, applications, and network devices. (This is a repeat recommendation from prior years.)
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement periodic reviews to minimize access by system users with incompatible roles, permissions in excess of required functional responsibilities, and unauthorized accounts. (This is a repeat recommendation from prior years.)
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology enable system audit logs on all critical systems and platforms and conduct centralized reviews of security violations across the enterprise. (This is a repeat recommendation from prior years.)
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Office of Personnel Security, Human Resources, and Contract Offices implement improved processes for establishing and maintaining accurate data within VA’s authoritative system of record for background investigations. (This is a modified repeat recommendation from prior years.)
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Office of Personnel Security, Human Resources, and Contract Offices strengthen processes to ensure appropriate levels of background investigations are completed for applicable VA employees and contractors. (This is a modified repeat recommendation from prior years.)
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement more effective automated mechanisms to continuously identify and remediate security deficiencies on VA’s network infrastructure, database platforms, and web application servers. (This is a repeat recommendation from prior years.)
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement a more effective patch and vulnerability management program to address security deficiencies identified during our assessments of VA’s web applications, database platforms, network infrastructure, and workstations. (This is a repeat recommendation from prior years.)
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology maintain a complete and accurate security baseline configuration for all platforms and ensure all baselines are appropriately monitored for compliance with established VA security standards. (This is a repeat recommendation from prior years.)
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement improved network access controls that restrict medical devices from systems hosted on the general network. (This is a repeat recommendation from prior years.)
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology consolidate the security responsibilities for networks not managed by the Office of Information and Technology, under a common control for each site and ensure vulnerabilities are remediated in a timely manner. (This is a repeat recommendation from prior years.)
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement improved processes to ensure that all devices and platforms are evaluated using credentialed vulnerability assessments. (This is a repeat recommendation from prior years.)
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Acting Assistant Secretary for Information and Technology implement improved procedures to enforce standardized system development and change control processes that integrates information security throughout the life cycle of each system. (This is a repeat recommendation from prior years.)
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology review system boundaries, recovery priorities, system components, and system interdependencies and implement appropriate mechanisms to ensure that established system recovery objectives can be measured and met. (This is a modified repeat recommendation from prior years.)
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology ensure that contingency plans for all systems are updated to include critical inventory components and are tested in accordance with VA requirements. (This is a repeat recommendation from prior years.)
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement more effective agency-wide incident response procedures to ensure timely notification, reporting, updating, and resolution of computer security incidents in accordance with VA standards. (This is a repeat recommendation from prior years.)
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology ensure that VA’s Cybersecurity Operations Center has full access to all security incident data to facilitate an agency-wide awareness of information security events. (This is a repeat recommendation from prior years.)
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement improved safeguards to identify and prevent unauthorized vulnerability scans on VA networks. (This is a repeat recommendation from prior years.)
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement improved measures to ensure that all security controls are assessed in accordance with VA policy and that identified issues or weaknesses are adequately documented and tracked within POA&Ms. (This is a repeat recommendation from prior years.)
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology fully develop a comprehensive list of approved and unapproved software and implement continuous monitoring processes to prevent the use of prohibited software on agency devices. (This is a repeat recommendation from prior years.)
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology develop a comprehensive inventory process to identify connected hardware, software, and firmware used to support VA programs and operations. (This is a repeat recommendation from prior years.)
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement improved procedures for monitoring contractor-managed systems and services and ensure information security controls adequately protect VA sensitive systems and data. (This is a repeat recommendation from prior years.)
Noncompliant and Deficient Processes and Oversight of State Licensing Board and National Practitioner Data Bank Reporting Policies by VA Medical Facilities
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20-00827-126
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Topics:  Medical Staff Privileging Credentialing ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2024

The Under Secretary for Health reviews the State Licensing Board reporting processes at the facility level to ensure compliance with Veterans Health Administration policy, identifies noncompliance, and takes action as warranted.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health ensures that the National Practitioner Data Bank facility reporting practices align with federal regulations and Veterans Health Administration policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2024

The Under Secretary for Health instructs facility directors to submit National Practitioner Data Bank reports regarding physicians and dentists consistent with Veterans Health Administration policy.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2025

The Under Secretary for Health ensures programmatic oversight of facility State Licensing Board and National Practitioner Data Bank reporting processes.

Improved Governance Would Help Patient Advocates Better Manage Veterans’ Healthcare Complaints
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21-00510-105
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Topics:  Healthcare Infrastructure

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2024

Review and update, as appropriate, program policy to formally align with the Office of Patient Advocacy’s program expectations, including when complaints must be entered into a patient advocate tracking system and the responsibilities of patient advocate supervisors.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2023
Implement controls that require facility patient advocate supervisors and Veterans Integrated Service Network patient advocate coordinators to perform regular, documented reviews of records in the patient advocate tracking system to monitor that the required information is entered properly.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2024

Provide guidance to medical facility directors to ensure they fulfill their required Patient Advocacy Program management duties, including timely complaint resolution and trending complaint data.

Public Disability Benefits Questionnaires Reinstated but Controls Could Be Strengthened
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21-02750-63

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/11/2022
Revise the Veterans Benefits Administration’s adjudication procedures manual to clarify and communicate steps that claims processors must take to ensure all certification elements on the publicly available disability benefits questionnaires are provided and are authentic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/11/2022
Update the Veterans Benefits Administration’s adjudication procedures manual to clarify the intent of guidance involving authenticity, face value, and validation of publicly available disability benefits questionnaires to ensure claims processors evaluate the questionnaires in accordance with evidentiary principles
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/26/2022
Implement actions to facilitate claims processors’ understanding of the need to document the evaluation of evidence within benefits entitlement decisions when using publicly available disability benefits questionnaires.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/21/2022
Amend the Veterans Benefits Administration’s adjudication procedures manual to define valid rationale to ensure medical opinions are well supported when deciding entitlement to benefits.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/30/2024

Correct all processing errors on cases identified by the review team and report the results to the Office of Inspector General.

Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 88,700.00
First-Party Billing Address Management Needs Improvement to Ensure Veteran Debt Notification before Collection Actions
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20-03086-70
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Topics:  Healthcare Infrastructure

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2025

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
Closed and Implemented Recommendation Image, Checkmark
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

Audit of Community Care Consults during COVID-19
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21-00497-46
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Topics:  COVID-19 ● Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
VA’s Use of the Defense Logistics Agency’s Electronic Catalog for Medical Items
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20-00552-30
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Topics:  Financial Management ● Supplies and Equipment

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
MISSION Act Market Assessments Contain Inaccurate Specialty Care Workload Data
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20-03351-08

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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.

Inadequate Oversight of VHA’s Home Oxygen Program
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19-07812-29
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Topics:  Supplies and Equipment

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Financial Efficiency Review of the Eastern Oklahoma VA Health Care System
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21-00942-16
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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: 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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Improvements Needed to Ensure Final Disposition of Unclaimed Veterans’ Remains
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19-09592-262

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Follow-Up Review of the Accuracy of Special Monthly Compensation Housebound Benefits
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20-04219-07
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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: 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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
VHA Improperly Paid and Reauthorized Non-VA Acupuncture and Chiropractic Services
|
20-01099-249
|
Topics:  Community Care ● Financial Management

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Open Recommendation Image, Square
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
VHA Risks Overpaying Community Care Providers for Evaluation and Management Services
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21-01807-251
|
Topics:  Community Care ● Financial Management

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
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
Closed and Implemented Recommendation Image, Checkmark
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
Systems and Tools Implemented to Track COVID-19 Vaccine Data
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21-00913-267
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Topics:  COVID-19

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
New Patient Scheduling System Needs Improvement as VA Expands Its Implementation
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21-00434-233
|
Topics:  Appointment Scheduling and Wait Times ● Electronic Health Records Modernization (EHRM)

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.

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