All Reports

Enforce procedures for Veterans Health Administration human resources officials to monitor employee service obligations and initiate a debt notice when an employee breaches that agreement, if warranted.

Identify and review active incentives of Veterans Health Administration employees who transferred within or left VA and take action, if appropriate.

Establish enhanced internal controls to ensure compliance with the law on recruitment, relocation, and retention incentives and take appropriate action when an employee with an active service obligation transfers within the Veterans Health Administration.

Complete the evaluation of the incentives awarded to the employees identified in this report who may not have fulfilled their service obligations, determine whether a debt was incurred, and take any appropriate action.

Require the chief operating officer to direct the Veterans Integrated Service Network directors to fully integrate the core services in accordance with policy to improve operational efficiencies and access for veterans.

Establish a process requiring medical facility directors to coordinate with the Office of Integrated Veteran Care and the clinical contact centers before setting up or maintaining a local phone queue for services the clinical contact center provides.

Require the Office of Integrated Veteran Care to direct the clinical contact center leaders to determine if schedulers are arbitrarily ending calls in the telephone system to remain in after-call work status longer than needed to reduce the number of calls routed to them.

Require the Office of Integrated Veteran Care to review and address inconsistencies in guidance on schedulers’ availability.

Direct clinical contact center leaders to routinely evaluate and, if needed, address schedulers’ handle time and availability time to improve performance and reduce inefficiencies.

Direct the Office of Integrated Veteran Care to include schedulers’ handle time and availability time as part of VA Health Connect’s annual performance plans to make sure clinical contact centers monitor and address these areas.

Make sure the Office of Integrated Veteran Care and chief operating officer evaluate VA Health Connect staffing for scheduling and, if necessary, reallocate staff so all clinical contact centers provide core services and meet required performance standards for scheduling.

Direct the Office of Integrated Veteran Care to formalize and clarify internal waiver guidance and include examples of the specific evidence that would be required for a clinical contact center not to provide 24-hour services—such as exploring the use of other strategies like routing calls to another service or partnering with other centers to provide coverage.

Ensure the assistant under secretary for health for the Office of Integrated Veteran Care and chief operating officer periodically review the clinical contact center waiver submissions and the planned actions to comply with VA Health Connect requirements.

Review all processing errors on cases the Office of Inspector General team identified, correct those errors, and report back on the results of those actions.

Collaborate with key stakeholders—such as the VA Secretary and representatives from the Office of Field Operations, the Office of General Counsel, and as needed the Board of Veterans’ Appeals—to prioritize consolidating the guidance for PACT Act claims processing into the Adjudication Procedures Manual.

Evaluate the effectiveness of control activities specifically for denials of nonpresumptive conditions under toxic exposure risk activity procedures and determine where new or stronger controls are needed.

Review all processing errors on cases the OIG review team identified, correct those errors to the extent possible, and report back on the results of those actions.

Evaluate the effectiveness of control activities specifically for authorization rate outliers and determine whether new or stronger controls are needed.

Strengthen controls in the Office of the Assistant Director to ensure inclusion of staffing monitoring contract requirements, in coordination with the contracting officer, to meet gradual staffing level goals during start-up periods in future community‑based outpatient clinic contracts.

Strengthen controls to ensure data used for monitoring contract performance standards are accurate and comply with the methodology required in the contract’s Quality Assurance Surveillance Plan.

Review the medical staff-driven phase of the credentialing process, to ensure action plans implemented to expedite the credentialing process are effective.

Strengthen controls to ensure contracted staff complete required scheduling training before granting them access to VA’s scheduling system and authorizing them to make veteran appointments.

Review the healthcare system’s staffing augmentation plan and coordinate with the contracting officer to ensure the full costs are recovered for all Veterans Health Administration staff who provided services for which the contractor was also compensated.

Review the unilateral memorandum related to staffing augmentation, establish a contract modification in compliance with the Federal Acquisition Regulation provisions regarding contract changes, and ensure relevant documentation is maintained in the contract file.

Recover government funds expended for Veterans Health Administration staff augmented at contracted community-based outpatient clinics using full cost amounts.

Review and enforce staffing contingency plan requirements for the Loma Linda Healthcare System contract, including maximizing the contractor’s use of temporary replacements, or locum tenens, to minimize staffing shortages.

Strengthen oversight mechanisms to ensure the enforcement of staffing requirements during contract start-up in future community‑based outpatient clinic contracts before the clinics become operational.

Ensure the Palo Alto major construction project (project number 640-424) is brought into the Acquisition Program Management Framework.

Ensure the activities and artifacts required during the verify phase of the Acquisition Program Management Framework are completed for the Palo Alto major construction project (project number 640-424)—including a business case with cost, schedule, and performance goals approved by the Secretary.

Ensure a decision event to verify the need of the acquisition is conducted for the Palo Alto major construction project (project number 640-424) and a determination is made to terminate or continue this project based on VA’s strategic needs and the VA Palo Alto Health Care System’s clinical needs.

Ensure VA’s FY 2025 Agency Capital Plan is revised to show the Palo Alto major construction project’s current total estimated cost and the progress the project has made toward meeting its critical objectives.

Ensure processes and guidance are in place for the director of the Office of Construction and Facilities Management to provide appropriate oversight and management over minor construction projects consistent with the authority and responsibilities described in 38 U.S.C. § 312A.

Revise the Veterans Health Administration directive on minor construction projects to incorporate 38 U.S.C. § 312A requirements and develop a review process for confirming compliance with the Office of Construction and Facilities Management’s guidance and any applicable industry standards.

Review the Audie L. Murphy emergency department exam and fast-track rooms for compliance with applicable design and equipment standards and provide any recommendations to the executive director of the South Texas Veterans Health Care System.

Review an assessment by the Office of Construction and Facilities Management of the Audie L. Murphy’s emergency department for compliance with design and equipment requirements to determine what changes, if any, are necessary and take appropriate corrective action.

Ensure a disability compensation examiner who has completed PACT Act training provides an independent assessment and medical opinion for the 29 VHA and five VBA nonpresumptive PACT Act opinions identified by the Office of Inspector General that were provided before completing PACT Act training, and readjudicate the claims as needed.

Establish and use agreements with other VA medical facilities to help identify and schedule direct care when services are unavailable at a veteran’s local VA facility.

At least annually, emphasize to schedulers the proper methods (including the use of codes) to document when veterans opt out of community care.

Require the medical facility director at the Jesse Brown VA Medical Center in Chicago to make sure veterans who request mental health services are assessed for community care and informed of all potential care options.

Require medical facility directors in Veterans Integrated Service Network 12 to review and process consults initiated in the first quarter of fiscal year 2024 that remain in a pending, active, or scheduled status.

Confirm that medical facility directors develop local guidance on using automated dispensing cabinets in accordance with VHA Directive 1108.21 (and any revisions to this directive) and that facilities comply with that local guidance.

Require Pharmacy Benefits Management Services to revise VHA Directive 1108.21 to include routine monitoring for the use of generic information as a requirement in facility-level guidance for automated dispensing cabinets.

Ensure, in coordination with the controlled substance coordinator, or appropriate designee, and Veterans Integrated Service Networks, that reports detailing cabinet transactions for controlled substances removed using generic information are reviewed as part of required controlled substance inspections.

Evaluate which staff should have access to and should update the Consult Toolbox when records are requested or received and update the “Consult Business Rules and Uses of the Consult Package Standard Operating Procedure” to reflect necessary changes.

Include controls within the Consult Toolbox to prevent errors and improve data quality, including controls on administrative closure of low-risk consults and documenting the records-retrieval method.

Update consult closure policies and procedures to clarify requirements for administrative closure and determine whether metrics for the percentage of records received should be a requirement and included in policy.

Determine whether Veterans Health Administration facilities’ community care offices should continue to be required to use the administrative closure report for oversight of administratively closed consults, and if not, determine what reports should be required.

Evaluate the workload of community care staff to determine the most efficient way to structure and execute their duties.

Determine if there are mechanisms to identify standardization opportunities and increase efficiency for improving records return processes.

Ensure community care staff follow procedures to reduce duplicate records received.

Evaluate ways to increase use of provider electronic records portals to reduce reliance on electronic fax when retrieving medical records.

Consider increased implementation of technologies to improve records processing once received to reduce the manual renaming of electronic files and uploading of records into the electronic health record.

Ensure records from the Joint Longitudinal Viewer are uploaded into the electronic health record.

Develop and implement a method to identify and report separate quality statistics for the Military Sexual Trauma Operations Center.

Update the existing two-signature review process for claims processors and designated reviewers to include an increased focus on military sexual trauma denials.

Develop and implement a process to assess designated reviewers’ competency in processing denied military sexual trauma claims and monitor effectiveness.

Update the relevant sections on transportation expenses in the Veterans Benefits Administration’s Adjudication Procedures Manual to align with each other.

Ensure automation is consistent with the policy for processing the transportation benefit.

Ensure all erroneous scenarios in the Veterans Benefits Management System for Rating special monthly compensation calculator identified in this review are corrected and certify the results to the VA Office of Inspector General.

Establish a plan to conduct additional testing of the Veterans Benefits Management System for Rating special monthly compensation calculator to ensure its accuracy.

Update the Fiduciary Program Manual to specify when a removed fiduciary should be flagged as “Do Not Appoint” and ensuring that staff understand if they are responsible for adding the flag.

Develop and provide training on updated Fiduciary Program Manual procedures on flagging barred individuals or entities as “Do Not Appoint” and include a mechanism to ensure that fiduciary hub staff have taken and understand the training.

Update the quality review process to include ensuring that fiduciaries are flagged “Do Not Appoint” when required.