All Reports

Clarify program responsibilities between the Veterans Health Administration and theOffice of Operations, Security, and Preparedness, and evaluate the need for a centralizedmanagement entity for the security and law enforcement program across all medicalfacilities.

Ensure police staffing models are implemented for determining facility-appropriate levelsfor officers at medical facilities.

Make certain medical facilities use strategies to address police staffing challenges such ashaving documented recruitment plans for police officer positions that include adetermination of the need for special salary rates and incentives.

Ensure procedures are developed for appropriately handling VA police investigations of medical facility leaders.

The Under Secretary for Benefits negotiates an amendment to State Approving Agency contracts to clarify requirements for program approvals and require, subject to the availability of resources, quarterly samples and reviews and evaluations of supporting documentation for State Approving Agency approvals to ensure approved programs meet Title 38 of the United States Code requirements.

The Under Secretary for Benefits negotiates amendments to State Approving Agency contracts that, subject to available resources, require the State Approving Agencies to periodically reapprove programs and evaluate program changes and other operational changes, such as advertisement practices, that may affect a program’s continued eligibility and compliance with Title 38 of the United States Code.

The Under Secretary for Benefits refers schools identified during the audit with potentially erroneous, deceptive, or misleading advertising practices to the Federal Trade Commission for it to decide whether any further reviews or actions are needed.

The Under Secretary for Benefits revises and strengthens compliance surveys to improve the assessment of program eligibility and compliance survey quality reviews to include the review of supporting documentation and an independent assessment of the quality of the completed compliance surveys.

The Under Secretary for Benefits negotiates an amendment to the State Approving Agency contracts to establish quality assurance metrics and ensure the Veterans Benefits Administration collects and uses quality assurance data from its reviews of the State Approving Agencies’ approvals, monitoring, and compliance surveys in its annual evaluations of the State Approving Agencies.

The Under Secretary for Benefits assesses whether funding for State Approving Agencies is sufficient to ensure the adequate review, approval, and monitoring of programs, in conjunction with the establishment of a contract to update the State Approving Agency funding allocation model.

The Under Secretary for Benefits implements a plan to improve the decisions and additional reviews of claims involving service-connected Amyotrophic Lateral Sclerosis, and monitors these claims to ensure staff demonstrate proficiency.

The Under Secretary for Benefits implements a plan to ensure veterans with service-connected Amyotrophic Lateral Sclerosis receive notice regarding additional special monthly compensation benefits that may be available.

The Executive in Charge, Veterans Health Administration, should develop requirements for medical facilities with emergency caches to perform at least annually a wall-to-wall inventory of all cache drugs and supplies, and develop processes to (1) label all expired or excess drugs that are purposefully maintained to respond to drug shortages or for the purposes of Shelf Life Extension testing, and (2) remove and rectify cases of other expired, missing, or excess drugs.

The Executive in Charge, Veterans Health Administration, should conduct an assessment to determine if the cost saving benefits of the Shelf Life Extension Program outweigh the risks expired drugs pose to the emergency cache’s mission and to take corrective action as appropriate.

The Executive in Charge, Veterans Health Administration, should improve emergency cache inventory management processes to ensure emergency cache national inventory data sorted by location is reliable and accurately identifies the expiration dates of all cache contents, including Shelf Life Extension Program drugs, and that this information is electronically accessible to each facility.

The Executive in Charge, Veterans Health Administration, should initiate steps to update and reissue the Veterans Health Administration directives specifying oversight responsibilities for the Emergency Cache Program with a requirement for inventory to be timely rotated into the emergency cache after it is received.

The Executive in Charge, Veterans Health Administration, should assess whether the Emergency Cache Program is properly aligned within VA and coordinate with other VA offices as necessary to determine the appropriate roles and responsibilities by program office, and then review, update, and reissue Emergency Cache Program requirements to include (1) robust annual cache inspection and activation exercise requirements, (2) processes to ensure cache inspection and activation requirements are met, (3) processes to ensure that violations identified during annual cache inspections are timely addressed, and (4) specific accountability measures for the program offices and local facility personnel responsible for program oversight.

The Executive in Charge, Veterans Health Administration, should conduct a comprehensive assessment of the cache inventory to identify drugs and supplies that can be readily used in medical facilities’ general operations and develop a mechanism to monitor and ensure medical facilities are maximizing the use of these items before they expire.

The Executive in Charge, Veterans Health Administration, should initiate steps to update and reissue the Veterans Health Administration directives specifying oversight responsibilities for the Emergency Cache Program to reflect the Office of Public Health’s reorganization and reassign responsibilities as needed.

The Under Secretary for Benefits ensures cases requiring final competency determinations are entered into the Beneficiary Fiduciary Field System as soon as the cases are established in the Veterans Benefits Management System.

The Under Secretary for Benefits reminds Veterans Benefits Administration staff of their responsibility to notify Fiduciary Hubs when waivers are received of the due process notification period for cases with proposed incompetency, and implements a plan to ensure compliance.

The Under Secretary for Benefits implements a plan to ensure the processing of final competency determinations under the jurisdiction of the Fiduciary Hubs meet Veterans Benefits Administration’s established timeliness standard.

The Under Secretary for Benefits implements a plan to prioritize the processing of final competency determinations under the jurisdiction of Veterans Service Centers and Pension Management Centers.

The Under Secretary for Benefits ensures the National Work Queue distributes final competency determinations according to the Veterans Benefits Administration policy for processing these cases.

The Under Secretary for Benefits implements a plan to ensure Fiduciary Hub staff who complete final competency determinations have access to documents containing federal taxpayer information in the Legacy Content Manager.

The Under Secretary for Benefits coordinate with the Under Secretary for Health to determine whether veterans who had received initial TBI medical examinations by VHA-contracted examiners and not by one of the four designated specialists, were unintentionally excluded from equitable relief. If additional veterans are identified, the OIG requests that those cases be referred to the VA Secretary for consideration of equitable relief.

The Under Secretary for Benefits confirm whether the names of veterans who were not on the initial list of veterans entitled to equitable relief and later identified by VBA staff and referred for potential equitable relief were submitted to the VA Secretary for consideration. The OIG requests an update of the current status and disposition of those cases.

The OIG recommended the Under Secretary for Benefits consider revising which claims are included in VBA’s reported disability claims backlog and provide a clear definition to all stakeholders.

The OIG recommended the Under Secretary for Benefits implement a plan to provide consistent oversight and training of Claims Assistants through national performance and training plans.

The Executive in Charge, Office of the Under Secretary for Health, continue to support processes to prevent duplicate payments made to third-party administrators through the bulk payment process and ensure that proper controls are in place to prevent duplicate payments to third-party administrators through all other current payment methodologies and under future Community Care contracts.

The Executive in Charge, Office of Under Secretary for Health, ensure that Office of Community Care staff and members of VA’s Office of General Counsel continue to work collaboratively with relevant government authorities to review and determine an appropriate process for reimbursement of overpayments by the third-party administrators.

The Under Secretary for Veterans Benefits Administration implement a plan to ensure staff timely process cases with reduced evaluations, after the decision, to prevent rework and improper payments.

The Under Secretary for Veterans Benefits Administration establish a plan to modify the Veterans Benefits Management System to apply correct effective dates for cases with reduced evaluations for conditions that were no longer service-connected and alert staff when the assigned effective dates are improper.

The Under Secretary for Veterans Benefits Administration remind VA Regional Office staff of the system defect that causes effective dates to be one month later than required for conditions that are no longer being classified as service-connected, until the Veterans Benefits Administration could implement a system change.

The Under Secretary for Veterans Benefits Administration implement a plan to provide refresher training on the proper processing of reduced evaluations to staff who process rating reductions and monitor the effectiveness of that training.

The Under Secretary for Veterans Benefits Administration provide updated guidance to include provisions for when amended proposal letters are necessary.

The Under Secretary for Veterans Benefits Administration implement a plan to conduct periodic reviews for veterans who had evaluations reduced after the first of the month following the final notification letter and before the first of the month following 60 days after the final notification letter, take corrective actions as needed, and provide certification of completion to the Office of Inspector General.

The Executive in Charge, Veterans Health Administration, should review the Prosthetic and Sensory Aids Service Ottobock microprocessor knee instructions (August 2011, March 2013, and August 2013), coordinate with appropriate officials to determine which Centers for Medicare and Medicaid Services’ Healthcare Common Procedure Coding System Level II L codes are appropriate to classify these items for reimbursement, and issue revised guidance.

The Executive in Charge, Veterans Health Administration, should coordinate with appropriate officials to establish a formal oversight and reporting structure that defines the roles and the responsibilities of the Prosthetic and Sensory Aids Service Orthotic and Prosthetic L Code Committee, as well as who has the authority to approve recommendations for the use of the Centers for Medicare and Medicaid Services’ Healthcare Common Procedure Coding System Level II L codes to classify specific prosthetic components for reimbursement.

The Executive in Charge, Veterans Health Administration, should develop and implement effective processes and procedures to monitor the use of Not Otherwise Classified codes and communicate these procedures to the Veterans Integrated Service Networks to ensure compliance with Veterans Health Administration Directive 1045, Healthcare Common Procedure Coding System (HCPCS) List for Prosthetic Limb and/or Custom Orthotic Device Prescription (December 30, 2013) and the Centers for Medicare and Medicaid Services’ Healthcare Common Procedure Coding System Level II Coding Procedures.

The Executive in Charge, Veterans Health Administration, should coordinate with the appropriate officials to develop and implement processes and procedures to ensure any pricing guidance with regard to the pricing of prosthetic items classified using a Not Otherwise Classified code is developed and concurred with by VA Office of General Counsel and Veterans Health Administration’s Procurement and Logistics Office prior to issuance.

The Executive in Charge, Veterans Health Administration, should issue corrected guidance to replace the Prosthetic and Sensory Aids Service Ottobock microprocessor knee instructions (March 2013 and August 2013) and the prosthetic limb contract template issued in August 2014, by coordinating with appropriate officials to develop and implement pricing guidance to ensure VA pays a fair and reasonable price for items classified using a Not Otherwise Classified code.

The OIG recommended the Under Secretary for Benefits take steps to prioritize the modernization of functionality within the Veterans Benefits Management System to assist rating personnel with assigning correct effective dates related to intent to file.

The OIG recommended the Under Secretary for Benefits implement a plan to conduct a special review of claims with intent to file submissions from March 24, 2015, through September 30, 2017, during which payment changes occurred, to determine whether rating personnel assigned correct effective dates when awarding compensation benefits.

The Under Secretary for Benefits reviews all denied military sexual trauma related claims since the beginning of FY 2017, determines whether all required procedures were followed, takes corrective action based on the results of the review, renders a new decision as appropriate, and reports the results back to the Office of Inspector General.

The Under Secretary for Benefits focuses processing of military sexual trauma related claims to a specialized group of Veterans Service Representatives and Rating Veterans Service Representatives.

The Under Secretary for Benefits requires an additional level of review for all denied military sexual trauma related claims and holds the second level reviewers accountable for accuracy.

The Under Secretary for Benefits conducts special focused quality improvement reviews of denied military sexual trauma related claims and takes corrective action as needed.

The Under Secretary for Benefits updates the current training for processing military sexual trauma related claims, monitors the effectiveness of the training, and takes additional actions as necessary.

The Under Secretary for Benefits updates the development checklist for military sexual trauma related claims to include specific steps claims processors must take in evaluating such claims in accordance with applicable regulations, and requires claims processors to certify that they completed all required development action for each military sexual trauma-related claim.

The Executive in Charge, Veterans Health Administration, will establish a governance environment for the Program of Comprehensive Assistance for Family Caregivers to ensure medical facilities process veteran applications within the required 45-day timeliness standard, consistently monitor veterans and their caregivers, adequately document the results and changes in veterans’ health status, and adjust the level of support provided or discharge veterans and their caregivers, as appropriate.

The Executive in Charge, Veterans Health Administration, will take steps to ensure caregiver support coordinators are properly applying eligibility criteria with processes, such as pre- or post-approval reviews, to ensure the accuracy of all veteran eligibility determinations.

The Executive in Charge, Veterans Health Administration, will update Directive 1152, Caregiver Support Program, to include a well-defined process for documenting changes in veterans’ health conditions during monitoring sessions to determine if those changes warrant a reassessment of the need for care or the level of care.

The Executive in Charge, Veterans Health Administration, will establish assessment guidelines that caregiver support coordinators should follow when a veteran’s need for care changes.

The Executive in Charge, Veterans Health Administration, will make sure that Veterans Integrated Service Network directors designate program leads at the network level with responsibility for Program of Comprehensive Assistance for Family Caregivers oversight.

The Executive in Charge, Veterans Health Administration, will assess the extent to which current staffing levels at medical facilities are adequate to implement the Program of Comprehensive Assistance for Family Caregivers, as intended.

The Principal Deputy Under Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against Employee 1.

The Principal Deputy Under Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against Employee 2.

The Principal Deputy Under Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against Employee 3.

The Principal Deputy Under Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against other OSI VERC employees identified by the OIG for misusing government time and resources associated with this endeavor.

The Principal Deputy Under Secretary assesses the adequacy of oversight and training for OSI VERC employees regarding the appropriate use of VA time and resources and addresses any deficiencies.

The Under Secretary for Benefits establishes internal controls sufficient to ensure that a reexamination is necessary prior to employees ordering it, and modifies VBA procedures as appropriate to reflect these improved business processes.

The Under Secretary for Benefits takes steps to prioritize the design and implementation of system automation reasonably designed to minimize unwarranted reexaminations.

The Under Secretary for Benefits enhances VBA’s quality assurance reviews to evaluate whether employees correctly requested reexaminations and categorize unwarranted reexaminations as errors.

The Under Secretary for Benefits conducts a special focused quality improvement review of cases with unwarranted reexaminations to develop data sufficient to understand and redress the causes of any avoidable errors.

The Under Secretary for Health refines and formalizes VHA’s position categorization of individuals (clinical and nonclinical) who are necessary to VHA’s mission of delivering health care by looking at various dimensions of each occupation, including staff skill set and function, enabling identification of positions based on the specific role a person would fill.

The Under Secretary for Health ensures the consistent implementation and use of the position categorization approach across all facilities.

The Executive in Charge, Office of the Under Secretary for Health, develops a timeline to reduce improper payments under the 10 percent threshold for the Beneficiary Travel; Communications, Utilities, and Other Rents; Medical Care Contracts and Agreements; Prosthetics; Purchased Long Term Services and Support; Supplies and Materials; and VA Community Care Programs and activities. This is a repeat finding and recommendation for the Purchased Long Term Services and Support and VA Community Care programs from our FY 2015 and 2016 reports.

The Executive in Charge, Office of the Under Secretary for Health, implements steps to achieve stated reduction targets for the Beneficiary Travel; Civilian Health and Medical Program of the Department of Veterans Affairs; Purchased Long Term Services and Support; Supplies and Materials; and VA Community Care Programs and activities. This is a repeat finding for all five programs from our FY 2016 report.

The Executive in Charge, Veterans Benefits Administration, implements steps to achieve reduction targets for the Pension and Post-9/11 GI Bill Programs.

The OIG recommended the Executive in Charge, Office of the Under Secretary for Health, implement procedures to ensure thorough testing of sample items used to estimate improper payments for Supplies and Materials purchases under indefinite delivery contracts.

The OIG recommended the Executive in Charge, Veterans Benefits Administration, continue working with the Department of Defense to increase the frequency of drill pay adjustments from annually to monthly. This is a repeat recommendation from our FY 2016 report.

The OIG recommended the Executive in Charge, Veterans Benefits Administration, continue to report statutory barriers preventing complete resolution of drill pay improper payments in future Agency Financial Reports until resolved.

The OIG recommended the Under Secretary for Health require Veterans Integrated Service Networks to implement periodic reviews to ensure clinicians and Beneficiary Travel Office staff comply with Veterans Health Procedure Guide 1601B.05 eligibility requirements for authorizing Special Mode of Transportation services.

The OIG recommended the Under Secretary for Health modify Veterans Health Administration Procedure Guide 1601B.05 to require the Beneficiary Travel Office staff to verify beneficiaries attended medical appointments prior to approving payment of Special Mode of Transportation vendor invoices.

The OIG recommended the Under Secretary for Health require Veterans Integrated Service Networks to implement periodic reviews to ensure VA Medical Centers comply with Veterans Health Administration policies for verifying beneficiaries listed on vendor invoices had been properly authorized for Special Mode of Transportation services or attended medical appointments prior to approving payment of Special Mode of Transportation vendor invoices.

The OIG recommended the Under Secretary for Health ensure the Improper Payments Elimination and Recovery Act reports provided to Veterans Integrated Service Networks are modified to include Special Mode of Transportation information specific to vendor payments by VA Medical Centers.

The OIG recommended the Under Secretary for Health implement use of Centers for Medicare and Medicaid Services Rates when savings can be achieved for Special Mode of Transportation ambulance services in accordance with 38 U.S.C. Section 111(b)(3)(C).

The OIG recommended the Under Secretary for Health implement controls to prevent beneficiaries using Special Mode of Transportation services from also obtaining mileage reimbursement for the same appointment(s).