All Reports

Telehealth Public-Use Questionnaires Were Used Improperly to Determine Disability Benefits
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19-07119-80

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/16/2020
Determine whether public-use disability benefits questionnaires continue to be an effective means of gathering evidence to support claims for benefit entitlement and, if necessary, take steps to discontinue their use.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/16/2020
Update the Veterans Benefits Administration’s adjudication procedures manual to assist claims processors in determining whether public-use disability benefits questionnaires were conducted through telehealth and include specific steps on what to do if claims processors suspect that public-use disability benefits questionnaires were completed via telehealth.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/16/2020
Revise public-use disability benefits questionnaire forms to include a mechanism for the private provider to indicate whether the examination was completed in person or through telehealth.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/16/2020
Notify veterans and private providers on public-facing forums and public-use disability benefits questionnaires that telehealth examinations are not acceptable for use in making benefit entitlement determinations.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 613,000.00
Veterans Received Inaccurate Disability Benefit Payments After Reserve or National Guard Drill Pay Adjustments
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18-05738-56
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Topics:  Claims and Fiduciary

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/4/2022
The OIG recommended the under secretary for benefits conduct a review of automatically and manually completed fiscal year 2016 drill pay adjustments that involved active duty military periods during that fiscal year, and take corrective actions as necessary.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/4/2022
The OIG recommended the under secretary for benefits conduct a review of automatically and manually completed fiscal year 2016 drill pay adjustments that involved a response to the proposal letter, and take corrective actions as necessary.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/16/2020
The OIG recommended the under secretary for benefits remind Intake Processing Center staff of their responsibilities for processing responses to drill pay proposal letters, including the appropriate actions to take when a response is received disagreeing with the proposal, and implement a plan to ensure staff compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/6/2020
The OIG recommended the under secretary for benefits implement a plan to provide detailed training for VBA staff who process drill pay adjustments and monitor the effectiveness of the training.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 56,800,000.00
Opportunities Missed to Contain Spending on Sleep Apnea Devices and Improve Veterans’ Outcomes
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19-00021-41
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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: 7/30/2020
Develop a mechanism to assess whether staffing levels within sleep medicine programs are sufficient for monitoring sleep apnea device use and conducting follow-ups with veterans.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2022
Ensure the Veterans Health Administration is leveraging existing technologies to make sure medical facilities are routinely monitoring veteran use of sleep apnea devices in a consistent and effective manner to more promptly identify individuals at risk of noncompliance with recommended therapies.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2021
Coordinate with the appropriate offices and services, including the Office of Procurement, Acquisitions, and Logistics, Prosthetic and Sensory Aids Service, sleep medicine, and the Veterans Health Administration National Infectious Diseases Service, to (a) assess the viability, potential patient care, and financial impact of an alternative to purchasing sleep apnea devices; (b) make and provide clear guidance on any changes to current Veterans Health Administration processes, including device returns, cleaning, and reissuance; and (c) designate an office with authority to ensure medical facilities implement any processes and recommendations from the assessment.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 261,300,000.00
Inadequate Oversight of the Medical/Surgical Prime Vendor Program’s Order Fulfillment and Performance Reporting for Eastern Area Medical Centers
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17-03718-240

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/17/2025

The executive in charge, office of under secretary for health, and the principal executive director, office of acquisition, logistics, and construction, require the Healthcare Commodities Program Office and Strategic Acquisition Center to develop a formal process to validate correct order fulfillment reporting by the prime vendors, ensure the correct algorithms are used, and help prevent missed opportunities to identify and mitigate issues.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The executive in charge, office of under secretary for health, requires the Healthcare Commodities Program Office to ensure Medical/Surgical Prime Vendor Next Generation contracting officer’s representatives get timely access to the performance metric reporting, such as reporting on correct order fulfillment.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2021
The executive in charge, office of under secretary for health, and the principal executive director, office of acquisition, logistics, and construction, require the Healthcare Commodities Program Office and Strategic Acquisition Center to monitor contracting officer’s representatives to ensure performance metric reporting is reviewed for accuracy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/31/2022
The executive in charge, office of under secretary for health, and the principal executive director, office of acquisition, logistics, and construction, require the Healthcare Commodities Program Office and Strategic Acquisition Center to strengthen processes and procedures so that staff use the Medical/Surgical Prime Vendor Next Generation formulary to change unit of issuance and product pricing information in the item master files.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The executive in charge, office of under secretary for health, and the principal executive director, office of acquisition, logistics, and construction, require the Healthcare Commodities Program Office and Strategic Acquisition Center to confirm that prime vendor American Medical Depot uses formulary sources when fulfilling requests for medical or surgical products under the Medical/Surgical Prime Vendor Next Generation.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The executive in charge, office of under secretary for health, requires the director, VHA Procurement and Logistics Office, to see that all those who order supplies under the Medical/Surgical Prime Vendor-Next Generation contract have proper delegated authority.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/17/2025

The executive in charge, office of under secretary for health, and the principal executive director, Office of Acquisition, Logistics, and Construction, require the Healthcare Commodities Program Office and Strategic Acquisition Center to monitor the Integrated Product Team’s development and implementation of a process to validate performance metric reporting such as on unadjusted fill rates.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/17/2025

The executive in charge, office of under secretary for health, requires the Procurement and Logistics Office to strengthen controls, monitor the Healthcare Commodities Program Office monthly, and ensure adherence to the established Medical/Surgical Prime Vendor Next Generation program control plan.

No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2020
The executive in charge, office of under secretary for health, and the principal executive director, Office of Acquisition, Logistics, and Construction, require the Healthcare Commodities Program Office and Strategic Acquisition Center to identify and resolve discrepancies between unadjusted fill rate reporting methods used by the Medical/Surgical Prime Vendor Next Generation prime vendor for select eastern area VA medical centers.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2020
The executive in charge, office of under secretary for health, and the principal executive director, office of acquisition, logistics, and construction, direct the Healthcare Commodities Program Office and Strategic Acquisition Center to see that all prime vendors use the unadjusted fill rate calculation methodology in accordance with the Medical/Surgical Prime Vendor Next Generation contract.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The executive in charge, office of under secretary for health, and the principal executive director, office of acquisition, logistics, and construction, instruct the Healthcare Commodities Program Office and Strategic Acquisition Center to require the Medical/Surgical Prime Vendor Next Generation prime vendor for select eastern area VA medical centers to provide corrected unadjusted fill rates for the fiscal year 2018 and current reporting periods.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 84,000,000.00
Insufficient Oversight of VA’s Undelivered Orders
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17-04859-196

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2020
The Veterans Health Administration chief financial officer and the Veterans Health Administration executive director for procurement should ensure relevant staff review and reconcile open orders to identify and deobligate excess funds for completed, canceled, or orders recorded more than once, and ensure the relevant staff follow existing policy regarding required reviews of open obligations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2020
The Veterans Health Administration chief financial officer and the Veterans Health Administration executive director for procurement should ensure that obligation policy includes specific time frames for effective interdepartmental communication to ensure timely identification of funds that are no longer needed for their original purpose and could be deobligated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM),Veterans Health Administration (VHA)
Closure Date: 11/27/2020
The assistant secretary for management and chief financial officer should develop a process for monitoring performance across the Department regarding reconciliation of open orders and develop a plan to share results with appropriate officials for their action.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2020
The Veterans Health Administration chief financial officer and the Veterans Health Administration executive director for procurement should ensure compliance with existing policy, which requires that obligations be adjusted when actual costs of goods and services are known to be less than the initially recorded amount.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2021
The Veterans Health Administration chief financial officer and the Veterans Health Administration executive director for procurement should ensure compliance with policy, which requires that obligations be supported by sufficient documentary evidence that substantiates the validity and proper authorization of obligations and that the evidence be retained and readily available upon request.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2020
The Veterans Health Administration executive director for procurement should ensure timely modifications or closing of contracts, when applicable, to allow for the deobligation of funds no longer required.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 132,600,000.00
Delays and Deficiencies in Management of Selected Radiology and Nuclear Medicine Outpatient Exams
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18-02300-236

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2020
Ensure facility staff evaluate scheduling workload and that medical support assistant staffing is adequately distributed for scheduling radiology exam requests in a timely manner.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2020
Provide formal guidance to facilities for establishing clinic management models for adequate radiology resources, including staffing and equipment.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2021
Ensure facility radiology and nuclear medicine services monitor exam requests pending greater than seven days and address them in a timely manner.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2019
Confirm with each facility director that they reviewed each record and took appropriate action as they deemed necessary for the three completed requests with additional follow-up care needs.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2020
Develop and implement a plan for improved radiology and nuclear medicine oversight at the Veterans Integrated Service Network level.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2021
Implement a mechanism to routinely audit canceled exam requests, ensuring the requests are in accordance with VA radiology and nuclear medicine policies and procedures for canceling exam requests, and taking corrective actions as needed based on audit results.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2020
Create a method to notify radiology and nuclear medicine leaders at all VA medical facilities when guidance is released. The method should be streamlined with maximum distribution and ensure receipt and acknowledgment by affected radiology and nuclear medicine leaders.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2019
Confirm with each facility director that they review each record and take appropriate action for five of the six canceled requests with outstanding exam needs.
VHA Did Not Effectively Manage Appeals of Non VA Care Claims
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18-06294-213

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2020
The Under Secretary for Health ensure the Payment Operations and Management directorate identifies its facilities that receive appeals but do not have sufficient staff assigned to process them, and then promptly transfers unprocessed appeals from those facilities to a Payment Operations and Management appeals-processing facility to ensure they are processed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/1/2020
The Under Secretary for Health ensure the Payment Operations and Management directorate updates communications to direct claimants to submit appeals to its facilities with designated appeals-processing staff.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2020
The Under Secretary for Health clearly define the roles and responsibilities of an accountable OCC official to oversee the Payment Operations and Management directorate’s appeals function.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2020
The Under Secretary for Health ensure the Payment Operations and Management directorate implements and communicates effective policies and procedures for its staff to promptly process their pending appeals workload.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2020
The Under Secretary for Health ensure the Payment Operations and Management directorate completely and accurately identifies and records its pending appeals inventory in a standard system of record and implements controls to effectively maintain the pending appeals inventory in the system of record.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2020
The Under Secretary for Health ensure all Payment Operations and Management directorate appeals processors obtain access to Caseflow promptly, and that Caseflow includes fields that are necessary to effectively manage Payment Operations and Management appeals.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2020
The Under Secretary for Health ensure the Payment Operations and Management directorate implements and communicates to all staff effective policies and procedures for processing and managing appeals under the new appeals process, including timeliness standards.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2020
The Under Secretary for Health ensure the Payment Operations and Management directorate completes a comprehensive assessment of its appeals workforce and inventory, and then reevaluates its appeals staffing needs.
Records Management Center Disclosed Third-Party Personally Identifiable Information to Privacy Act Requesters
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19-05960-244

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/13/2020
The Under Secretary for Benefits implements the Veterans Benefits Administration’s commitment to update its Privacy Act release policy and begin redacting third-party personally identifiable information.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/13/2020
The Under Secretary for Benefits ensures VA’s website is updated to reflect current Veterans Benefits Administration policy regarding release of third-party personally identifiable information.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2021
The Under Secretary for Benefits implements a plan to ensure the Records Management Center complies with requirements for mailing Privacy Act responses in accordance with VA Directive 6609.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/13/2020
The Under Secretary for Benefits establishes a plan to ensure that Records Management Center management receives a report for any site visit of the Records Management Center completed by the Veterans Benefits Administration and takes corrective action as needed.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/13/2020
The Records Management Center director implements a plan to improve quality reviews and ensures staff are held accountable for the accuracy of their Privacy Act releases.
FY 2019 Audit of VA’s Compliance under the DATA Act of 2014
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19-07247-251

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/12/2021
We recommend the Assistant Secretary for Management and Chief Financial Officer continue the system modernization efforts that provide VA with the capability to generate the required DATA Act reporting files containing the necessary elements to meet compliance with the DATA Act. Ensure the modernization will provide the following: a. Accurate reporting of object class, program activity codes, program activity names and all other elements required by the DATA Act. b. Store award identification to allow VA to be able to develop a File C and reconcile the File C to both summary level data (Files A and B) and award level data (File D). The reconciliations should be performed prior to the quarterly certification. c. Report reconciliation with its subsidiary systems. d. A mechanism to ensure transactions are reported that currently may be excluded due to the use of 1358s. e. Standardize data field use to allow for management to record an award ID across financial and supporting systems.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/12/2021
We recommend the Assistant Secretary for Management and Chief Financial Officer Ensure a DQP is finalized and implemented for future DATA Act submissions which meets the requirements for DATA Act reporting. In addition, the Office of Management, Office of Internal Control, and the Office of Enterprise Risk Management should ensure that the DQP supports the annual assurance statement and quarterly certification.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/12/2021
We recommend the Assistant Secretary for Management and Chief Financial Officer Implement a grants management solution that will be either integrated with the new financial system or interface into it once completed. The VA should identify a grants management solution that can be implemented across all of VA’s grant programs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/12/2021
We recommend the Assistant Secretary for Management and Chief Financial Officer Work with the SAO and component level SAO’s to ensure that all certifications are signed, dated by the component SAO and received prior to the submission date.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/12/2021
We recommend the Assistant Secretary for Management and Chief Financial Officer Ensure that the four CFDA programs (64.014, 64.015, 64.026, and 64.024) report obligations according to the definitions established for FABS reporting or obtain OMB and Treasury’s approval for any deviations.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/12/2021
We recommend the Assistant Secretary for Management and Chief Financial Officer Ensure the Office of Budget implements monitoring controls over CFDA numbers to ensure any CFDA numbers that require activation are identified and activated promptly to avoid interruptions in expenditure reporting.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/12/2021
We recommend the Assistant Secretary for Management and Chief Financial Officer Research the basis for the delays in reporting expenditure data for FABS for the VHA Veterans Prescription Service program (CFDA # 64.012) and implement a corrective action plan for timely reporting going forward. The VA PMO should also seek an exemption from OMB and Treasury regarding the reporting delays for the program if no viable solutions are identified to mitigate the timing delays.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/12/2021
We recommend the Assistant Secretary for Management and Chief Financial Officer Obtain and document guidance from Treasury and OMB on the proper treatment of payments to contractors for VA’s Veterans Choice Program as either contract award (File D1) or financial assistance (File D2).
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/12/2021
We recommend the Assistant Secretary for Management and Chief Financial Officer Obtain and document guidance from Treasury and OMB regarding inclusion of payroll and contract costs in the FABS (File D2) and the duplication of the same contract costs in the FPDS-NG (File D1).
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/12/2021
We recommend the Assistant Secretary for Management and Chief Financial Officer Implement internal controls and update policies and procedures to improve the accuracy of and completeness of the information submitted for FABS reporting. The internal controls should ensure the following: a. Excluded payments not reported due to zip code issues are researched, cleared, and reported in VBA’s sub certification. b. The default code “90” for Congressional District is not used when the county or zip code are unknown; instead, perform research to obtain the required data. c. Support from Treasury and OMB on the proper reporting of face amount of insurance in its FABS submissions. d. The information submitted for each data element is adequately supported and readily available. e. All data elements are reported in compliance with the definitions established by the DAIMS.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/12/2021
We recommend the Assistant Secretary for Management and Chief Financial Officer Improve review procedures prior to submission to identify errors and ensure all transactions are included in procurement and financial assistance data.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/12/2021
We recommend the Assistant Secretary for Management and Chief Financial Officer Perform research to determine the extent to which 1358 transactions are not reported for File D1 and develop solutions.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/12/2021
We recommend the Assistant Secretary for Management and Chief Financial Officer Develop solutions and continue system modernization efforts to reduce the use of the default object class. Research and develop program activity crosswalk for medical services.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/12/2021
We recommend the Assistant Secretary for Management and Chief Financial Officer Strengthen procedures over the process to report all program activity names and program activity codes that are reported in the quarterly OMB MAX Collect Exercise in accordance with the latest Budget Data request requirements.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/12/2021
We recommend the Assistant Secretary for Management and Chief Financial Officer Reinforce guidance for Contracting Officers concerning areas where exceptions were noted in DATA Act reporting.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/12/2021
We recommend the Assistant Secretary for Management and Chief Financial Officer Obtain OMB and Treasury approval for aggregating and reporting transactions based on beneficiary address. Ensure controls around the aggregation process are implemented and operating effectively.
Failures Implementing Aspects of the VA Accountability and Whistleblower Protection Act of 2017
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18-04968-249

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Accountability and Whistleblower Protection (OAWP)
Closure Date: 7/1/2020
The Assistant Secretary for Accountability and Whistleblower Protection directs a review of the Office of Accountability and Whistleblower Protection’s compliance with the VA Accountability and Whistleblower Protection Act of 2017 requirements in order to ensure proper implementation and eliminate any activities not within its authorized scope.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Accountability and Whistleblower Protection (OAWP)
Closure Date: 7/1/2020
The VA Secretary rescinds the February 2018 Delegation of Authority and consults with the Assistant Secretary for Accountability and Whistleblower Protection, the VA Office of General Counsel, and other appropriate parties to determine whether a revised delegation is necessary, and if so, ensures compliance with statutory requirements.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Accountability and Whistleblower Protection (OAWP)
Closure Date: 1/19/2021
The Assistant Secretary for Accountability and Whistleblower Protection, in consultation with the Office of General Counsel, Office of Inspector General, Office of the Medical Inspector, and the Office of Resolution Management establishes comprehensive processes for evaluating and documenting whether allegations, in whole or in part, should be handled within the Office of Accountability and Whistleblower Protection or referred to other VA entities for potential action or referred to independent offices such as the Office of Inspector General.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Accountability and Whistleblower Protection (OAWP)
Closure Date: 4/14/2021
The Assistant Secretary for Accountability and Whistleblower Protection makes certain that policies and processes are developed, in consultation with the VA Office of General Counsel and Office of Resolution Management, to consistently and promptly advise complainants of their right to bring allegations of discrimination through the Equal Employment Opportunity process.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Accountability and Whistleblower Protection (OAWP)
Closure Date: 4/17/2020
The Assistant Secretary for Accountability and Whistleblower Protection ensures that the divisions of the Office of Accountability and Whistleblower Protection adopt standard operating procedures and related detailed guidance to make certain they are fair, unbiased, thorough, and objective in their work.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to General Counsel (OGC)
Closure Date: 8/27/2021
The VA General Counsel updates VA Directive 0700 and VA Handbook 0700 with revisions clarifying the extent to which VA Directive 0700 and VA Handbook 0700 apply to the Office of Accountability and Whistleblower Protection, if at all.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Accountability and Whistleblower Protection (OAWP)
Closure Date: 7/1/2020
The Assistant Secretary for Accountability and Whistleblower Protection assigns a quality assurance function to an entity positioned to review Office of Accountability and Whistleblower Protection divisions’ work for accuracy, thoroughness, timeliness, fairness, and other improvement metrics.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Accountability and Whistleblower Protection (OAWP)
Closure Date: 1/19/2021
The Assistant Secretary for Accountability and Whistleblower Protection directs the establishment of a training program for all relevant personnel on appropriate investigative techniques, case management, and disciplinary actions.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 7/10/2020
The VA Secretary, in consultation with the VA Office of General Counsel, provides comprehensive guidance and training reasonably designed to instill consistency in penalties for actions taken pursuant to 38 U.S.C. §§ 713 and 714.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 1/19/2021
The VA Secretary ensures the provision of comprehensive guidance and training to relevant disciplinary officials to maintain compliance with the mandatory adverse action criteria outlined in 38 U.S.C. § 731.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Accountability and Whistleblower Protection (OAWP)
Closure Date: 4/30/2021
The Assistant Secretary for Accountability and Whistleblower Protection makes certain that in any disciplinary action recommended by the Office of Accountability and Whistleblower Protection, all relevant evidence is provided to the VA Secretary (or the disciplinary officials designated to act on the Secretary’s behalf).
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Accountability and Whistleblower Protection (OAWP)
Closure Date: 7/1/2020
The Assistant Secretary for Accountability and Whistleblower Protection implements safeguards consistent with statutory mandates to maintain the confidentiality of employees that make submissions, including guidelines for communications with other VA components.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Accountability and Whistleblower Protection (OAWP)
Closure Date: 3/11/2021
The Assistant Secretary for Accountability and Whistleblower Protection leverages available resources, such as VA’s National Center for Organizational Development and the Office of Resolution Management, to conduct an organizational assessment of Office of Accountability and Whistleblower Protection employee concerns and develop an appropriate action plan to strengthen Office of Accountability and Whistleblower Protection workforce engagement and satisfaction.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Accountability and Whistleblower Protection (OAWP)
Closure Date: 9/24/2020
The Assistant Secretary for Accountability and Whistleblower Protection develops a process and training for the Triage Division staff to identify and address potential retaliatory investigations.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 9/24/2020
The Assistant Secretary for Accountability and Whistleblower Protection collaborates with the Assistant Secretary for Human Resources and Administration, and the VA Secretary to develop performance plan requirements as required by 38 U.S.C. § 732.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Accountability and Whistleblower Protection (OAWP)
Closure Date: 4/17/2020
The Assistant Secretary for Accountability and Whistleblower Protection ensures the implementation of whistleblower disclosure training to all VA employees as required under 38 U.S.C. § 733.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 7/10/2020
The VA Secretary makes certain supervisors’ training is implemented as required under § 209 of the VA Accountability and Whistleblower Protection Act of 2017.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Accountability and Whistleblower Protection (OAWP)
Closure Date: 3/18/2021
The Assistant Secretary for Accountability and Whistleblower Protection confers with the VA Office of General Counsel to develop processes for collecting and tracking justification information related to proposed disciplinary action modifications consistent with 38 U.S.C. § 323(f)(2).
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Accountability and Whistleblower Protection (OAWP)
Closure Date: 3/18/2021
The VA Secretary in consultation with the Office of General Counsel and the Assistant Secretary for Accountability and Whistleblower Protection ensures compliance with the 60-day reporting requirement in 38 U.S.C. § 323(f)(2) consistent with congressional intent.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Accountability and Whistleblower Protection (OAWP)
Closure Date: 4/17/2020
The Assistant Secretary for Accountability and Whistleblower Protection develops or enhances database systems to provide the capability to track all data required by the VA Accountability and Whistleblower Protection Act of 2017.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Accountability and Whistleblower Protection (OAWP)
Closure Date: 7/1/2020
In consultation with the VA Office of General Counsel, the Assistant Secretary for Accountability and Whistleblower Protection completes the publication of Systems of Records Notices for all systems of records maintained by the Office of Accountability and Whistleblower Protection, and adopts procedures reasonably designed to ensure that the Office of Accountability and Whistleblower Protection does not create additional systems of records without complying with the requirements of the Privacy Act of 1974.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Accountability and Whistleblower Protection (OAWP)
Closure Date: 9/24/2020
The Assistant Secretary for Accountability and Whistleblower Protection consults with the VA Chief Freedom of Information Act Officer to ensure adequate training and staffing of the Office of Accountability and Whistleblower Protection’s Freedom of Information Act Office, and establishes procedures to comply with FOIA requirements including timeliness.
VA’s Management of Mobile Devices Generally Met Information Security Standards
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18-04608-212

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 9/9/2020
The OIG recommended the assistant secretary for the Office of Information and Technology enforce blacklisting or formally assess and document the approach of using training as the mitigating control to prevent users from downloading and using non-VA-approved applications.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/9/2020
The OIG recommended the assistant secretary for the Office of Information and Technology use configuration management tools to prevent premature or late updating of mobile devices or develop proactive policies and procedures to ensure users do not update mobile devices and applications until after the mobile device management team has conducted testing.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 9/9/2020
The OIG recommended the assistant secretary for the Office of Information and Technology validate that users of mobile devices are completing the required annual Mobile Training: Security of Apps on iOS Devices before user accounts are activated.
Mishandling of Veterans’ Sensitive Personal Information on VA Shared Network Drives
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19-06125-218

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT),Veterans Benefits Administration (VBA)
Closure Date: 7/8/2020
The assistant secretary for information and technology and the under secretary for benefits provide remedial training to users on the safe handling and storage of sensitive personal information on network drives.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 10/17/2019
The assistant secretary for information and technology establishes technical controls to ensure users cannot store sensitive personal information on shared network drives.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 12/14/2022
The assistant secretary for information and technology implements improved oversight procedures, including specific facility-level procedures, to ensure that sensitive personal information is not being stored on shared network drives.
Oversight and Resolution of Home Loan Defaults
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18-03979-204

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/23/2020
The under secretary for benefits implements controls to identify and address unreported monthly loan status in the upgraded VA Loan Electronic Reporting Interface system and implement compensating controls in the interim.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/24/2020
The under secretary for benefits ensures that loan servicers report when loss mitigation letters are sent and impose necessary regulatory infractions when required.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/24/2020
The under secretary for benefits ensures post-audit and adequacy of servicing reviews are compiled and trended and generate key loan servicer performance statistics.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/30/2019
The under secretary for benefits develops a plan to implement a formal tier-ranking system following the implementation of the upgraded VA Loan Electronic Reporting Interface system.
OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages, FY 2019
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19-00346-241
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Topics:  Staffing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2020
The Under Secretary for Health ensures completion of all open action plans related to recommendations from previous iterations of this report.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/10/2020
The Under Secretary for Health identifies a plan of action that will address the underlying causes of severe occupational staffing shortages identified in this report.
State Prescription Drug Monitoring Programs Need Increased Use and Oversight
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18-02830-164

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2021
Develop national processes to oversee medical facility compliance with VHA Directive 1306, Querying State Prescription Drug Monitoring Programs, and coordinate the possible automated information technology solutions and inter-office and -disciplinary communications necessary to improve prescription drug monitoring program monitoring and usage in Veterans Health Administration.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/13/2021
Update the Pain Management and Opioid Safety training course to specifically address VHA Directive 1306, Querying State Prescription Drug Monitoring Programs, query requirements and recommendations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2021
Ensure VA clinicians who prescribe opioids take the Pain Management and Opioid Safety training once, with annual refresher training.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
Add an addendum to VHA Directive 1306, Querying State Prescription Drug Monitoring Programs, that references the VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain and ensure VA clinicians are educated and receive annual training on the Clinical Practice Guideline, to include the Centers for Disease Control and Prevention’s recommended frequency for prescription drug monitoring program queries based on the patients’ risk factors.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
Direct Veterans Integrated Service Networks and their VA medical facilities to ensure local policies are consistent with VHA Directive 1306, Querying State Prescription Drug Monitoring Programs.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 2/11/2021
Develop automated information technology solutions to facilitate clinicians’ access toprescription drug monitoring program query information and reinforce the need tocomplete minimum annual VA-required prescription drug monitoring program queries.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/11/2020
Ensure non-VA care clinicians are in good standing and have a current state medical license that requires adherence to their state’s prescription drug monitoring program query requirements; adhere to the Veterans Affairs Opioid Safety Initiative Guidelines, including guidelines for prescription drug monitoring program queries; and are monitored to ensure appropriate corrective actions are taken if their prescribing practices are found to be inconsistent with VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
Ensure Veterans Integrated Service Networks implement an effective prescription drug monitoring program oversight process that includes the review of compliance rates with medical facility directors.
Sole-Source Service Contracting at Regional Procurement Office East Needs Improvement
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18-01836-184

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/17/2019
The OIG recommended that the executive director, VHA Procurement ensure awareness of approval procedures and the requirement to prepare a writtenjustification and approval document for sole-source contracts.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2020
The OIG recommended that the executive director, VHA Procurement establish procedures to help ensure all justification and approval documents areprepared and approved by the appropriate authority.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2020
The OIG recommended that the executive director, VHA Procurement review the actions of contracting personnel involved in the cited contracts anddetermine whether administrative actions are warranted.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/2/2020
The OIG recommended that the executive director, VHA Procurement establish formal coordination with the requiring activity to ensure adequate time isallotted for soliciting and awarding recurring services competitively.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 14,245,166.00
Security and Access Controls for the Beneficiary Fiduciary Field System Need Improvement
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18-05258-193

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT),Veterans Benefits Administration (VBA)
Closure Date: 8/26/2020
The assistant secretary for information and technology, in conjunction with the under secretary for benefits, reevaluate the risk determination for the Beneficiary Fiduciary Field System and determine if the system should be set to a security categorization level.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT),Veterans Benefits Administration (VBA)
Closure Date: 8/26/2020
The assistant secretary for information and technology, in conjunction with the under secretary for benefits, perform a risk assessment of access levels to beneficiary and fiduciary records, based upon the least privilege principle, and regularly review access to ensure that principle is enforced.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 8/26/2020
The assistant secretary for information and technology ensures audit logs within the Beneficiary Fiduciary Field System allow for management tracking of end-user access in order to reduce unauthorized browsing and the risk of data theft due to malicious activity.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/13/2020
The under secretary for benefits ensures field examiners submit reports with a cursory lock engaged to protect their data integrity and to prevent separation of duties issues.
National Review of Hospice and Palliative Care at the Veterans Health Administration
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17-05251-194

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2021
The Under Secretary for Health ensures the development and implementation of a consistent and standardized approach for hospice and palliative care documentation, consult management, and coding.
Accuracy of Claims Decisions Involving Conditions of the Spine
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18-05663-189

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/3/2021
Implement a plan to conduct a focused analysis of claims processor compliance with the requirements set forth by recent court decisions regarding examiner opinions and formulate a plan to review and take corrective action on affected claims if deemed necessary based on the results of that review.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/24/2023
Develop a plan to update the rating schedule to establish more objective criteria for each level of evaluation for peripheral nerves.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/3/2021
Review all sections of the procedures manual related to peripheral nerve disability evaluations and develop a plan to make updates and clarifications where applicable.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/6/2020
Review the disability benefits questionnaire forms for conditions of the spine and determine whether updates are needed to help ensure more accurate and consistent claims decisions.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/3/2021
Update the Evaluation Builder tool to help users provide more accurate, comprehensive, and consistent information for claims decisions involving the spine and peripheral nerves.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 64,800,000.00
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