All Reports

Review of Veterans Health Administration’s Response to a Medication Recall
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21-02194-198
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2022
The Under Secretary for Health evaluates current guidance regarding the monitoring and reporting of medication recall adverse drug events and makes changes as necessary.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2022
The Under Secretary for Health reviews vulnerabilities in the medication recall process due to variances in Veterans Health Administration medical facility processes and makes changes as necessary.
The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm
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22-01137-204
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Topics:  Electronic Health Records Modernization (EHRM) ● Patient Safety

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No. 1
Not Implemented Recommendation Image, X character'
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 9/28/2022

The Deputy Secretary reviews the process that led to Oracle Cerner’s failure to inform VA of the unknown queue and takes action as indicated.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 2/13/2023

The Deputy Secretary evaluates the unknown queue technology and mitigation process and takes action as indicated.

Contract Closeout Compliance Needs Improvement at Regional Procurement Offices Central and West
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21-02599-156
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Topics:  Contract Integrity

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2023
Establish procedures for consistent quality assurance reviews to ensure all contract closeout requirements, such as identifying and deobligating excess funds, closing out contracts timely, and properly completing and uploading closeout documentation, are performed in accordance with the Federal Acquisition Regulation and the Veterans Health Administration procurement manual. Further, update Veterans Health Administration policies and procedures to provide guidance on conducting and documenting the reviews.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2022
Assess and determine how to effectively distribute contracting officer workload and address imbalances among staff to help ensure contract closeouts are completed in accordance with the Federal Acquisition Regulation and the Veterans Health Administration procurement manual.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2022
Clarify the Veterans Health Administration procurement manual to indicate when simplified acquisition procedures closeout processes are to be used and the documentation requirements for each contract closeout step.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2022
Determine whether setting aside specific time weekly to focus on contract administration tasks, such as contract closeout, and using contractors to perform closeout procedures could improve contract closeout compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2022
Ensure the contract files for the 81 sampled contracts have complete closeout documentation in accordance with the Federal Acquisition Regulation and the Veterans Health Administration procurement manual.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 4,400,000.00
Financial Efficiency Review of the VA Boston Healthcare System in Massachusetts
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21-03853-174
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Topics:  Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2022
Ensure that healthcare system finance office staff are made aware of policy requirements and that reviews are conducted on all inactive open obligations, and deobligate any identified excess funds as required by VA Financial Policy, vol. 2, chap. 5, “Obligations Policy.”
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
Ensure cardholders comply with record retention requirements as stated in VA’s Financial Policy, vol. XVI, “Charge Card Programs.”
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
Establish controls to confirm approving officials and purchase cardholders review their purchases and make sure contracting is used when it is in the best interest of the government.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2022
Require purchase cardholders to submit a request for ratification for any unauthorized commitments identified.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2022
Ensure quarterly purchase card audits are performed as required by the Veterans Health Administration’s standard operating procedure, “Internal Audits—Purchase Cards and Convenience Checks.”
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2023
Ensure supply chain management staff implement a plan to improve data reliability within the Generic Inventory Package system.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2023
Ensure the chief of supply chain management signs quarterly physical inventory memorandums of “A” classified items and makes them available to Veterans Integrated Service Network personnel as required in the VHA’s Directive 1761 Supply Chain Management Operations.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
Develop and implement a plan to increase inventory turnover to meet the level recommended by the Veterans Health Administration Pharmacy Benefits Management Office.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 379,439.00
Mission Accountability Support Tracker Lacked Sufficient Security Controls
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21-03080-142
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Topics:  Information Technology and Security

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 10/25/2022
The OIG recommends the Assistant Secretary for Information and Technology develop controls to help ensure minor applications are not misclassified as assets and undergo the appropriate security accreditation and certification process.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT),Veterans Benefits Administration (VBA)
Closure Date: 8/7/2023
The OIG recommends the Assistant Secretary for Information and Technology in conjunction with the Under Secretary for Benefits, make certain that appropriate security and privacy controls are implemented during the development of information technology systems before being hosted on VA’s network.
No. 3
Open Recommendation Image, Square
to Information and Technology (OIT),Veterans Benefits Administration (VBA)
The OIG recommends the Under Secretary for Benefits, in conjunction with the Assistant Secretary for Information and Technology, establish a mechanism to gain assurance that proper Office of Information Technology project management processes and protocols are followed when establishing information technology systems and applications.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/25/2022
The OIG recommends the Under Secretary for Benefits establish policies and procedures to ensure the Mission Accountability Support Tracker is used appropriately and does not contain unnecessary personally identifiable information.
Contract Medical Exam Program Limitations Put Veterans at Risk for Inaccurate Claims Decisions
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21-01237-127
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Topics:  Claims and Medical Exams

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/24/2023
Assess and modify contracts and any renewals to ensure that vendors can be heldaccountable for unsatisfactory performance by applying monetary disincentives.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/5/2023
Assess and modify contracts and any renewals to ensure procedures are established for vendors to correct errors identified by the Medical Disability Examination Office.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/5/2023
Implement procedures requiring the Medical Disability Examination Office tocommunicate exam errors to the Office of Field Operations and the regional officesand demonstrate progress in correcting the identified errors.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/10/2022
Implement procedures requiring the Medical Disability Examination Office toanalyze all available error data and provide systemic exam issues and error trends tovendors.
Inspection of Information Technology Security at the Consolidated Mail Outpatient Pharmacy in Tucson, Arizona
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21-02453-99
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Topics:  Information Technology and Security

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/1/2022
Implement more effective inventory management tools for all network segments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 9/29/2022
Implement a more effective vulnerability and flaw remediation program that can accurately identify vulnerabilities and enforce flaw remediation.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/1/2022
Develop and implement methods to ensure delivery, receipt, and understanding of assigned roles and responsibilities for Consolidated Mail Outpatient Pharmacy activities to ensure full implementation of approved policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 9/25/2023
Develop and implement a disaster recovery plan and capability that will restore operations in the event of a disruption to critical operations.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/1/2022
Task the facility manager to change the default username and password for the security camera system.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 9/29/2022
Request the Office of Information and Technology to configure audit logging on the misconfigured devices in accordance with established baselines, policy, and procedures.
Veterans Data Integration and Federation Enterprise Platform Lacks Sufficient Security Controls
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21-01123-97
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Topics:  Information Technology and Security

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No. 1
Not Implemented Recommendation Image, X character'
to Information and Technology (OIT)
Closure Date: 8/7/2023
The assistant secretary for information and technology and chief information officer will ensure the Veterans Data Integration and Federation Enterprise Platform security objectives are all set at a categorization level of high based upon both the sensitive personal information maintained in the system and the approved risk assessment.
No. 2
Not Implemented Recommendation Image, X character'
to Information and Technology (OIT)
Closure Date: 8/7/2023
The assistant secretary for information and technology and chief information officer will act to reestablish the Veterans Data Integration and Federation Enterprise Platform in the Enterprise Mission Assurance Support Service to ensure appropriate security controls are implemented and the system is assessed at the high risk level.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/4/2023
The assistant secretary for information and technology and chief information officer will ensure the Office of Information Technology provides appropriate oversight and follows proper program management processes and protocols when establishing and monitoring security controls for IT systems.
Inspection of Information Technology Security at the Consolidated Mail Outpatient Pharmacy in Dallas, Texas
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21-03305-139
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Topics:  Information Technology and Security

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 10/20/2022
Implement an effective inventory management system for all network segments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/23/2023
Implement an effective vulnerability and flaw remediation program that can accurately identify vulnerabilities and enforce flaw remediation
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/1/2022
Develop and implement methods to ensure delivery, receipt, and understanding of assigned roles and responsibilities for local activities to ensure full implementation of approved policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/1/2022
Implement effective configuration control processes that ensure network devices maintain standards mandated by the VA Office of Information and Technology Configuration Control Board.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/14/2025

Remove or disable group accounts to comply with established requirements and criteria.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/1/2022
Ensure employees lock devices when they are unattended.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/1/2022
Implement database authentication processes that comply with National Institute of Standards and Technology standards and VA security requirements.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 10/20/2022
Implement a process to retain database logs for a period consistent with VA’s record retention policy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/1/2022
Establish a process for validating and logging the sanitization of hard drives.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 10/20/2022
Implement parking barriers that meet VA Physical Security & Resiliency Design Manual requirements.
Care in the Community Healthcare Inspection of VA Midwest Health Care Network (VISN 23)
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21-01820-159
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Topics:  Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2023
The VISN 23 Director ensures implementation and sustainment of initial and annual home visits for patients accepted into the VISN 23 home dialysis program.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2023
The VISN 23 Director ensures the implementation and sustainment of quality monitoring of contracted clinical services for home dialysis.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2023
The VISN 23 Director ensures that VA providers receive mammography reports from non-VA providers within the established acceptable timeframe.
Joint Audit of the Department of Defense and the Department of Veterans Affairs Efforts to Achieve Electronic Health Record System Interoperability
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18-04227-91
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Topics:  Electronic Health Records Modernization (EHRM)

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 1/3/2023

We recommend that the Deputy Secretary of Defense and Deputy Secretary of Veterans Affairs review the actions of the Federal Electronic Health Record Modernization Program Office and direct the Federal Electronic Health Record Modernization Program Office to develop processes and procedures in accordance with the Federal Electronic Health Record Modernization Program Office charter and the National Defense Authorization Acts.

Additional Actions Can Help Prevent Benefits Payments from Being Sent to Deceased Veterans
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21-00836-124
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Topics:  Claims and Medical Exams ● Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/20/2022
The under secretary for benefits implements procedures to identify failed automated weekly death matches and demonstrate progress towards processing all failed matches.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/28/2023
The under secretary for benefits implements a process to review the social security number verification program and demonstrate progress towards ensuring the accuracy of social security numbers in VBA’s electronic systems.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/28/2023
The under secretary for benefits implements an intra-agency data-sharing process with the Veterans Health Administration and demonstrate progress in obtaining information on veterans’ deaths.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 677,385.00
Federal Information Security Modernization Act Audit for Fiscal Year 2021
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21-01309-74
|
Topics:  FISMA

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology consistently implement an improved continuous monitoring program in accordance with the NIST Risk Management Framework. Specifically, implement an independent security control assessment process to evaluate the effectiveness of security controls prior to granting authorization decisions. (This is a repeat recommendation from prior years.)
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement improved mechanisms to ensure system stewards and Information System Security Officers follow procedures for establishing, tracking, and updating Plans of Action and Milestones for all known risks and weaknesses including those identified during security control assessments. (This is a repeat recommendation from prior years.)
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement controls to ensure that system stewards and responsible officials obtain appropriate documentation prior to closing Plans of Action and Milestones. (This is a repeat recommendation from prior years.)
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology develop mechanisms to ensure system security plans reflect current operational environments, include an accurate status of the implementation of system security controls, and all applicable security controls are properly evaluated. (This is a repeat recommendation from prior years.)
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement improved processes for reviewing and updating key security documents such as security plans, risk assessments, and interconnection agreements on an annual basis and ensure the information accurately reflects the current environment. (This is a repeat recommendation from prior years.)
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement improved processes to ensure compliance with VA password policy and security standards on domain controls, operating systems, databases, applications, and network devices. (This is a repeat recommendation from prior years.)
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement periodic reviews to minimize access by system users with incompatible roles, permissions in excess of required functional responsibilities, and unauthorized accounts. (This is a repeat recommendation from prior years.)
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology enable system audit logs on all critical systems and platforms and conduct centralized reviews of security violations across the enterprise. (This is a repeat recommendation from prior years.)
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Office of Personnel Security, Human Resources, and Contract Offices implement improved processes for establishing and maintaining accurate data within VA’s authoritative system of record for background investigations. (This is a modified repeat recommendation from prior years.)
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Office of Personnel Security, Human Resources, and Contract Offices strengthen processes to ensure appropriate levels of background investigations are completed for applicable VA employees and contractors. (This is a modified repeat recommendation from prior years.)
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement more effective automated mechanisms to continuously identify and remediate security deficiencies on VA’s network infrastructure, database platforms, and web application servers. (This is a repeat recommendation from prior years.)
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement a more effective patch and vulnerability management program to address security deficiencies identified during our assessments of VA’s web applications, database platforms, network infrastructure, and workstations. (This is a repeat recommendation from prior years.)
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology maintain a complete and accurate security baseline configuration for all platforms and ensure all baselines are appropriately monitored for compliance with established VA security standards. (This is a repeat recommendation from prior years.)
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement improved network access controls that restrict medical devices from systems hosted on the general network. (This is a repeat recommendation from prior years.)
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology consolidate the security responsibilities for networks not managed by the Office of Information and Technology, under a common control for each site and ensure vulnerabilities are remediated in a timely manner. (This is a repeat recommendation from prior years.)
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement improved processes to ensure that all devices and platforms are evaluated using credentialed vulnerability assessments. (This is a repeat recommendation from prior years.)
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Acting Assistant Secretary for Information and Technology implement improved procedures to enforce standardized system development and change control processes that integrates information security throughout the life cycle of each system. (This is a repeat recommendation from prior years.)
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology review system boundaries, recovery priorities, system components, and system interdependencies and implement appropriate mechanisms to ensure that established system recovery objectives can be measured and met. (This is a modified repeat recommendation from prior years.)
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology ensure that contingency plans for all systems are updated to include critical inventory components and are tested in accordance with VA requirements. (This is a repeat recommendation from prior years.)
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement more effective agency-wide incident response procedures to ensure timely notification, reporting, updating, and resolution of computer security incidents in accordance with VA standards. (This is a repeat recommendation from prior years.)
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology ensure that VA’s Cybersecurity Operations Center has full access to all security incident data to facilitate an agency-wide awareness of information security events. (This is a repeat recommendation from prior years.)
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement improved safeguards to identify and prevent unauthorized vulnerability scans on VA networks. (This is a repeat recommendation from prior years.)
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement improved measures to ensure that all security controls are assessed in accordance with VA policy and that identified issues or weaknesses are adequately documented and tracked within POA&Ms. (This is a repeat recommendation from prior years.)
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology fully develop a comprehensive list of approved and unapproved software and implement continuous monitoring processes to prevent the use of prohibited software on agency devices. (This is a repeat recommendation from prior years.)
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology develop a comprehensive inventory process to identify connected hardware, software, and firmware used to support VA programs and operations. (This is a repeat recommendation from prior years.)
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/17/2023
We recommended the Assistant Secretary for Information and Technology implement improved procedures for monitoring contractor-managed systems and services and ensure information security controls adequately protect VA sensitive systems and data. (This is a repeat recommendation from prior years.)
Noncompliant and Deficient Processes and Oversight of State Licensing Board and National Practitioner Data Bank Reporting Policies by VA Medical Facilities
|
20-00827-126
|
Topics:  Medical Staff Privileging Credentialing ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2024

The Under Secretary for Health reviews the State Licensing Board reporting processes at the facility level to ensure compliance with Veterans Health Administration policy, identifies noncompliance, and takes action as warranted.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health ensures that the National Practitioner Data Bank facility reporting practices align with federal regulations and Veterans Health Administration policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2024

The Under Secretary for Health instructs facility directors to submit National Practitioner Data Bank reports regarding physicians and dentists consistent with Veterans Health Administration policy.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2025

The Under Secretary for Health ensures programmatic oversight of facility State Licensing Board and National Practitioner Data Bank reporting processes.

Improved Governance Would Help Patient Advocates Better Manage Veterans’ Healthcare Complaints
|
21-00510-105
|
Topics:  Healthcare Infrastructure

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2024

Review and update, as appropriate, program policy to formally align with the Office of Patient Advocacy’s program expectations, including when complaints must be entered into a patient advocate tracking system and the responsibilities of patient advocate supervisors.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2023
Implement controls that require facility patient advocate supervisors and Veterans Integrated Service Network patient advocate coordinators to perform regular, documented reviews of records in the patient advocate tracking system to monitor that the required information is entered properly.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2024

Provide guidance to medical facility directors to ensure they fulfill their required Patient Advocacy Program management duties, including timely complaint resolution and trending complaint data.

Public Disability Benefits Questionnaires Reinstated but Controls Could Be Strengthened
|
21-02750-63

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/11/2022
Revise the Veterans Benefits Administration’s adjudication procedures manual to clarify and communicate steps that claims processors must take to ensure all certification elements on the publicly available disability benefits questionnaires are provided and are authentic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/11/2022
Update the Veterans Benefits Administration’s adjudication procedures manual to clarify the intent of guidance involving authenticity, face value, and validation of publicly available disability benefits questionnaires to ensure claims processors evaluate the questionnaires in accordance with evidentiary principles
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/26/2022
Implement actions to facilitate claims processors’ understanding of the need to document the evaluation of evidence within benefits entitlement decisions when using publicly available disability benefits questionnaires.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/21/2022
Amend the Veterans Benefits Administration’s adjudication procedures manual to define valid rationale to ensure medical opinions are well supported when deciding entitlement to benefits.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/30/2024

Correct all processing errors on cases identified by the review team and report the results to the Office of Inspector General.

Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 88,700.00
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