All Reports

Create and mandate standardized due process letters for clear and unmistakable errors and severance of service connection, drafted in compliance with 38 C.F.R. § 3.103.

Update procedures to require an enhanced level of review for all final decisions associated with proposed adverse actions resulting from clear and unmistakable errors so that decisions are compliant with 38 C.F.R. § 3.105 and the M21-1 Adjudication Procedures Manual.

Develop an automated report that periodically identifies proposed adverse actions without a final decision and applicable pending end product, and ensure identified cases are reviewed and resolved as appropriate, to maintain compliance with the M21-1 Adjudication Procedures Manual and the M21-4 Manual.

Correct all errors identified by this review as appropriate, so claim processing actions are compliant with 38 C.F.R. § 3.103 and 3.105, the M21-1 Adjudication Procedures Manual, and the M21-4 Manual.

The Wm. Jennings Bryan Dorn VA Medical Center Director ensures that all patients admitted to the intensive care unit receive access to continuous critical care, particularly after hours, and clearly defines the role and responsibilities of the on-site intensivist and TeleCritical Care in the care of surgical intensive care unit admissions.

The Wm. Jennings Bryan Dorn VA Medical Center Director ensures that in the absence of patient-specific orders for vital sign parameters that warrant provider notification, intensive care unit nurses adhere to facility policy for provider notification parameters.

The Wm. Jennings Bryan Dorn VA Medical Center Director reviews VHA Directive 1155(1), Treatment of Acute Ischemic Stroke, August 22, 2025, and ensures the facility is in full compliance with current stroke center designation requirements, including protocols for inpatient stroke response, diagnostic imaging, consultation, and transfer processes.

The Wm. Jennings Bryan Dorn VA Medical Center Director clarifies the qualifications for provider coverage in the intensive care unit and ensures all intensive care unit providers are appropriately privileged to deliver care in the intensive care unit prior to providing care.

The Wm. Jennings Bryan Dorn VA Medical Center Director determines whether providers delivered patient care in the intensive care unit without approved, current, facility‑specific privileges and, if so, completes required reviews and assessments in accordance with VHA requirements.

The Wm. Jennings Bryan Dorn VA Medical Center Director creates a process ensuring contract ICU physicians covering in the intensive care unit have access to the electronic health record for documentation and order writing from the start of their tour.

The Wm. Jennings Bryan Dorn VA Medical Center Director reviews this patient’s case and any associated quality management reviews, and if gaps are identified, develops an action plan to ensure quality management processes are completed in accordance with relevant VHA quality management directives.

Facility leaders take appropriate actions so staff develop a written workflow for each service that is consistent with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director takes appropriate actions so fire doors close completely and latch, as required by National Fire Protection Association 80 Standard for Fire Doors and Other Opening Protectives.

The Director takes appropriate actions so staff update the facility policy on test result communications to meet the requirements of Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director for Patient Care Services/Nurse Executive take appropriate actions so staff develop, for each service, written workflows consistent with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director takes appropriate actions for the Chief of Staff to review Patient Centered Management Module data and address efficiency, capacity, and staffing needs, in accordance with Veterans Health Administration Directive 1406(3), Patient Centered Management Module (PCMM) for Primary Care.

The Director develops workflows for all services that communicate test results to patients and includes the process for assigning designees (surrogates) for providers who order tests in the facility’s policy, as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Northport VA Medical Center Director considers reviewing the inclusion of psychotherapy extended-care caseload metrics into performance measures such as Focused Professional Practice Evaluations for Cause, and takes action as warranted.

The Northport VA Medical Center Director considers a strategy to review patients terminated from individual psychotherapy while the psychotherapist was on a Focused Professional Practice Evaluation for Cause, determines whether any harm occurred, and takes action as warranted.

The District Director monitors district leaders’ compliance with completion of morbidity and mortality reviews for client deaths by suicide, including timeliness, as required.

The District Director ensures district leaders are aware of the Readjustment Counseling Service policy requirements to provide oversight of morbidity and mortality review completion, including all review components, the appropriateness of recommendations, and reporting delays to the Deputy Chief Officer.

The Readjustment Counseling Service Chief Officer ensures morbidity and mortality review lessons learned are distributed nationally across Readjustment Counseling Service to support suicide prevention efforts.

The District Director identifies reasons for noncompliance with HRSF SharePoint-related RCSNet documentation requirements, ensures requirements are met, and monitors compliance.

The Readjustment Counseling Service Chief Officer ensures implementation of a planned solution to address the high risk suicide flag SharePoint site malfunction and ensures data accuracy and functionality as intended.

Implement comprehensive national policy on how staff should process enrollment applications that are missing information—including a firm and clear requirement that they enter incomplete applications in the Veterans Health Administration Enrollment System.

Coordinate with the Veterans Benefits Administration to identify opportunities to further streamline enrolling veterans in both administrations.

Define and implement guidelines for applications received at community-based outpatient clinics to make certain that they are processed consistently and promptly across the Veterans Health Administration.

Ensure the Health Eligibility Center regularly evaluates medical center enrollment practices.

Establish and implement procedures to make sure enrollment staff adhere to requirements in reviewing the records of veterans who may qualify for higher‑priority groups.

Standardize how Veterans Integrated Service Networks assess whether medical facilities are complying with Veterans Health Administration enrollment policies.

Determine whether enrollment coordinators nationwide should employ the Health Eligibility Center’s audit tool, and if so, direct that its use is required.

Define in policy how medical facility enrollment coordinators should conduct oversight.

The Under Secretary for Health develops a process to identify patients with a diagnosis of heart failure with reduced ejection fraction and implements an action plan that ensures monitoring of compliance with evidence-based care.

The Under Secretary for Health reviews Veterans Health Administration’s compliance with American Heart Association/American College of Cardiology/Heart Failure Society of America guideline-directed medical therapy medications for the treatment of heart failure with reduced ejection fraction (stages C or D) in women veterans and implements an action plan to ensure compliance.

The Under Secretary for Health ensures women veterans with a diagnosis of heart failure with reduced ejection fraction who are not receiving guideline-directed medical therapy medications have a documented rationale for the exception and implements an action plan to ensure compliance.

Ensure the Veterans Benefits Administration updates its Toxic Exposures Fund cost estimation methodology to reflect how it plans to use the funds.

Implement monitoring procedures to ensure Veterans Health Administration expenditure transfers follow statutes.

Assess lessons learned and establish standard operating procedures to integrate oversight roles, responsibilities, and clear guidance for reconciling Toxic Exposures Fund costs.

Make certain that the Veterans Benefits Administration’s Office of Financial Management and Office of Human Capital Services validate the actual number of Toxic Exposures Fund–supported employees and properly code them in VA’s HR Smart.

The Chief of Staff and Associate Director for Patient Care Services develop workflows that describe how each team member participates in the process for communicating test results.

The Central Virginia VA Health Care System Director evaluates inpatient mental health unit discharge practices and develops processes to assess a caregiver’s capability to ensure a safe discharge.

The Central Virginia VA Health Care System Director ensures complaints to the patient advocate are reviewed and addressed in accordance with Veterans Health Administration Directive 1003.04, VHA Patient Advocacy.

The Central Virginia VA Health Care System Director ensures medication reconciliation is completed at discharge and during post-discharge encounters according to Veterans Health Administration Directive 1345, Medication Reconciliation.

The Central Virginia VA Health Care System Director ensures compliance with Veterans Health Administration Directive 1199, Reporting Cases of Abuse and Neglect, requirements related to clinical staff escalating encounters involving potential abuse and neglect.

The Central Virginia VA Health Care System Director conducts a comprehensive review of the patient’s hospitalization and post-discharge encounters and takes action as indicated, including quality management improvement processes.

The Under Secretary for Health considers establishing a process, to be used on non‑business days, that enables Veterans Crisis Line responders to timely escalate concerns of non‑imminent abuse to a mandated reporter.

The Associate Director keeps patient care areas clean and stores dirty and clean items separately.

Update the Adjudication Procedures Manual to require documentation of each specific action taken when staff certify mail as unidentifiable.

Provide all employees who process unidentified mail appropriate access to all systems and resources necessary to identify a claimant.

Implement a plan to ensure all Veterans Benefits Administration contact and correspondence with claimants is documented and stored as required by the Adjudication Procedures Manual. As part of this plan, ensure documentation is easily accessible to appropriate staff.

Provide claims assistants who process unidentified mail with consistent quality reviews specific to their handling of unidentified mail.

Consider implementing a training module on processing unidentified mail, including guidance on appropriate work credit for claims assistants, and incorporating it into the national training curriculum. This training could be beneficial for all personnel involved in mail processing, including supervisors and records management officers.

Develop and maintain a Benefits Enterprise Platform modernization program schedule that (1) captures both agile and nonagile tasks and (2) documents the time frame for the delivery of all system modernization requirements.

Ensure staff follow VA’s Product (Line) Accountability and Reporting System Guide to include all program schedule information in the System.

Develop reliable, validated life cycle cost estimates for the Benefits Enterprise Platform modernization program that support planning and budgeting as required by Office of Management and Budget Circulars A-130 and A‑11.

Include all Benefits Enterprise Platform modernization costs in the VA’s Product (Line) Accountability and Reporting System as required by the Veteran-Focused Integration Process Guide, and track Cost of War Toxic Exposures Fund obligations and expenditures in the Office of Information and Technology PACT Act Dashboard consistent with VA financial policy.

Establish a mechanism for enforcing VA policy that requires minor applications to include an approved security assessment before being placed on VA’s network.