All Reports

Facility leaders ensure staff follow facility policies and maintain a cleanenvironment.

Facility leaders ensure staff develop service-level workflows for the communication of urgent, noncritical test results.

Executive leaders monitor the effectiveness of the patient notification process.

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.

Veteran Readiness and Employment should coordinate with VA’s Office of General Counsel to assess the eligibility decision process and ensure all legal and regulatory requirements are accounted for and confirmed by the appropriate staff. If necessary, Veteran Readiness and Employment should update the process to conform with the general counsel’s interpretation of legal requirements.

Veteran Readiness and Employment should develop a standard documentation method for verifying eligibility periods, deferrals, extensions, and final eligibility decisions and train appropriate staff, including vocational rehabilitation counselors, on how to properly document eligibility decisions.

Veteran Readiness and Employment should develop a quality assurance review process to monitor the accuracy of eligibility decisions.

Veteran Readiness and Employment should coordinate with VA’s Office of General Counsel to assess the entitlement requirements and whether those used to confirm and document entitlement decisions are compliant with laws and regulatory requirements. If changes are needed, Veteran Readiness and Employment should update the manual and train appropriate staff accordingly.

Veteran Readiness and Employment should develop additional controls to ensure official entitlement decisions in the narrative report are documented in a manner that is clear and would allow for effective oversight from both internal and external entities, such as containing clear documentation of the assessment of employability factors and additional evidence used to substantiate the claim.

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.

The VA New York Harbor Healthcare System Director reviews facility processes to ensure medical and psychosocial health care for residents who report abuse, and staff are educated on the requirements.

The VA New York Harbor Healthcare System Director ensures that community living center nursing leaders and factfinding investigators complete factfindings in accordance with Veterans Health Administration policy.

The VA New York Harbor Healthcare System Director reviews responses to other incidents of suspected abuse and ensures actions are completed for resolution, including notifications.

The VA New York Harbor Healthcare System Director ensures community living center staff are compliant with Veterans Health Administration Prevention and Management of Disruptive Behavior Program education and training requirements.

The VA New York Harbor Healthcare System Director ensures community living center nursing and clinical staffs’ electronic health records documentation meets requirements for timeliness, accuracy, and completion, and takes action as needed.

The Under Secretary for Health ensures that VHA abuse policy addresses compliance with federal statutes and regulations, including 42 C.F.R. § 483.12, and outlines suspected elder abuse processes to notify leaders, interdisciplinary care team members, VA Police, patients’ families or designees, and state regulatory agencies; and identifies roles and responsibilities of reviewing officials for investigative reviews.

The VA New York Harbor Healthcare System Director ensures system abuse policies include required elements to comply with Veterans Health Administration, state, and federal regulations, including 42 C.F.R. § 483.12; and clearly outlines processes for leaders and staff when responding to suspected abuse related to reporting (for example, to interdisciplinary care team members, VA Police, family or designee, and state regulatory agencies); and conducting factfinding investigations.

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.

Develop a plan to ensure manual journal vouchers are justified, documented, and approved before they are entered into the Financial Management System and that they are reviewed after posting to verify accuracy and support compliance, transparency, and audit readiness.

Require ongoing training for all staff who prepare, review, or approve manual journal vouchers, including a process to ensure that new employees complete initial training and that refresher courses are provided when policies or tools are updated.

Clarify expectations for using macro-enabled journal voucher tools by defining when the standardized macro must be used; establishing a process to communicate macro tool updates and prompt the adoption of newly released versions; and providing guidance, training, and user support to promote correct and consistent application of the tools.

Define and communicate clear oversight responsibilities for Veterans Integrated Service Network financial managers by requiring routine monitoring of documentation and compliance at facilities.

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.

Implement procedures to monitor the data used to measure productivity to ensure the data accurately reflect the complete work of clinical resource hub physicians.

Work with appropriate officials, such as Office of Primary Care and clinical resource hub leaders, to determine whether hub physicians should be subject to existing productivity measures. If so, issue clear hubs guidance requiring adherence; if not, clearly define what should be used, and issue thorough guidance on the steps hubs must take to measure physician productivity consistently.

Clarify oversight responsibilities for monitoring productivity measures, including detailed procedures and actions that should be taken when thresholds are not met.

The VA Fayetteville Coastal Healthcare System Director reviews the endocrine consult management process and takes actions as needed to ensure compliance with current Veterans Health Administration directives and guidance.

The VA Fayetteville Coastal Healthcare System Director implements a strategy to review patients affected by delayed endocrine consults to evaluate whether harm occurred and the appropriateness of institutional disclosures.

The VA Fayetteville Coastal Healthcare System Director ensures a sustainable and effective service line agreement between endocrine and primary care services is developed and agreed upon by both services, and monitors implementation.

The VA Fayetteville Coastal Healthcare System Director confirms effective utilization of endocrine clinic appointments to ensure timely access to care.

The VA Fayetteville Coastal Healthcare System Director ensures a process is in place for monitoring and tracking clinic profile modification requests.

The VA Mid-Atlantic Health Care Network Director reviews the leadership performance of the chief of medicine related to communication and collaboration and takes action as necessary.

The VA Fayetteville Coastal Healthcare System Director evaluates communication gaps identified in this report between leaders of primary care and the Medicine Service and takes action to ensure consistency with Veterans Health Administration High Reliability Organization goals.

Executive leaders ensure there are clear signs during construction projects, and maps at the main entrance information desk to help veterans navigate the facility.

The Medical Center Director ensures contractors inspect and test emergency generators and fire doors as required, and staff report compliance to an environment of care committee.

The Medical Center Director ensures an environment of care committee meets, as required.

The Associate Director of Patient Care Services/Nurse Executive ensures nursing staff monitor proper food clean-up, storage, and disposal in the Mental Health Residential Rehabilitation Treatment Program’s areas.

The Medical Center Director ensures staff refill hands-free sanitizer dispensers throughout the facility.

The Medical Center Director ensures the emergency management plan includes guidance for managing shelter-in-place supplies.

Executive leaders ensure staff develop service-level workflows for the communication of test results for each service.

The Medical Center Director ensures staff implement a process to monitor providers’ compliance with communicating abnormal test results to patients.

Executive leaders ensure staff complete improvement actions from root cause analyses within one year.

The Under Secretary for Health ensures that VA homeless program staff consistently document, in patients’ electronic health records, the clinical information from the Homeless Operations Management and Evaluation System.

The Under Secretary for Health makes certain that a suicide risk screening is completed with patients during intake into VA homeless programs, consistent with Veterans Health Administration policy.

The Under Secretary for Health ensures that staff complete suicide risk screening in response to danger of self-harm identified in the Homeless Operations Management and Evaluation System.

The Under Secretary for Health makes certain that homeless program staff provide and document care coordination to address patients’ mental health and substance use disorder treatment needs as identified in the Homeless Operations Management and Evaluation System.

Facility leaders ensure providers who order tests communicate the results to patients timely.

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.

The facility Director ensures staff review primary care panel sizes and capacity levels to ensure they are accurate.

Reassess and clarify physical inventory requirements for equipment in medical facilities to ensure they are consistent with and meet the intent of VA Directive 7002.

Ensure that facility directors require custodial officers to regularly review nonexpendable inventory to determine whether the equipment is required and take appropriate action.

Ensure medical facility directors review inventory list compliance data to identify noncompliant services and implement a process to resolve noncompliance.

Ensure the Veterans Health Administration’s Procurement and Logistics Office, in coordination with VA’s Office of Acquisition and Logistics, regularly monitors inventory compliance data to identify and communicate with noncompliant facilities to proactively address delinquent inventories.

Require medical facilities to use a standardized report of survey dashboard to centrally report all lost, stolen, or damaged items.

Require medical facility directors to review inventory compliance and establish a process to ensure noncompliant equipment—to include equipment identified in this audit—is reported as lost, stolen, or damaged within required time frames.