All Reports

OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages FY 2018
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18-01693-196
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Topics:  Staffing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2020
The Under Secretary for Health refines and formalizes VHA’s position categorization of individuals (clinical and nonclinical) who are necessary to VHA’s mission of delivering health care by looking at various dimensions of each occupation, including staff skill set and function, enabling identification of positions based on the specific role a person would fill.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/28/2019
The Under Secretary for Health ensures the consistent implementation and use of the position categorization approach across all facilities.
Comprehensive Healthcare Inspection Program Review of the Phoenix VA Health Care System, Phoenix, Arizona
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18-00611-180

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2018
The Facility Director ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors the advisors’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2019
The Facility Director ensures all patient incidents are entered into WebSPOT and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2018
The Associate Director ensures required team members consistently participate on environment of care rounds and monitors team members’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2018
The Deputy Director and Associate Director ensure personal protective equipment is readily accessible and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2019
The Associate Director ensures that a clean environment is maintained throughout the Facility and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2018
The Associate Director requires Nutrition and Food Service managers ensure garbage receptacles are stored separately from food preparation areas and properly covered with tight-fitting lids and monitors managers’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2018
The Associate Director requires Nutrition and Food Services managers ensure all food items are properly labeled with expiration dates, as appropriate, and monitors managers’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2019
The Associate Director requires Nutrition and Food Services managers ensure temperature monitoring occurs in the dry food storage area and monitors managers’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2018
The Facility Director ensures that Controlled Substances Inspectors complete routine monthly controlled substances inspections and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2018
The Facility Director ensures that controlled substances inspections are randomly performed to ensure the element of surprise and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2019
The Facility Director ensures that reconciliation of controlled substances returns to pharmacy stock is performed during controlled substances inspections and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2019
The Chief of Staff ensures that acceptable providers offer further diagnostic evaluations to patients with positive post-traumatic stress disorder screens and monitors providers’ compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2018
The Chief of Staff ensures that geriatric evaluation providers complete a medical evaluation of patients admitted to the program and monitors providers’ compliance.
Colorectal Cancer Screening, Timely Colonoscopies, and Physician Coverage in the Intensive Care Unit at the James H. Quillen VA Medical Center, Mountain Home, Tennessee
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16-02940-183

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2019
The Veterans Integrated Service Network 9 Director ensures that clinical reviews are completed on the patients discussed in this report to determine whether delays adversely affected patients’ clinical care, notifies patients of lapses in care as needed, and/or takes other action as appropriate.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2018
The James H. Quillen VA Medical Center Director improves and monitors mechanisms to track and recall patients who require surveillance colonoscopies.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2018
The James H. Quillen VA Medical Center Director improves and monitors mechanisms to track patients for whom a diagnostic colonoscopy after a positive fecal immunochemical test is indicated as required by Veterans Health Administration and James H. Quillen VA Medical Center policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2018
The James H. Quillen VA Medical Center Director improves efforts to ensure non-VA colonoscopy reports are available for viewing in patients’ VA electronic health records.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2018
The James H. Quillen VA Medical Center Director ensures that processes are in place to monitor providers’ compliance with Veterans Health Administration Colorectal Cancer Screening policy including the referral of the patient for a diagnostic colonoscopy after a positive fecal immunochemical test rather than a repeat fecal immunochemical test.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2018
The James H. Quillen VA Medical Center Director takes action to identify patients who submitted fecal immunochemical test kits that could not be processed and notifies these patients of a need to re-submit fecal immunochemical test specimens.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2019
The James H. Quillen VA Medical Center Director ensures that processes are strengthened to track and monitor the distribution of fecal immunochemical test kits to patients.
Comprehensive Healthcare Inspection Program Review of the Cincinnati VA Medical Center, Cincinnati, Ohio
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17-05398-172

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2018
The Facility Director ensures all patient incidents are entered into the VHA Patient Safety Information System and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/2/2019
The Chief of Staff ensures clinical managers initiate Focused Professional Practice Evaluations that include clearly delineated timeframes and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2019
The Chief of Staff ensures clinical managers consistently collect and review Ongoing Professional Practice Evaluation data and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/2/2019
The Associate Director ensures required team members participate on environment of care rounds and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/15/2018
The Associate Director ensures bottom shelves in equipment storage areas are solid or have impervious shelf liners and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2018
The Director ensures that the Alternate Control Substance Coordinator’s position description or functional statement includes an addendum for the Control Substance Coordinator’s duties and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2018
The Director ensures that all Controlled Substance Inspectors complete the physical inventory of the controlled substance storage areas on the same day initiated and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the William Jennings Bryan Dorn VA Medical Center, Columbia, South Carolina
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18-00412-173

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2019
The Chief of Staff ensures Service Chiefs complete required elements of Focused Professional Practice Evaluations for review by the Medical Executive Board and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2019
The Chief of Staff ensures that Service Chiefs include all required elements for Ongoing Professional Practice Evaluations and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2019
The Associate Director ensures all required team members consistently participate on environment of care rounds and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/25/2018
The Associate Director ensures that Facility managers maintain a safe and clean environment throughout the Facility and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/25/2018
The Associate Director ensures all medical equipment is identified as safe for patient use and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/25/2018
The Chief of Staff ensures providers complete suicide risk assessments, within the required timeframe, for patients with positive Post-Traumatic Stress Disorder screens and monitors providers’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/25/2018
The Chief of Staff ensures that geriatric evaluation program performance improvement activities are presented to an appropriate leadership board and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/25/2018
The Chief of Staff ensures that clinicians accurately identify and implement the Geriatric Evaluation plan of care interventions and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the VA Sierra Nevada Health Care System, Reno, Nevada
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18-00605-174

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2018
The Facility Director requires the Patient Safety Manager to ensure completion of the required minimum of eight root cause analyses each fiscal year and monitors the Patient Safety Manager’s compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2019
The Chief of Staff ensures that service chiefs include service-specific performance data for Ongoing Professional Practice Evaluations and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2019
The Associate Director ensures required team members participate on environment of care rounds and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2018
The Associate Director requires the Nutrition and Food Services Chief to develop and implement a Hazard Analysis Critical Control Point Food Safety plan and monitors the Chief’s compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2019
The Associate Director requires the Nutrition and Food Services Chief to establish a food service-focused inspection process to occur at no less than quarterly intervals and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2019
The Associate Director requires the Nutrition and Food Services Chief to ensure that food items are properly labeled and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2019
The Chief of Staff ensures that providers complete suicide risk assessments, within the required timeframe, for patients with positive post-traumatic stress disorder screens and monitors the providers’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2018
The Associate Director for Patient Care Services ensures that nursing staff involved in managing central lines receive the required central line-associated bloodstream infection prevention education and monitors staff compliance.
VA’s Compliance with the Improper Payments Elimination and Recovery Act for FY 2017
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17-05460-169

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2020
The Executive in Charge, Office of the Under Secretary for Health, develops a timeline to reduce improper payments under the 10 percent threshold for the Beneficiary Travel; Communications, Utilities, and Other Rents; Medical Care Contracts and Agreements; Prosthetics; Purchased Long Term Services and Support; Supplies and Materials; and VA Community Care Programs and activities. This is a repeat finding and recommendation for the Purchased Long Term Services and Support and VA Community Care programs from our FY 2015 and 2016 reports.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The Executive in Charge, Office of the Under Secretary for Health, implements steps to achieve stated reduction targets for the Beneficiary Travel; Civilian Health and Medical Program of the Department of Veterans Affairs; Purchased Long Term Services and Support; Supplies and Materials; and VA Community Care Programs and activities. This is a repeat finding for all five programs from our FY 2016 report.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/14/2020
The Executive in Charge, Veterans Benefits Administration, implements steps to achieve reduction targets for the Pension and Post-9/11 GI Bill Programs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2019
The OIG recommended the Executive in Charge, Office of the Under Secretary for Health, implement procedures to ensure thorough testing of sample items used to estimate improper payments for Supplies and Materials purchases under indefinite delivery contracts.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/7/2020
The OIG recommended the Executive in Charge, Veterans Benefits Administration, continue working with the Department of Defense to increase the frequency of drill pay adjustments from annually to monthly. This is a repeat recommendation from our FY 2016 report.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/22/2020
The OIG recommended the Executive in Charge, Veterans Benefits Administration, continue to report statutory barriers preventing complete resolution of drill pay improper payments in future Agency Financial Reports until resolved.
Comprehensive Healthcare Inspection Program Review of the VA Puget Sound Health Care System, Seattle, Washington
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18-00334-164

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/28/2018
The Deputy Director ensures required team members consistently participate on environment of care rounds and monitors team members’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/24/2018
The Deputy Director ensures all medical equipment at the South Sound VA Clinic is identified as safe for patient use and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/24/2018
The Chief of Staff ensures the Infection Control Committee consistently documents discussions of on-going construction activities and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/24/2018
The Assistant Director ensures temperature monitoring occurs in dry food storage areas and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/28/2018
The Facility Director ensures that reconciliation of controlled substance refills to automated dispensing units in patient care areas and returns to pharmacy stock are performed during controlled substance inspections and monitors compliance.
Audit of the Beneficiary Travel Program, Special Mode of Transportation, Eligibility and Payment Controls
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15-00022-139

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2019
The OIG recommended the Under Secretary for Health require Veterans Integrated Service Networks to implement periodic reviews to ensure clinicians and Beneficiary Travel Office staff comply with Veterans Health Procedure Guide 1601B.05 eligibility requirements for authorizing Special Mode of Transportation services.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2019
The OIG recommended the Under Secretary for Health modify Veterans Health Administration Procedure Guide 1601B.05 to require the Beneficiary Travel Office staff to verify beneficiaries attended medical appointments prior to approving payment of Special Mode of Transportation vendor invoices.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2019
The OIG recommended the Under Secretary for Health require Veterans Integrated Service Networks to implement periodic reviews to ensure VA Medical Centers comply with Veterans Health Administration policies for verifying beneficiaries listed on vendor invoices had been properly authorized for Special Mode of Transportation services or attended medical appointments prior to approving payment of Special Mode of Transportation vendor invoices.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2019
The OIG recommended the Under Secretary for Health ensure the Improper Payments Elimination and Recovery Act reports provided to Veterans Integrated Service Networks are modified to include Special Mode of Transportation information specific to vendor payments by VA Medical Centers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2023
The OIG recommended the Under Secretary for Health implement use of Centers for Medicare and Medicaid Services Rates when savings can be achieved for Special Mode of Transportation ambulance services in accordance with 38 U.S.C. Section 111(b)(3)(C).
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2019
The OIG recommended the Under Secretary for Health implement controls to prevent beneficiaries using Special Mode of Transportation services from also obtaining mileage reimbursement for the same appointment(s).
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 173,829,000.00
Alleged Contracting and Appropriation Irregularities at the Office of Transition, Employment, and Economic Impact
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16-04555-138

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/31/2019
The OIG recommended the Executive in Charge for Benefits coordinate with the Head of VA Contracting Activity and the Office of General Counsel to determine what actions need to be taken to remedy the unauthorized commitment.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/7/2018
The OIG recommended the Executive in Charge for Benefits obtain appropriate funding for all future information technology costs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/3/2020
The OIG recommended the Executive in Charge for Benefits coordinate with the Office of Information Technology, the Office of Management, and the Office of General Counsel to make accounting adjustments to debit the information technology account that should have been used and credit the general operating expense account that was inappropriately used, determine whether Antideficiency Act violations occurred, and report the violations as appropriate.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 11,700,000.00
Healthcare Inspection - Testosterone Replacement Therapy Initiation and Follow-Up Evaluation in VA Male Patients
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15-03215-154

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2020
The Under Secretary for Health ensures that providers establish clinical signs and symptoms consistent with androgen deficiency, prior to testing patients’ testosterone level for confirmation in alignment with Veterans Health Administration guidance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2019
The Under Secretary for Health ensures that providers biochemically confirm hypogonadism through repeated testosterone testing prior to initiation of testosterone replacement therapy in alignment with Veterans Health Administration guidance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2019
The Under Secretary for Health ensures that providers determine whether the etiology of hypogonadism is primary or secondary, prior to testosterone replacement therapy initiation in alignment with Veterans Health Administration guidance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2019
The Under Secretary for Health ensures that providers discuss and document the risks and benefits of testosterone therapy with patients prior to initiation in alignment with Veterans Health Administration guidance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2019
The Under Secretary for Health ensures that providers assess and document patients’ symptoms improvement and adverse effects within 3–6 months of initiation before continuing testosterone replacement therapy in alignment with Veterans Health Administration guidance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2019
The Under Secretary for Health ensures that providers monitor patients’ hematocrit levels within 3–6 months of initiation, before continuing testosterone replacement therapy in alignment with Veterans Health Administration guidance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2019
The Under Secretary for Health ensures that providers assess and document patients’ adherence to therapy and perform testosterone level test within 3–6 months of initiation, before continuing testosterone replacement therapy in alignment with Veterans Health Administration guidance.
VA’s Federal Information Security Modernization Act Audit for Fiscal Year 2017
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17-01257-136

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology fully implement an agency-wide risk management governance structure, along with mechanisms to identify, monitor, and manage risks across the enterprise. (This is a repeat recommendation from prior years.)
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement mechanisms to ensure sufficient supporting documentation is captured to justify closure of Plans of Action and Milestones. (This is a repeat recommendation from prior years.)
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement improved processes to ensure that all identified weaknesses are incorporated into the Governance Risk and Compliance tool, in a timely manner, and corresponding Plans of Actions and Milestones are developed to track corrective actions and remediation. (This is a repeat recommendation from prior years.)
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement clear roles, responsibilities, and accountability for developing, maintaining, completing, and reporting on Plans of Action and Milestones. (This is a repeat recommendation from prior years.)
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology develop mechanisms to ensure system security plans reflect current operational environments, include an accurate status of the implementation of system security controls, and all applicable security controls are properly evaluated. (This is a modified repeat recommendation from prior years.)
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement improved processes for reviewing and updating key security documents such as risk assessments and security control assessments on an annual basis and ensure the information accurately reflects the current environment. (This is a modified repeat recommendation from prior years.)
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement mechanisms to enforce VA password policies and standards on all operating systems, databases, applications, and network devices. (This is a repeat recommendation from prior years.)
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement periodic reviews to minimize access by system users with incompatible roles, permissions in excess of required functional responsibilities, and unauthorized accounts. (This is a repeat recommendation from prior years.)
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology enable system audit logs on all critical systems and platforms and conduct centralized reviews of security violations across the enterprise. (This is a repeat recommendation from prior years.)
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology fully implement two-factor authentication for all network access methods throughout the agency. (This is a repeat recommendation from prior years.)
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement more effective automated mechanisms to continuously identify and remediate security deficiencies on VA’s network infrastructure, database platforms, and web application servers. (This is a repeat recommendation from prior years.)
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement a more effective patch and vulnerability management program to address security deficiencies identified during our assessments of VA’s web applications, database platforms, network infrastructure, and workstations. (This is a repeat recommendation from prior years.)
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology maintain a complete and accurate security baseline configurations for all platforms and ensure all baselines are appropriately implemented for compliance with established VA security standards. (This is a modified repeat recommendation from prior years.)
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement improved network access controls to ensure medical devices and networks, not managed by the Office of Information and Technology, are appropriately segregated from general networks and mission-critical systems. (This is a repeat recommendation from prior years.)
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology consolidate the security responsibilities for networks not managed by the Office of Information and Technology, under a common control for each site and ensure vulnerabilities are remediated in a timely manner. (This is a repeat recommendation from prior years.)
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement improved processes to ensure that all devices and platforms are evaluated using credentialed vulnerability assessments. (This is a repeat recommendation from prior years.)
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement improved procedures to enforce a standardized system development and change control framework that integrates information security throughout the life cycle of each system. (This is a repeat recommendation from prior years.)
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement improved processes for ensuring the encryption of backup data prior to transferring the data offsite for storage. (This is a repeat recommendation from prior years.)
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement improved processes for the testing of contingency plans and failover capabilities for critical systems to ensure that all components can be recovered at the assigned sites and within stated timeframes. (This is a modified repeat recommendation from prior years.)
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology identify all external network interconnections and implement improved processes for monitoring VA networks, systems, and connections for unauthorized activity. (This is a repeat recommendation from prior years.)
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement more effective agency-wide incident response procedures to ensure timely reporting, updating, and resolution of computer security incidents in accordance with VA standards. (This is a repeat recommendation from prior years.)
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology ensure that VA’s Network Security and Operations Center has full access to all security incident data to facilitate an agency-wide awareness of information security events. (This is a repeat recommendation from prior years.)
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement improved safeguards to identify and prevent unauthorized vulnerability scans and data exfiltrations from VA networks. (This is a repeat recommendation from prior years.)
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology fully develop a comprehensive list of approved and unapproved software and implement continuous monitoring processes to prevent the use of unauthorized software on agency devices. (This is a repeat recommendation from prior years.)
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology develop a comprehensive software inventory process to identify major and minor software applications used to support VA programs and operations. (This is a repeat recommendation from prior years.)
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement improved procedures for overseeing contractor-managed cloud-based systems and ensure information security controls adequately protect VA sensitive systems and data. (This is a repeat recommendation from prior years.)
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/11/2018
We recommended the Executive in Charge for Information and Technology implement mechanisms for updating systems inventory, including contractor-managed systems and interfaces, and provide this information in accordance with Federal reporting requirements. (This is a repeat recommendation from prior years.)
Administrative Investigation - Conflict of Interest, Nepotism, and False Statements, VA Office of General Counsel, Washington, DC
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17-03324-123

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 6/6/2019
The VA Deputy Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against Mr. Fleck.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 6/6/2019
The VA Deputy Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against Ms. KW.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 6/6/2019
The VA Deputy Secretary confers with the Offices of General Counsel and Human Resources to determine the total amount of funds unlawfully expended to pay for Ms. KW’s salary since her initial VA appointment on January 8, 2017, and ensures that a bill of collection is issued to Ms. KW in that amount.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 6/6/2019
The VA Deputy Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate corrective action to take concerning Ms. KW’s VA appointment and takes such action.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 6/6/2019
The VA Deputy Secretary confers with VA’s Designated Agency Ethics Official to ensure Deputy General Counsel for Legal Policy staff members receive appropriate ethics training as related to our findings in this report.
Comprehensive Healthcare Inspection Program Review of the VA North Texas Health Care System, Dallas, Texas
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17-05404-149

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2018
The Chief of Staff ensures practitioners’ Focused Professional Practice Evaluation competency reviews include clearly delineated timeframes and criteria and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2018
The Chief of Staff ensures that Ongoing Professional Practice Evaluations include the review of service- and practitioner-specific data and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2020
The Chief of Staff ensures that Ongoing Professional Practice Evaluations include the utilization of service-specific criteria and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2019
The Chief of Staff and Associate Director for Patient Care Services ensure personal protective equipment is readily accessible and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2018
The Facility Director ensures that reconciliation of controlled substance refills to automated dispensing units in patient care areas and reconciliation of returns to pharmacy stock are performed during controlled substance inspections and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2019
The Chief of Staff ensures ordering providers or designees communicate mammogram results to patients and monitors providers’ compliance.
Review of Research Service Equipment and Facility Management, Eastern Colorado Health Care System
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16-02742-77

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The OIG recommended the VA Eastern Colorado Health Care System Director establish a policy requiring the Research Service implement a process to identify all accountable equipment annually that does not have a barcode label, and ensure these items are communicated to the Logistics Service so they receive a barcode label and are recorded in the automated inventory system.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2018
The OIG recommended the VA Eastern Colorado Health Care System Director develop an action plan that would ensure all Research Service sensitive information technology equipment is assigned to an information technology equipment inventory list.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
3. The OIG recommended the VA Eastern Colorado Health Care System Director implement a training program to ensure Information Technology, Research, and Logistics Service staffs are properly trained to enable them to identify and place sensitive information technology equipment under control.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2019
The OIG recommended the VA Eastern Colorado Health Care System Director implement a policy requiring the Logistics Service perform recurring, at least annually, quality reviews of Research Service automated equipment data to identify and correct incomplete, inaccurate, and unreliable records, maintain copies of the reviews, and provide the completed reviews to the director.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2019
The OIG recommended the VA Eastern Colorado Health Care System Director implement a policy requiring the Logistics Service perform recurring quality reviews, at least annually, to ensure equipment transaction records are maintained, logically organized, and easily accessible for assigned research equipment, in accordance with policy.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2018
The OIG recommended the VA Eastern Colorado Health Care System Director develop a local policy requiring the Logistics Service to perform recurring reviews of inventory dates for all Research Service accountable equipment and sensitive items, to ensure all equipment has been inventoried on an annual basis, which is from the month of completion to the next 12-month period, as required by VA Handbook 7002.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The OIG recommended the VA Eastern Colorado Health Care System Director implement a procedure to ensure compliance with the VA Handbook 6500.1 requirement to attach VA Form 0751, Information Technology Equipment Sanitization Certificate, to VA Form 2237, Request, Turn-In, and Receipt for Property or Services, prior to disposal of sensitive information technology equipment.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The OIG recommended the VA Eastern Colorado Health Care System Director take steps necessary to ensure required Report of Survey actions listed in VA Handbook 7002 are completed for the missing items reported lost by the Research Service on the eight Reports of Survey initiated in calendar year 2015.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The OIG recommended the VA Eastern Colorado Health Care System Director require the accountable officer to follow policy, establish, and maintain a Report of Survey register by fiscal year, to track, monitor, and ensure required actions are completed timely.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The OIG recommended the VA Eastern Colorado Health Care System Director ensure there are an adequate number of officials who have the required training to complete Report of Survey actions so Reports of Survey can be fully processed, timely.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The OIG recommended the VA Eastern Colorado Health Care System Director implement a mechanism to ensure all Research Service Custodial Officers complete their required annual Custodial Officer’s training.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The OIG recommended the VA Eastern Colorado Health Care System Director ensure Delegation of Authority letters for all current Research Service Custodial Officers are completed in accordance with VA Handbook 7002.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The OIG recommended the VA Eastern Colorado Health Care System Director ensure all materials and specimens are stored in a freezer with a remote temperature monitoring system.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The OIG recommended the VA Eastern Colorado Health Care System Director ensure exterior doors on Research Service buildings are repaired so they consistently lock upon closure.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The OIG recommended the VA Eastern Colorado Health Care System Director ensure all exterior doors to Research Service buildings are secured by self-closing doors with automatic locking upon closure with access by keycard or a system that is equal to or exceeds the security of a keycard system.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The OIG recommended the VA Eastern Colorado Health Care System Director establish procedures to timely decommission vacant laboratories, and collect, store or dispose of unused chemicals and personally identifiable information in accordance with applicable policies.
Comprehensive Healthcare Inspection Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York
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17-05407-141

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/3/2018
The Chief of Staff ensures the Executive Committee of the Medical Staff uses the results of Ongoing Professional Practice Evaluations in the determination of whether to recommend continuation of licensed independent practitioners’ privileges and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/3/2018
The Chief of Staff ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors the advisors’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2019
The Chief of Staff ensures the interdisciplinary group or committee that reviews utilization management data includes representatives from the Chief, Business Office Revenue-Utilization Review.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2019
The Facility Director ensures the Patient Safety Manager or designee provides feedback about root cause analysis actions to the reporting individuals or departments and monitors the Patient Safety Manager’s compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2019
The Associate Director ensures environment of care rounds are conducted in all areas of the facility at the required frequency and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/12/2019
The Associate Director ensures required team members consistently participate on environment of care rounds and monitors team members’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2019
The Associate Director ensures medical biohazardous waste storage rooms are secured and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2019
The Facility Director ensures that controlled substances inspectors perform controlled substances order verification as required and monitors inspectors’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2019
The Facility Director ensures controlled substances inspectors complete monthly pharmacy prescription pad inventories and monitors inspectors’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2019
The Chief of Staff ensures providers communicate mammogram results to patients and monitors providers’ compliance.
Healthcare Inspection—Inadequate Intensivist Coverage and Surgery Service Concerns, Gulf Coast Veterans Healthcare System, Biloxi, Mississippi
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17-03399-150

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2018
We recommended that the System Director continue to follow through on incomplete actions as discussed in Issues 1 and 2 of this report.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2018
We recommended that the Veterans Integrated Service Network Director provide oversight of intensive care unit and Surgery Service-related operations until corrective actions are completed and conditions have been resolved.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2018
We recommended that the System Director take action as appropriate related to Physicians A and B and their improper electronic health record documentation as discussed in this report.
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