All Reports

Take action to help reduce unwarranted reexaminations by updating guidance and enhancing information systems to require rating specialists to cite objective evidence and provide justification for establishing reexamination controls.

Consider establishing criteria to define a “locally-designated claims processor with expertise in review examination ordering” and ensure these claims processors meet all training requirements related to establishing and ordering medical reexaminations.

Update training materials to include the guidance from VBA Policy Letter 21-01, “Updated Guidance on Routine Future Examination Requests” and ensure these claims processors meet all training requirements related to establishing and ordering medical reexaminations

The executive director for the Veterans Health Administration Office of Integrity and Compliance implements planned revisions of policies and procedures for the Office of Integrity and Compliance to ensure it performs accurate List of Excluded Individuals and Entities monitoring, including for individuals with alternative or prior names or using social security numbers (if accessible), and provides timely notification of potential violations to appropriate staff.

The executive director for the Veterans Health Administration (VHA) Office of Integrity and Compliance performs a one-time audit of VA employment records using corrected matching practices to determine whether any individuals on the List of Excluded Individuals and Entities are receiving payments using VA healthcare program funds, and, if so, whether additional revisions to policies and procedures of the VHA Office of Integrity and Compliance, the VHA Office of Human Capital Management, or any other element of VA are required to address the causes, including any related screening and/or monitoring process failures.

The Secretary of Veterans Affairs delegates to a responsible official the monitoring of VA facilities’ security-related vacancies and reports monthly on hiring trends and whether recent recruitment and hiring authorities established since the fiscal year 2021 Police National Strategic Recruitment Plan are resulting in improvements.

The Secretary of Veterans Affairs authorizes sufficient staff for the Human Resources and Administration/Operations, Security and Preparedness’ Office of Security and Law Enforcement to inspect the VA police forces, per the OIG’s 2018 unimplemented recommendation.

The under secretary for health ensures medical facility directors use appropriate measures to assess VA police staffing needs, authorizes associated positions, and leverages available mechanisms to fill vacancies.

The under secretary for health verifies that medical facility directors commit sufficient resources to make certain that facility security measures are adequate, current, and operational.

The under secretary for health directs Veterans Integrated Service Network police chiefs, in coordination with medical facility directors, facility police chiefs, and facility emergency management leaders, to present a plan to remedy identified security weaknesses, including inoperative cameras, unsecured doors, and the lack of security presence at main entrances.

The assistant secretary for Human Resources and Administration/Operations, Security, and Preparedness establishes policy that standardizes the review and retention requirements for footage captured by facility security cameras.

Ensure supply chain management staff implement a plan for staff training to increase awareness of internal controls and data reliability within the Generic Inventory Package.

Ensure the chief of supply chain services signs quarterly physical inventory memorandums of “A” classified items and make them available to Veterans Integrated Service Network personnel as required in the Veterans Health Administration’s Directive 1761 Supply Chain Management Operations.

Develop and implement a plan to increase inventory turnover to meet the level recommended by the Veterans Health Administration Pharmacy Benefits Management Office.

Develop and implement a plan to complete monthly B09 reconciliation consistently to ensure discrepancies are corrected in a timely manner.

The Under Secretary for Health ensures the Office of Mental Health and Suicide Prevention develops, implements, and monitors action plans to meet Intensive Community Mental Health Recovery visit frequency requirements, to include program resource needs and the ongoing role for virtual care.

The Under Secretary for Health requires the Office of Mental Health and Suicide Prevention to develop a process for Intensive Community Mental Health Recovery programs to ensure veterans receiving low-intensity services do not represent greater than 20 percent of caseloads and to distinguish between veterans receiving high- and low-intensity services for accurate and effective program oversight.

The Under Secretary for Health identifies barriers and ensures healthcare systems develop, implement, and maintain contingency plans specific to Intensive Community Mental Health Recovery programs regarding veteran access to medications during emergencies, including long-acting injectable antipsychotic medications.

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

Verify that access control lists have been applied to network segments that contain medical systems.

Validate that appropriate physical and environmental security measures are implemented and functioning as intended.

The Under Secretary for Health ensures compliance with suicide risk and lethal means safety training requirements.

The Under Secretary for Health evaluates the efficacy of the May 2022 Veterans Integrated Service Network and Office of Mental Health and Suicide Prevention oversight structure for suicide risk training and considers inclusion of an oversight structure for lethal means safety training compliance.

The Under Secretary for Health evaluates the adequacy of the one-time lethal means safety training requirement and takes action as appropriate.

The Under Secretary for Health ensures clinician completion of comprehensive suicide risk evaluations including the discussion and documentation of firearms access and safe storage as required, and monitors compliance.

The Under Secretary for Health evaluates staff’s perceived barriers to completion of the suicide risk identification strategy and takes action as appropriate.

Monitor facility follow-up rates by type of care and on a month-over-month basis, establish monitoring metrics, and assist facilities if they fall below these metrics.

Evaluate and update, as appropriate, whether activities that occurred before cancellation and notations of “No Action Other Reason” should be tracked as follow-up.

Absent such relief, provide information detailing the limitations that prevent VA from reporting the average number of days that potential title 38 or hybrid title 38 hires spent in each phase of the hiring model in accordance with section 3008(a)(E)(iii) of the Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020.

Assign specific roles and responsibilities to the Office of Integrated Veteran Care to ensure effective oversight of the Referral Coordination Initiative.

Make certain that staff with Referral Coordination Initiative responsibilities are sufficiently trained on how to triage, communicate key information on options to veterans, schedule, or document consults, according to their respective duties.

Direct relevant VA medical facilities to establish local processes by which VA medical facility staff identify and share available community care wait time data with referral coordination team members within each facility, and then establish controls to help ensure that this information is consistently communicated to patients.

Establish a mechanism or update the Referral Coordination Initiative checklist to effectively track and monitor each facility’s challenges with implementation and progress toward implementing the initiative for all relevant specialty services.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility surgical work groups meet monthly and core members consistently attend meetings.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facility surgical work groups consistently review surgical deaths.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that chiefs of staff and associate directors for patient care services ensure all required members attend disruptive behavior committee or board meetings.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that medical center directors ensure staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work area.

The Under Secretary for Health ensures that Intimate Partner Violence Assistance Program protocols are developed at all medical centers consistent with the national requirement.

The Under Secretary for Health evaluates the sufficiency of current guidance and operational status regarding Intimate Partner Violence Assistance Program coordinators’ dedicated time and population needs, and takes action as warranted.

The Under Secretary for Health determines the appropriate guidance for dedicated administrative staff support in consideration of the Intimate Partner Violence Assistance Program coordinators’ responsibilities, and takes action as warranted.

The Under Secretary for Health considers the establishment of standardized Intimate Partner Violence staff training content and format as well as the evaluation of training efficacy, and takes action as warranted.

The Under Secretary for Health develops intimate partner violence screening requirements based on the current guidance and patient population needs, and takes action as warranted.

The Under Secretary for Health expedites standardized program evaluation processes with oversight and reporting responsibilities to ensure identification of implementation and program deficiencies and monitoring of corrective action and performance improvement plans.

The Under Secretary for Health evaluates the current guidance and operational status related to the roles and oversight functions of the Veterans Integrated Service Network Intimate Partner Violence Assistance Program champions and lead coordinators and clarifies expectations and requirements.

Assess compliance weaknesses identified by VA Office of Procurement Policy, Systems and Oversight internal reviews, and implement corrective actions determined appropriate.

Require contracting officers responsible for Buy American Act compliance deficiencies identified by contract file reviewers and VA Office of Procurement Policy, Systems and Oversight internal reviews to attend refresher Buy American Act–specific training.

Perform security control assessments of the video surveillance system and obtain an authorization to operate in accordance with set policy.