All Reports

Review and update applicable sections of the VA Fiduciary Program Manual to clarify how to properly evaluate an allegation, including detailing what constitutes a misuse allegation that must be documented and reviewed, and when an investigation is needed, in coordination with the VA Office of General Counsel if necessary.

Clarify in the VA Fiduciary Program Manual how potential misuses of beneficiary funds, such as red flag indicators, must be addressed and documented, and reinforce with training or resources as needed.

Clearly communicate the evidentiary standard staff should use in the allegation phase to help ensure application of different standards is accurate and easily understood and results in consistent compliance with how investigations are initiated, and consider consulting with the VA Office of General Counsel if necessary.

Develop a plan to implement or enhance the national quality review program to ensure compliance with procedural guidance for processing all phases of misuse allegations.

Create a process for facilities to regularly update and verify specialty care clinics’ phone numbers listed in internal facility directories and on websites.

Annually evaluate and verify that automated interactive phone systems route veterans directly to the correct specialty care clinic and assess whether the phone systems support first-call resolution.

Reconfigure specialty care clinics’ phone lines to be able to collect required call performance data and assess whether centralized queues enhance the efficiency of phone management.

Provide guidance to specialty care clinics on how they should manage and respond to voicemails, including for routine reviews of voicemail data.

Provide guidance that assigns both the responsibility for and the frequency of routine monitoring of call performance data and analyses of complaint data trends from the patient advocate system to identify and address veterans’ phone access issues for specialty care clinics.

Standardize and enforce a documented monthly process for reviewing and validating open obligations—including undelivered orders and accruals—with defined staff roles, responsibilities, and communication protocols, in alignment with VA financial policy.

In conjunction with the Office of Acquisition, Logistics, and Construction, establish and document procedures that define roles and communication requirements with requesting and contracting offices to ensure timely end-date modifications and deobligation of funds that are no longer needed.

In coordination with the VA Office of Financial Policy, develop VBA‑specific procedures aligned with appendix F of VA Financial Policy, “Obligations,” and confirm those procedures are consistently implemented to support reconciliation, documentation, and closure of open obligations in the Integrated Financial and Acquisition Management System.

Facility leaders ensure staff follow procedures to properly separate and store soiled and clean equipment.

Facility leaders ensure environmental management services staff clean ice machines daily to help prevent infection risk.

Facility leaders ensure staff properly label and store oxygen tanks.

Facility leaders ensure staff update the facility policy to include all elements to communicate test results to patients, as required in Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

Executive leaders ensure staff maintain a clean and safe environment.

The Medical Center Director ensures providers complete secondary toxic exposure screenings within 30 days.

Ensure that authorizations are reassessed when a significant change affects the security or privacy posture of an application, consistent with the requirements of VA Handbook 6500.

Reevaluate the risk determination for the Patient Advocate Tracking System‑Replacement and determine the appropriate security categorization level and system classification based on (1) the sensitive personal information maintained in the system and (2) the System Security Categorization Report.

Reevaluate whether there is a continued business need to maintain access to veterans’ medical records in the Patient Advocate Tracking System-Replacement.

Institute a process to ensure user roles are regularly reviewed for continued access and evaluate the effectiveness of the access control principle of least privilege to ensure roles for the Patient Advocate Tracking System-Replacement are correctly configured and allow access only for authorized users.

Update the Patient Advocate Tracking System-Replacement user guides and training materials.

Improve the existing vulnerability management process to make sure all vulnerabilities are identified, plans of action and milestones are created for vulnerabilities that cannot be mitigated by VA deadlines, and software is updated before vendor support ends.

Implement a baseline configuration process to make sure network devices and databases are running authorized software that is configured to approved baselines and free of vulnerabilities.

Implement a process to disable access to the active directory and the electronic health record when temporary staff leave before their expected end date.

Separate the duties of maintaining physical blank key stock and making keys to improve physical access controls over key inventories.

Secure network infrastructure in accordance with VA environmental protection standards.

Complete the installation of grounding measures for all telecommunication closets to protect information technology equipment.

Routinely monitor and service uninterruptible power supplies that support the network infrastructure.

Establish a process to make sure a witness observes the destruction of temporary paper files that contain personally identifiable information and protected health information.

Develop and establish guidance detailing how medical facility staff must document evidence to support their decisions when they make pharmaceutical purchases through the open market.

Ensure medical facility leaders conduct routine assessments of pharmaceutical purchases made through the open market so purchases are made in accordance with policy.

Develop a mechanism, in coordination with VHA’s purchase card program office and VA’s Office of General Counsel, that provides visibility into all pharmaceutical purchases, including purchases outside the prime vendor contract.

Update the local inventory procedure to include a process for securing information technology equipment when temporary space is needed and for tracking and distributing this equipment, in accordance with federal and VA requirements.

Assess the age of all unused information technology inventory to determine what should be used and what should be disposed of based on federal and VA requirements, and take action to address the results.

The Veterans Integrated Service Network 7 VA Southeast Network Director ensures relevant system staff and leaders are trained on state licensing board reporting requirements to include timeliness of reporting.

The Chief of Staff ensures facility leaders develop workflows for all services to identify team members’ roles in the process for communicating test results.

The Veterans Integrated Service Network Director ensures actions are completed to address findings from the electronic health record audit expected to be completed by June 2026 and the annual site visit(s) of the Eastern Oklahoma VA Health Care System homemaker/home health aide program.

The Veterans Health Administration Executive Director of Geriatrics and Extended Care, in collaboration with the Veterans Health Administration Geriatrics and Extended Care program manager, provides guidance for Veterans Integrated Service Network and Veterans Health Administration systems’ leaders to evaluate homemaker/home health aide programs in accordance with the Veterans Health Administration Office of Integrated Veteran Care Community Care Field Guidebook and Veterans Health Administration Notice 2024-01, Purchased Home and Community-Based Services.

Require medical facility directors in Veterans Integrated Service Network 8 to ensure supply chain staff periodically review unit conversion factors in the Generic Inventory Package to ensure accurate system values and quantities are recorded and then correct any discrepancies.

Require medical facility directors in Veterans Integrated Service Network 8 to develop and implement procedures to maintain stock within the required thresholds as outlined in Veterans Health Administration Directive 1761.

Require medical facility directors in Veterans Integrated Service Network 8 to ensure supply chain staff review and update ABC classification labels on expendable supplies in accordance with Veterans Health Administration guidance and establish a process to routinely verify that labeling aligns with the official ABC classification report.

Ensure medical facility directors in Veterans Integrated Service Network 8 develop a process to ensure facility staff safeguard expendable supplies in accordance with Veterans Administration Handbook 0730.

Ensure medical facility directors in Veterans Integrated Service Network 8 develop and implement local procedures that require clinical service areas to notify supply chain staff when equipment is relocated and establish protocols to validate and update equipment location during clinical moves or room changes and ensure equipment items are properly tagged.

Require medical facility directors in Veterans Integrated Service Network 8 to enforce timely completion of reports of survey in accordance with Veterans Health Administration policy and implement oversight mechanisms to monitor the timely initiation, approval, and closure of reports.

Ensure facilities implement corrective actions to effectively address deficiencies identified during the Veterans Integrated Service Network’s quality control reviews.

Require medical facility directors in Veterans Integrated Service Network 22 to develop and implement procedures to maintain stock within the required thresholds as outlined in Veterans Health Administration Directive 1761.

Require medical facility directors in Veterans Integrated Service Network 22 to ensure supply chain staff review and update ABC classification labels on expendable supplies in accordance with Veterans Health Administration guidance and establish a process to routinely verify that labeling aligns with the official ABC classification report.

Ensure medical facility directors in Veterans Integrated Service Network 22 develop a process to ensure facility staff safeguard expendable supplies in accordance with Veterans Administration Handbook 0730.

Ensure medical facility directors in Veterans Integrated Service Network 22 develop and implement local procedures that require clinical service areas to notify supply chain staff when equipment is relocated, establish protocols to validate and update the equipment location, and ensure equipment items are properly tagged.

Require medical facility directors in Veterans Integrated Service Network 22 to ensure facilities conduct annual inventory of nonexpendable equipment.

Require medical facility directors in Veterans Integrated Service Network 22 to enforce timely completion of reports of survey in accordance with Veterans Health Administration policy and implement oversight mechanisms to monitor the timely initiation, approval, and closure of reports.

Ensure facilities implement corrective actions to effectively address deficiencies identified during the Veterans Integrated System Network’s quality control reviews.

The Director ensures Environmental Management Services staff keep patient care areas clean and well maintained.

Conduct a strategic business evaluation of the process used by VA medical facilities’ scheduling departments to determine whether alternatives could improve consult processing, scheduling efficiency, and timeliness.

Establish procedures to track and provide oversight of consults that schedulers have not acted on to schedule and prioritize processing of those consults when identified.

Establish and use agreements with other VA medical facilities to help identify and schedule direct care when local services are not available.

Assess options to improve the scheduling process and system to provide schedulers with access to community care provider appointment availability when discussing care options with wait time–eligible veterans.

Review services in the Consult Toolbox to make sure it accurately reflects available services and avoids inaccurate eligibility determinations.

Reinforce requirements for schedulers to review scheduling systems to identify the next available date for appointments and input that information in the Consult Toolbox.

Implement a process to verify that schedulers check all community care eligibility criteria for all veterans.

Emphasize to schedulers at least annually the proper methods (including the use of opt-out codes) to document when veterans opt out of community care.

The Michael E. DeBakey VA Medical Center Director uses available resources to help recruit and hire an assistant chief of Sterile Processing Services.

The Michael E. DeBakey VA Medical Center Director, in conjunction with the chief of Sterile Processing Services, reviews reusable medical device inventory management and oversight processes to ensure compliance with Veterans Health Administration requirements, identifies deficiencies, and takes action as warranted.

The Michael E. DeBakey VA Medical Center Director reviews processes to track issue briefs related to surgery cancellations resulting from reusable medical device issues from initiation to closure, identifies deficiencies, and takes action as necessary.