Date Issued
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Report Number
12-03705-383
All Reports
Date Issued
|
Report Number
13-01419-384
Date Issued
|
Report Number
13-03380-386
Date Issued
|
Report Number
14-02790-393
Date Issued
|
Report Number
15-04231-223
Date Issued
|
Report Number
16-01613-326
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/29/2016
We recommended that the Under Secretary for Health ensure that the Veterans Health Administration establishes system-wide requirements for competency assessment and validation, including frequency, for nursing employees who provide post-anesthesia care after operational hours.
Date Issued
|
Report Number
13-02255-276
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 9/13/2017
We recommended the Acting Under Secretary for Benefits review the data on Federal incarcerations from May 2008 through June 2015 and issue bills of collection to recover improper payments made to veterans while they were incarcerated.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 9/13/2017
We recommended the Acting Under Secretary for Benefits review the data on Federal incarcerations from May 2008 through June 2015 and take action to make appropriate benefits adjustments and issue bills of collection to recover improper payments for veterans currently incarcerated in Federal penal institutions.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 9/13/2017
We recommended the Acting Under Secretary for Benefits increase the priority placed on the Federal incarceration adjustment workload by using monthly data on Federal incarcerations to make appropriate and timely compensation and pension benefits adjustments.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 9/24/2016
We recommended the Acting Under Secretary for Benefits monitor the terms of the current agreement with the Bureau of Prisons and take timely action to extend the agreement when appropriate.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 9/13/2017
We recommended the Acting Under Secretary for Benefits increase the priority placed on state and local incarceration adjustment workload by initiating timely development action after receiving notifications of incarceration from the Social Security Administration.
No. 6
to Veterans Benefits Administration (VBA)
Closure Date: 9/13/2017
We recommended the Acting Under Secretary for Benefits increase priority of state and local incarceration adjustment workload by making timely incarceration adjustments and issue bills of collection to recover improper payments, as appropriate, after providing due process notification to veterans.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 307,900,000.00
Date Issued
|
Report Number
15-01296-203
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/25/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic staff complete diagnostic assessments for patients with a positive alcohol screen and that managers monitor for compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/27/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic staff document the offer of further treatment to patients diagnosed with alcohol dependence and that managers monitor for compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/27/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that that clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care and that managers monitor for compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 4/21/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 4/21/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic providers and clinical associates receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Date Issued
|
Report Number
16-01040-324
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/1/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Risk Managers invite clinicians involved in Level 2 or 3 peer reviews to submit comments to and/or appear before the Peer Review Committee.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/25/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network managers, ensure Facility Directors review all privilege forms annually and document the review.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/10/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Medical Staff Coordinators complete the conversion from six-part to two-part credentialing and privileging folders and ensure non-allowed information is not placed in the folders.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 11/10/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Chiefs of Surgery discuss surgical deaths with identified problems in Surgical Work Group meetings.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 11/10/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities designate a committee to oversee safe patient handling activities, track patient handling injury data, and share data with safe patient handling champions.
Date Issued
|
Report Number
15-03700-283
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to National Cemetery Administration (NCA)
Closure Date: 5/14/2018
We recommended the Interim Under Secretary for Memorial Affairs rescind and replace Chapters 6 and 7 from Manual 40-2, National Cemeteries, Administration, Operation, and Maintenance.
No. 2
to National Cemetery Administration (NCA)
Closure Date: 1/17/2018
We recommended the Interim Under Secretary for Memorial Affairs recertify or rescind Directive 3170/1, Ceremonies and Special Events at VA National Cemeteries.
No. 3
to National Cemetery Administration (NCA)
Closure Date: 5/14/2018
We recommended the Interim Under Secretary for Memorial Affairs incorporate National Cemetery Administration’s three interim guidance documents into directives or handbooks.
No. 4
to National Cemetery Administration (NCA)
Closure Date: 11/4/2016
We recommended the Interim Under Secretary for Memorial Affairs develop mechanisms to ensure staff begin the process of updating guidance and compensate for the time needed to draft guidance and obtain staff concurrence.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 2/3/2017
We recommended the Under Secretary for Health recertify or rescind Veterans Health Administration’s three religious belief guidance documents that need to be updated.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 6/12/2017
We recommended the Under Secretary for Health develop mechanisms to ensure staff begin the process of updating guidance and compensate for the time needed to draft guidance and obtain staff concurrence.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 2/3/2017
We recommended the Under Secretary for Health provide staff a means to request senior official assistance, when necessary, to obtain timely agency-level concurrences.
Date Issued
|
Report Number
16-01489-311
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/14/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facility clinicians consistently include ‘inpatient’ in the inpatient consult title and that facility managers monitor compliance.
Date Issued
|
Report Number
15-04252-284
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/6/2017
We recommended the Under Secretary for Health ensure implementation of the corrective action plans included in VA’s Agency Financial Report to make procurement practices for the VA Community Care and Purchased Long Term Services and Support programs compliant with laws and regulations.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/15/2017
We recommended the Under Secretary for Health implement steps to achieve reduction targets or appropriately adjust them for the VA Community Care, Purchased Long Term Services and Support, Beneficiary Travel, and Supplies and Materials programs.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 2/2/2017
We recommended the Acting Under Secretary for Benefits implement steps to achieve reduction targets or appropriately adjust them for the Compensation, Education Chapter 1606, and Education Chapter 1607 programs.
No. 4
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 2/2/2017
We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction, implement steps to achieve reduction targets for the Disaster Relief Act-Hurricane Sandy program.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/15/2017
We recommended the Under Secretary for Health implement additional training for personnel who evaluate Improper Payment Elimination and Recovery Act samples for the Supplies and Materials program.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/27/2017
We recommended the Under Secretary for Health provide contracting expertise to the Improper Payment Elimination and Recovery Act review team, as needed.
No. 7
to Veterans Benefits Administration (VBA)
Closure Date: 3/3/2017
We recommended the Acting Under Secretary for Benefits develop a solution for correcting the concurrent payment of Compensation and Pension benefits and military drill pay and seek Office of Management and Budget assistance in coordinating a future resolution of the matter.
Date Issued
|
Report Number
15-02459-260
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Information and Technology (OIT)
Closure Date: 4/3/2018
We recommended the Assistant Secretary for Information and Technology create read-only access capability for the Project Management Accountability System.
No. 2
to Information and Technology (OIT)
Closure Date: 4/3/2018
We recommended the Assistant Secretary for Information and Technology assess the current level of each user’s access to the Project Management Accountability System Dashboard to ensure each user’s access is based on the least privilege needed.
No. 3
to Information and Technology (OIT)
Closure Date: 1/3/2018
We recommended the Assistant Secretary for Information and Technology develop Project Management Accountability System Dashboard access logs.
No. 4
to Information and Technology (OIT)
Closure Date: 4/3/2018
We recommended the Assistant Secretary for Information and Technology periodically review Project Management Accountability System Dashboard access logs to ensure users have a need for system access.
Date Issued
|
Report Number
16-00693-269
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities’ policies include automated dispensing machine user training and competency assessment requirements and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that employees perform and document monthly inspections of all medication storage areas and that facility managers monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when employees identify deficiencies during medication storage area inspections, they document corrective actions and that facility managers monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities have oral syringes available for medication administration and clearly label and store them separately from parenteral syringes and that facility managers monitor compliance.
Date Issued
|
Report Number
15-04652-146
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 5/14/2019
We recommended the Acting Under Secretary for Benefits revise Veterans Benefits Administration’s Policy on Management of Veterans’ and Other Governmental Paper Records to ensure documents printed from Veterans Benefits Management System are clearly identified.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 4/5/2018
We recommended the Acting Under Secretary for Benefits revise Veterans Benefits Administration’s Policy on Management of Veterans’ and Other Governmental Paper Records to include detailed, standardized procedures for the collection and review of material by records management staff at VA Regional Offices.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 4/5/2018
We recommended the Acting Under Secretary for Benefits implement a plan to ensure all claims-related documents receive the mandated levels of review to comply with Veterans Benefits Administration’s policy.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 3/15/2017
We recommended the Acting Under Secretary for Benefits implement a plan that requires supervisors to conduct periodic reviews of employees’ red boxes and track all shredding policy violations they identify.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 4/5/2018
We recommended the Acting Under Secretary for Benefits implement a plan to ensure records management staff comply with Veterans Benefits Administration’s policy to track all shredding violations they identify.
No. 6
to Veterans Benefits Administration (VBA)
Closure Date: 6/23/2017
We recommended the Acting Under Secretary for Benefits implement a plan to ensure management and staff receive refresher training on the proper handling of both claims-related and non-claims-related documents.
No. 7
to Veterans Benefits Administration (VBA)
Closure Date: 6/23/2017
We recommended the Acting Under Secretary for Benefits develop specific procedures regarding the maintenance and disposition of congressional correspondence.
Date Issued
|
Report Number
16-00969-257
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/23/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure facilities’ policies include plans for managing difficult airways.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/23/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facility clinical managers provide all required initial training for designated employees who will perform airway management and ensure initial competency assessment includes all required testing and demonstration and that facility managers monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/23/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facility clinical managers include all required elements in airway management competency reassessments and that facility managers monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 3/23/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility clinical managers ensure competent clinicians provide emergency airway management during all hours of patient care unless the facility is exempt and that facility managers monitor compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 3/23/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facility clinical managers conduct root cause analyses when clinicians without demonstrated airway management competency perform emergency intubations and that facility managers monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/23/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility clinical managers ensure scopes of practice for non-licensed independent practitioners who perform airway management include a statement related to airway management and that facility managers monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 3/23/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility Chiefs of Staff ensure clinicians complete required training and experience within a short timeframe after recommending airway management privileges and that facility managers monitor compliance.
Date Issued
|
Report Number
15-02781-153
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 8/31/2016
We recommended the Assistant Secretary for Human Resources and Administration correct all Section 508 compliance issues with the MyCareer@VA Web site and seek certification of Section 508 compliance from the appropriate component within VA Section 508.
No. 2
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 8/31/2016
We recommended the Assistant Secretary for Human Resources and Administration develop and implement a process to ensure their products conform with Section 508 requirements prior to their deployment, which includes defining what support is required to document a product¿s compliance with Section 508 requirements.
No. 3
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 8/31/2016
We recommended the Assistant Secretary for Human Resources and Administration provide and require training for all individuals involved in developing and maintaining products to ensure they are aware of the requirements and expectations for conformance with Section 508 requirements.
No. 4
to Information and Technology (OIT)
Closure Date: 2/22/2019
We recommended the Assistant Secretary for Information and Technology strengthen policy to ensure Electronic and Information Technology products are compliant with Section 508 prior to their deployment, which includes providing an expectation of when to establish compliance, how to document compliance, and what specifically constitutes compliance with Section 508.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 34,011.00
Date Issued
|
Report Number
15-01227-129
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Office of Management (OM)
Closure Date: 1/13/2017
We recommended the Interim Assistant Secretary for Management update existing guidance to address if and when a Conference Package may be used to summarize the budgets for multiple events and how to present the budget for each event to ensure adequate line item detail for each event.
No. 2
to Office of Management (OM)
Closure Date: 1/13/2017
We recommended the Interim Assistant Secretary for Management update existing guidance to address how to present line item detail of expenditures in the Final Conference Reports if the approved Conference Package was for multiple events to ensure traceability to source documents.
No. 3
to Office of Management (OM)
Closure Date: 1/31/2017
We recommended the Interim Assistant Secretary for Management establish review procedures that ensure Conference Packages and Final Conference Reports comply with law and VA policy and report the results to the Deputy Secretary or VA Chief of Staff.
No. 4
to Office of Management (OM)
Closure Date: 1/31/2017
We recommended the Interim Assistant Secretary for Management update existing policy to provide adequate accountability to ensure that VA organizations comply with conference policies.
No. 5
to Office of Management (OM)
Closure Date: 1/31/2017
We recommended the Interim Assistant Secretary for Management update existing policy to reinstate the Conference Certifying Official as the reviewer of the Conference Package instead of the Responsible Conference Executive.
No. 6
to Office of Management (OM)
Closure Date: 1/31/2017
We recommended the Interim Assistant Secretary for Management update existing policy to reinstate the Corporate Travel Reporting Office review of Conference Packages with a budget of $100,000 or more before submitting the package for Deputy Secretary or Secretary approval.
Date Issued
|
Report Number
16-01031-142
Date Issued
|
Report Number
16-01027-141