All Reports

The Pension and Fiduciary Service clarifies procedural requirements to fiduciary hub staff on how to verify whether VA-derived funds of deceased beneficiaries must be returned to VA, including whether the fiduciary identified any valid will or heir to whom the funds are otherwise due.

The Pension and Fiduciary Service identifies existing or implements new electronic controls that allow VBA staff to track Fiduciary Program tasks, timeliness, and workload related to the return of deceased beneficiaries’ VA-derived funds to VA that would otherwise escheat to a state if not disbursed to heirs.

The Pension and Fiduciary Service and the Office of Field Operations establish a methodology and monitor workload to ensure the prompt return of deceased beneficiaries’ VA-derived funds.

The Under Secretary for Health reviews the operational memorandum for lung cancer screening implementation and assesses whether lung cancer screening rates could be enhanced by allowing a facility to conduct lung cancer screening while developing all mandated elements.

The Under Secretary for Health reviews the operational memorandum for lung cancer screening implementation and assesses whether lung cancer screening rates could be enhanced by reevaluating, prioritizing, and clarifying the mandated elements.

The Under Secretary for Health considers mandating eligible patients be offered lung cancer screening consistent with other required cancer screening in the Veterans Health Administration.

Implement consistent data entry, standardized organizational codes, and periodic reviews for HR Smart community care data.

Develop staffing reports that can be searched by service departments to ensure appropriate resources to meet their assigned missions.

Assess whether consolidated community care units would more broadly support veterans’ access to community care and help mitigate the impact of staffing shortages, and, if so, develop a project management plan for implementing those units.

Assess the use of monetary and nonmonetary incentives to evaluate whether they are effective in recruiting and retaining administrative staff within community care departments.

Implement a more effective vulnerability management program to address security deficiencies identified during the inspection.

Implement an improved inventory process to ensure that all connected devices used to support VA programs and operations are documented in the Enterprise Mission Assurance Support Service.

Ensure network infrastructure equipment is properly installed.

Ensure physical access controls are implemented for communication rooms.

Ensure a video surveillance system is operational and monitored for the data center.

Ensure communication rooms with infrastructure equipment have fire-detection and suppression systems.

Ensure water detection sensors are implemented in the data center.

The Under Secretary for Health directs the Office of Primary Care and Office of Mental Health and Suicide Prevention to identify barriers to provider documentation of opioid use disorder in progress notes and implement solutions addressing these barriers.

The Under Secretary for Health ensures the Office of Primary Care and Office of Mental Health and Suicide Prevention determine impediments to maintaining accurate identification of opioid use disorder in electronic health record problem lists and implement policy and training to support accurate use of problem lists.

The Under Secretary for Health confirms the Office of Primary Care and Office of Mental Health and Suicide Prevention evaluate barriers affecting provider access and use of Department of Defense treatment records in Joint Longitudinal Viewer and implement solutions.

The Under Secretary for Health ensures the Office of Primary Care and Office of Mental Health and Suicide Prevention improve continuity of care by confirming providers are educated on the navigation and retrieval of Department of Defense treatment records in Joint Longitudinal Viewer.

The Under Secretary for Health requires the Assistant Under Secretary for Health for Clinical Services/Chief Medical Officer to evaluate and update processes for identification of veterans with a history of opioid use disorder for the provision of opioid overdose risk mitigation strategies.

Update the reporting methodology used in public reports to reflect the total time veterans wait for a final claims decision when their higher level reviews require a supplemental claim be established and completed due to an error.

Revise and clearly state the measures used for calculating and reporting the average duration, from the filing of an initial claim until the claim is resolved and claimants no longer take any action under the Appeals Modernization Act claim, and ensure consistency with subsection M of the act.

The assistant secretary for information and technology and chief information officer implement processes to prevent the use of prohibited software on agency devices.

The assistant secretary for information and technology and chief information officer ensure network segmentation controls are applied to all network segments with medical devices and special-purpose systems.

The St. Cloud VA Medical Center director ensure video surveillance systems are operational and monitored for the data center.

The St. Cloud VA Medical Center director ensure communication rooms with infrastructure equipment have adequate environmental controls.

Improve vulnerability management processes to ensure system changes occur within organization timelines.

Develop and approve an authorization to operate for the special-purpose system.

The under secretary for benefits reduces improper and unknown payments to below 10 percent for the Pension Program.

The under secretary for health reduces improper and unknown payments to below 10 percent for the Purchased Long-Term Services and Supports Program.

Director of the Veterans Transportation Program determines what system changes are needed to meet auto-adjudication goals and implement these changes.

Director of the Veterans Transportation Program conducts outreach to users, solicits feedback, and considers whether system changes are needed based on feedback, to increase self-service portal usage.

Assistant Under Secretary for Health for Operations create an action plan to phase out continued use of the VistA beneficiary travel function.

Assistant Under Secretary for Health for Operations coordinates with the veteran’s health administration office of finance and assess whether duplicate payments were made to veterans requesting travel reimbursement since the new system went live.

The District Director determines reasons administrative quality review remediation plans did not include documentation of deficiency resolution and the time frame of resolution for the Dundalk, Raleigh, and Richmond Vet Centers; takes indicated actions to ensure completion; and monitors compliance.

The District Director determines reasons for lack of evidence for administrative quality review deficiency resolution for the Dundalk, Raleigh, and Richmond Vet Centers; takes indicated actions to ensure completion; and monitors compliance.

The District Director ensures the intake portion of the psychosocial assessment is completed and monitors compliance across all zone vet centers.

The District Director ensures suicide risk assessments are completed on the first clinical visit and monitors compliance across all zone vet centers.

The District Director ensures clinical staff complete safety plans for clients that are assessed at intermediate or high suicide risk level in either acute, chronic, or both categories as required; and monitors compliance across all zone vet centers.

The District Director ensures clinical staff consult with the vet center director, external clinical consultant, associate district director for counseling, or support VA medical facility mental health provider following a client’s suicide risk assessment as required; and monitors compliance across all zone vet centers.

The District Director, in collaboration with the support VA medical facility clinical or administrative liaisons, determines the reasons for noncompliance with staff participation on the mental health council for the Baltimore, Dundalk, Raleigh, and Richmond Vet Centers; and takes action as indicated to ensure compliance with Readjustment Counseling Services requirements.

The District Director determines reasons for noncompliance with High Risk Suicide Flag SharePoint site requirements and the tracking of continuity of care for clients at risk at the Raleigh Vet Center and takes action to ensure requirements are met, and monitors compliance.

The District Director determines the reasons for noncompliance with staff access to critical event plans that included a desktop reference at the Baltimore and Dundalk Vet Centers and takes actions as indicated to ensure compliance with Readjustment Counseling Service requirements.

The District Director determines reasons for noncompliance with a process for completing and tracking four hours of external clinical consultation per month at the Baltimore, Dundalk, and Raleigh Vet Centers; ensures vet center directors implement processes; and monitors compliance.

The District Director determines reasons employees at the Baltimore, Dundalk, Raleigh, and Richmond Vet Centers did not complete required trainings; ensures all staff complete mandatory trainings; and monitors compliance.

The District Director reviews reasons for noncompliance with maintaining a current and comprehensive emergency and crisis plan at the Raleigh and Richmond Vet Centers and ensures all emergency and crisis plans are updated and comprehensive as required.

The District Director determines reasons for lack of evidence that clinical quality review deficiencies were resolved at the Center City, Huntington, Northeast, and Scranton Vet Centers; takes indicated actions to ensure completion; and monitors compliance.

The District Director determines reasons administrative quality review remediation plans did not include documentation of deficiency resolution and the time frame for resolution for the Center City, Huntington, Northeast, and Scranton Vet Centers; takes indicated actions to ensure completion; and monitors compliance.

The District Director determines reasons for lack of evidence for administrative quality review deficiency resolution for the Center City, Huntington, Northeast, and Scranton Vet Centers; takes indicated actions to ensure completion; and monitors compliance.

The District Director ensures the intake portion of the psychosocial assessment is completed, and monitors compliance across all zone vet centers.

The District Director ensures suicide risk assessments are completed on the first clinical visit, and monitors compliance across all zone vet centers.

The District Director ensures clinical staff consult and coordinate care with the support VA medical facility for shared clients flagged as high risk for suicide, and monitors compliance across all zone vet centers.

The District Director confirms clinical staff make timely notification to the suicide prevention coordinator at the support VA medical facility for clients with significant safety risks, and monitors compliance across all zone vet centers.

The District Director ensures clinical staff complete safety plans for clients that are assessed at intermediate or high suicide risk level in either acute, chronic, or both categories as required, and monitors compliance across all zone vet centers.

The District Director ensures clinical staff consult with the vet center director, external clinical consultant, associate district director for counseling, or support VA medical facility mental health provider following a client’s suicide risk assessment as required, and monitors compliance across all zone vet centers.

The District Director, in collaboration with the support VA medical facility clinical or administrative liaisons, determines the reasons for noncompliance with staff participation on the mental health council for the Center City, Huntington, Northeast, and Scranton Vet Centers, and takes actions as indicated to ensure compliance with Readjustment Counseling Service requirements.

The District Director determines reasons employees at the Center City, Huntington, Northeast, and Scranton Vet Centers did not complete required trainings; ensures all staff complete mandatory trainings; and monitors compliance.

The District Director reviews reasons for noncompliance with having a current and comprehensive emergency and crisis plan at the Center City and Northeast Vet Centers, ensures completion of a current and comprehensive emergency and crisis plan, and monitor’s compliance.

Establish guidance that outlines the type of documentation required to support the amounts identified in the manual journal vouchers when processing expenditure transfers.

Require medical facility staff have documented authority, through proper delegation, to make purchases.

Verify that medical facility staff segregate duties so that the same person is not both authorizing and receiving goods and services.

Make certain the purchase card holder is not the requestor or approver for the purchase.

Ensure contracting officer’s representatives know and understand their duties and responsibilities for the certification and payment of invoices.

Check vendors’ compliance with contract terms to include the comparison of invoiced amounts with the contract line-item unit costs.esponse to the pandemic and develop appropriate action plans to integrate oversight roles, responsibilities, and clear guidance into the use of supplemental funds.

Ensure that medical facility staff track the receipt of goods to make certain they are the correct quantity.

The Under Secretary for Health evaluates provider knowledge and utilization of VA Video Connect technology, including resources such as the Digital Divide Consult, Connected Devices Support Program, and VVC Now and takes action as indicated.

The Under Secretary for Health evaluates availability of clinical and administrative support to providers initiating and completing VA Video Connect encounters and clarifies expectations and requirements to ensure access to virtual care emulates in-person encounters.

The Under Secretary for Health ensures education of providers and support staff regarding VA Video Connect scheduling processes.