All Reports

Date Issued
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Report Number
20-03075-138
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Topics:  COVID-19

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2023
The under secretary for health direct the Medical Supplies Program Office to provide Veterans Integrated Service Network and VA medical facility chief logistics officers guidance on how to use and monitor the emergency and continuous supply strategies offered in prime vendors’ contingency plans to help mitigate acute emergency and continuous supply shortages during the current pandemic and future emergencies.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 1/6/2023
The Office of Acquisition, Logistics, and Construction direct the Strategic Acquisition Center’s Medical/Surgical Prime Vendor Program contracting officer to provide guidance to Veterans Integrated Service Network and VA medical facilities’ program contracting officer’s representatives on the emergency and continuous supply provisions in the contracts, and ensure contracting officers’ representatives inform network and facility managers of the strategies offered by the prime vendors.
Date Issued
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Report Number
20-02967-121
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Topics:  COVID-19

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2023
The OIG recommends that the Principle Deputy Under Secretary for Health coordinate with VA’s Office of Management to implement internal control procedures to ensure the completeness and accuracy of the data in VA’s reports to the Office of Management and Budget and to Congress.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2023
The OIG recommends that the Principle Deputy Under Secretary for Health coordinate with VA’s Office of Management to execute data validation procedures to make certain that reports to the Office of Management and Budget and to Congress can be traced back efficiently to the source transactions.
Date Issued
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Report Number
20-00541-133
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Topics:  Staffing

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No. 1
Open Recommendation Image, Square
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
The OIG recommended the acting assistant secretary for human resources and administration/operations, security, and preparedness develop and implement an enterprise wide plan to independently examine and validate the HR Smart position inventory.
No. 2
Open Recommendation Image, Square
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
The OIG recommended the acting assistant secretary for human resources and administration/operations, security, and preparedness establish standard guidance to ensure positions are consistently approved, created, and maintained.
No. 3
Open Recommendation Image, Square
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
The OIG recommended the acting assistant secretary for human resources and administration/operations, security, and preparedness implement enterprise wide oversight mechanisms to monitor position management on a regular basis and ensure the HR Smart position inventory is properly maintained.
No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The OIG recommended the acting under secretary for health develop and implement a standardized national policy and procedures for the documentation and communication of staffing level approvals at VA medical facilities.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/31/2023
The OIG recommended the acting under secretary for health publish detailed and prescriptive guidance establishing authoritative position management documents.
Date Issued
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Report Number
20-03326-124
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Topics:  COVID-19 ● Supplies and Equipment

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2023
The OIG recommended that the under secretary for health initiate efforts to revise or amend VHA Directive 1047 to clarify when changes to emergency cache activation procedures are appropriate, and develop the communication and documentation requirements for these situations to ensure all relevant parties—including medical facility directors and pharmacy chiefs—are aware of and comply with any changes to routine activation protocols as well as the responsibilities they maintain.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2023
The OIG recommended that the under secretary for health establish minimum time frames, for example by assessing Emergency Pharmacy Service’s data on the typical length of time it takes to replenish emergency cache inventory items, by which the Emergency Pharmacy Service initiates resupply orders to make sure caches are fully stocked with unexpired inventory.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2023
The OIG recommended that the under secretary for health make sure that the Emergency Pharmacy Service and the Watch Office are maintaining accurate and complete records of emergency cache activations.
Date Issued
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Report Number
20-00178-24
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Topics:  System Development and Implementation

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 11/8/2021
The OIG recommended the acting assistant secretary for information and technology, in conjunction with the acting under secretary for health, establish policies and procedures for joint governance by OIT and program offices on all information.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 11/8/2021
The OIG recommended the acting assistant secretary for information and technology require the Office of Information and Technology to develop controls for making certain the program management review process is consistently enforced for future information technology projects to deliver and sustain the intended outcomes and to ensure underperforming projects are identified for evaluation by the Program and Acquisition Review Council.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 11/8/2021
The OIG recommended the acting assistant secretary for information and technology, in conjunction with the acting under secretary for health, reevaluate the risk determination for the Caregiver Record Management Application and determine if the system should be set to a security categorization level of high based on the personal health information and other sensitive data maintained therein.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 11/8/2021
The OIG recommended the acting assistant secretary for information and technology establish VA wide policies and responsibilities for managing VA information technology projects under the Development Operations process.
Date Issued
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Report Number
20-00817-123

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/14/2021
Implement a timeliness requirement or performance measure for handling proceeds.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/27/2021
Develop oversight and monitoring procedures to ensure timely handling of proceeds.
Date Issued
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Report Number
20-03178-116
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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

The executive director for the Office of Electronic Health Record Modernization should ensure an independent cost estimate is performed for program life cycle cost estimates including related physical infrastructure costs funded by the Veterans Health Administration.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/9/2022

The VA Assistant Secretary for Management and Chief Financial Officer  should ensure the Office of Programming, Analysis and Evaluation, or another office performing its duties, conducts independent cost 

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2022

 The director of Special Engineering Projects for the Veterans Health  Administration’s Office of Healthcare Environment and Facilities Programs should develop a  reliable cost estimate for Electronic Health Record Modernization program-related physical  infrastructure in accordance with VA cost-estimating standards and incorporate costs for upgrade  needs identified in facility self-assessments and scoping sessions.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2022

The director of Special Engineering Projects should also continuously update physical infrastructure cost estimates based on emerging requirements and identified project needs.

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

Ensure costs for physical infrastructure upgrades funded by the Veterans Health Administration or other sources needed to support the Electronic Health Record Modernization program are disclosed in program life cycle cost estimates presented to Congress.

Date Issued
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Report Number
20-00049-122

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/10/2023
Develop and implement a written plan to strengthen oversight of the quality assurance program for disability compensation benefits and monitor the plan to ensure identified deficiencies are adequately addressed.
Date Issued
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Report Number
20-01927-104
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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: 4/13/2022
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.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/13/2022
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.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/13/2022
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.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/13/2022
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.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/13/2022
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.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/13/2022
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.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/13/2022
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.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/13/2022
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.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/13/2022
We recommended the Office of Personnel Security strengthen processes to ensure appropriate levels of background investigations are completed for applicable VA employees and contractors and applicable investigation data is accurately tracked within the authoritative system of record.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/13/2022
We recommended the Office of Personnel Security formalize the Position Descriptions and methodology used within the Human Resource business processes to ensure that employees with similar positions are required to have the same level of background investigation.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/13/2022
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.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/13/2022
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.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/13/2022
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 implemented for compliance with established VA security standards.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/13/2022
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.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/13/2022
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.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/13/2022
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.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/13/2022
We recommended the 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.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/13/2022
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 are met.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/13/2022
We recommended the Assistant Secretary for Information and Technology ensure contingency plans for all systems and applications are updated and tested in accordance with VA requirements.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/13/2022
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.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/13/2022
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.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/13/2022
We recommended the Assistant Secretary for Information and Technology implement improved safeguards to identify and prevent unauthorized vulnerability scans on VA networks.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/13/2022
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.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/13/2022
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.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/13/2022
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.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/13/2022
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.
Date Issued
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Report Number
19-06147-50
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Topics:  Supplies and Equipment ● Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/23/2024

Direct the Medical Supplies Program Office to implement procedures requiring chief logistics officers at Veterans Integrated Service Networks to monitor facility processes for verification and certification of distribution fee invoices to ensure invoice accuracy prior to payment by the Financial Services Center.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/11/2025

Require Veterans Integrated Service Network directors to ensure their chief logistics officers develop distribution fee monitoring and review procedures for facility logistics audits and compliance reviews to ensure invoices are adequately reviewed, verified, and certified.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/31/2023
Require Veterans Integrated Service Network directors to ensure facility chief logistics officers and contracting officer’s representatives review and update the election forms according to contract requirements and provide copies to the Medical/Surgical Prime Vendors for acknowledgment.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/11/2025

Require Veterans Integrated Service Network directors to ensure facility contracting officer’s representatives verify that distribution fee rates match with those on the election forms and pricing schedule by comparing transaction data from the vendors to VHA-maintained transaction data, and reconcile payments as appropriate.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 3/25/2022
Require the Strategic Acquisition Center to develop and add modifications to the Medical/ Surgical Prime Vendor-Next Generation contract requiring prime vendors to provide reports to VA medical facilities with detailed medical and surgical transaction data, fee amounts, and fee percentage rates applied to each transaction on distribution fee invoices.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 3/25/2022
Require the Strategic Acquisition Center contracting officer to work with the Medical Supplies Program Office to ensure that Medical/Surgical Prime Vendor contracting officer’s representatives are assigned to each VA medical facility.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 5/2/2022
Require the Strategic Acquisition Center to appropriately modify the Medical/Surgical Prime Vendor contract to define annual facility purchase as well as adding a provision for paying the annual facility purchase amount based on the estimated total spend until year-end reconciliation.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 5/2/2022
Require the Strategic Acquisition Center to also appropriately modify the Medical/ Surgical Prime Vendor contract to require the prime vendors—rather than the facility—to reconcile to annual facility purchases at the end of the year.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/31/2023
Require the Medical Supplies Program Office to establish policy that clearly defines the source VA medical facilities should use to estimate their annual facility purchase amounts and determine the year-end amounts.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2024

Require VA medical facilities to review their on-site representative fees paid during fiscal year 2018 and future years to ensure they were paid based on the actual annual facility purchase amounts, consistent with the Medical/Surgical Prime Vendor-Next Generation contract, and reconcile payment discrepancies as appropriate.

Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 3,700,000.00
Date Issued
|
Report Number
20-00421-63

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/10/2024

The under secretary for benefits creates written guidelines for tracking, identifying, notifying, registering, and exempting individuals required to take skills certification tests.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/10/2024

The under secretary for benefits establishes a tracking mechanism to ensure all eligible individuals required to take tests are identified and notified of testing dates at least 30 days prior to test administration.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/25/2023
The under secretary for benefits provides an update to the plan submitted to Congress explaining why all employees and supervisors who have claims-processing functions listed in the original plan are not subject to skills certification testing.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/10/2024

The under secretary for benefits implements a plan to ensure staff who failed their most recent skills certification test and remain in the same position are provided training from individual training plans to remediate the deficiencies in their skills and competencies.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/10/2024

The under secretary for benefits establishes an oversight plan to ensure training set out in approved training plans is provided to individuals who fail skills certification tests.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/5/2023

The under secretary for benefits notifies Congress of plans to take personnel actions against individuals who fail consecutive skills certification tests after remediation for the same positions in compliance with the Honoring America’s Veterans and Caring for Camp Lejeune Families Act of 2012.

Date Issued
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Report Number
19-06902-23
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Topics:  Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2021
The OIG recommended the under secretary for health ensures the Payment Operations and Management directorate reevaluates all sample claims identified in this audit as not processed in accordance with Office of Community Care guidance, and takes appropriate corrective action as needed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2022
The OIG recommended the under secretary for health ensures there is a contract requirement that the contractor’s employees must follow Office of Community Care guidance for processing non-VA care claims.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2022
The OIG recommended the under secretary for health ensures the contractor’s standard operating procedures for claims processing are accurate and a mechanism is put in place to keep the contractor’s procedures updated to reflect current Office of Community Care claims processing procedures.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2021
The OIG recommended the under secretary for health ensures the Office of Community Care develops and implements clear controls for reviewing and updating, if necessary, the quality assurance surveillance plan requirements at least annually
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2021
The OIG recommended the under secretary for health ensures the Payment Operations and Management personnel make full use of the established communication tracking tool.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/2/2021
The OIG recommended the under secretary for health ensures the Payment Operations and Management leaders provide timely training and additional guidance to their staff and the contractor’s employees on applying and using standardized denial and rejection reasons, and employees follow procedures to process claims with no authorizations to ensure consistent and accurate claims processing.
Date Issued
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Report Number
19-07053-51
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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: 11/29/2021
Provide clarifying guidance and controls to clinic staff on making determinations to send purchase requests and consult notifications to the appropriate purchasing agents.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2021
Provide clarifying guidance to purchasing agents on how to effectively evaluate biologic implant purchase requests for the correct funding source.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2021
Provide clarifying guidance to prosthetic agents to ensure they receive clinic staff consult notifications on all prosthetic purchases of biologic implants.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2022
Create a biologic implant cost code for general-purpose funds to improve funding accountability and potentially assist in ensuring all biologic implant use is tracked.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2021
Direct the Procurement and Logistics Office to clarify guidance on the use of an approved inventory management system specific to biologic implants and the related VHA network, office, and facility staff responsibilities.
No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Monitor facility compliance with the use of an approved inventory management system for completeness and accuracy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/5/2023
Direct the Procurement and Logistics Office to ensure logistics staff perform inventory reviews of biologic implants, as required.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2021
Monitor medical facility compliance with required reviews of on-site inventory.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/19/2024

Establish a structure for oversight responsibility that can provide guidance for tracking implanted biologics.

No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2024

Create policies and procedures for facilities to follow as they implement effective controls for tracking biologic implants.

No. 11
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Establish standardized systems and requirements for facility staff to appropriately record necessary biologic implant attributes for accurate and accessible tracking of recipients to advance patient safety.
Date Issued
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Report Number
20-02959-62
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Topics:  COVID-19 ● Supplies and Equipment

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2021
Provide specific guidance for personnel in facilities and Veterans Integrated Service Network offices to report expired personal protective equipment supplies into the Response Monitoring Tool and refine the tool to allow the entry of expired supply levels on hand.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2022
Communicate effective verification measures for facilities and Veterans Integrated Service Networks to improve the reliability and consistency of reported personal protective equipment on-hand quantity and usage information.
Date Issued
|
Report Number
20-00295-61

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA),Veterans Health Administration (VHA)
Closure Date: 4/12/2021
The OIG recommended that the under secretary for benefits and the under secretary for health formalize interagency sharing processes between the Veterans Benefits Administration’s Denver regional office and the Veterans Health Administration’s Office of Community Care on how data and information will be shared between both offices to prevent payments from continuing to deceased spina bifida beneficiaries.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA),Veterans Health Administration (VHA)
Closure Date: 4/12/2021
The OIG recommended that the under secretary for benefits and the under secretary for health take the following actions establish clear written guidance on sharing beneficiary data between the Veterans Benefits Administration’s Denver regional office and the Veterans Health Administration’s Office of Community Care to ensure all entitled beneficiaries are enrolled in health care.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/7/2021
The OIG recommended that the under secretary for benefits institute standardized procedures to help the Veterans Benefits Administration’s national call center agents provide accurate and comprehensive information about spina bifida benefits.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/14/2022
The OIG recommended that the under secretary for health direct the Veterans Health Administration’s Office of Community Care to develop a process to ensure those beneficiaries who are not using the services for which they are eligible, or need assistance with locating those services, receive them.
Date Issued
|
Report Number
18-00972-38
|
Topics:  Patient Care Services Operations

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: 11/5/2021
Ensure Prosthetic and Sensory Aids Service business practice guidelines include specific requirements for conducting and properly documenting reviews of cloned and pending consults.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2021
Ensure Prosthetic and Sensory Aids Service staff develop a process to verify that consults include accessory and consumable supplies for prosthetic items prior to issuance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2021
Ensure Prosthetic and Sensory Aids Service establishes field consistency requirements for conducting program reviews and evaluations.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2021
Ensure the executive director of the Prosthetic and Sensory Aids Service complies with existing policy for reviewing program assessments and evaluations and communicates review and evaluation results to the regional prosthetic representatives.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 79,200,000.00