All Reports

Veterans Integrated Service Network 21’s Management of Medical Facilities’ Nonrecurring Maintenance
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19-06004-225
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Topics:  Maintenance and Construction

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The director of the VA Sierra Pacific Network (VISN 21) should ensure out-of-cycle projects conform to NRM policy urgent-need criteria before approving projects.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The director of VISN 21 should study the feasibility of using non-engineering staff to oversee NRM contracts, contracting out for project requirements to free up VISN engineering resources, and sharing engineering resources between VISN 21 facilities.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The under secretary for health should implement an engineering staffing model for medical facilities that supports the achievement of VA strategic goals.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The under secretary for health should perform annual reviews of the engineering staffing model to determine if adjustments are needed to achieve VA strategic goals.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The under secretary for health should ensure medical facilities design long-range action plans that are feasible based on expected NRM budget levels.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Asset Enterprise Management (OAEM)
The executive director of the Office of Asset Enterprise Management, in coordination with the under secretary for health, should enforce NRM policy’s urgent-need criteria on out-of-cycle NRM project approvals.
No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The under secretary for health in coordination with the executive director of the Office of Asset Enterprise Management should create a standardized set of performance measures and reporting standards for offices involved in developing, approving, and executing long-range action plans to ensure NRM projects that align with strategic goals are executed.
VA’s Management of Land Use under the West Los Angeles Leasing Act of 2016: Five-Year Report
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20-03407-253
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Topics:  Leases and Major Contracts

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No. 1
Open Recommendation Image, Square
to Acquisitions, Logistics, and Construction (OALC),Veterans Health Administration (VHA)
Implement a plan that brings the five new noncompliant land use agreements into compliance with the West Los Angeles Leasing Act of 2016, the draft master plan, and other federal laws, allowing reasonable time to correct deficiencies noted in this report.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Ensure VA’s capital asset inventory accurately reflects all land use agreements lasting six months or longer on the West Los Angeles campus.
Better Oversight of Prosthetic Spending Needed to Reduce Unreasonable Prices Paid to Vendors
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20-01802-234
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Topics:  Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Coordinate with appropriate officials, including the VA Office of General Counsel, and determine if 38 U.S.C. § 1703(i) and other reimbursement practices cited in this report apply to the reimbursement rates medical facilities should pay for prosthetic and orthotic items provided by vendors. If they do apply, develop and issue guidance requiring medical facilities to adhere to them; if they do not apply, develop and issue guidance on steps medical facilities need to take to ensure they purchase prosthetic and orthotic items at reasonable prices.
No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Develop and implement effective procedures to monitor prosthetic spending to make sure medical facilities reimburse vendors at reasonable prices for all prosthetic and orthotic items in accordance with updated pricing policies and processes.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Coordinate with appropriate officials such as the Prosthetic and Sensory Aids Service executive director and the executive director, Rehabilitation and Prosthetics Service, to establish a formal oversight structure that defines the roles and responsibilities of those charged with providing oversight of the prosthetics program, rescind handbooks that reflect an outdated oversight structure, and communicate updated oversight expectations to the Veterans Integrated Service Networks to promote consistent program oversight.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

Resolve National Prosthetics Patient Database limitations and establish requirements to routinely monitor medical facilities’ input of data to improve accuracy.

Total Monetary Impact of All Recommendations
Open: $ 20,000,000.00
Closed: $ 0.00
Ineffective Governance of Prescription Drug Return Program Creates Risk of Diversion and Limits Value to VA
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20-00418-166
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Topics:  Supplies and Equipment

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommends that the under secretary for health ensure that responsible VA medical facility personnel secure prescription drugs set aside for return credit either by following procedures outlined in VHA Directive 1108.07(1) or by adhering to a superseding policy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommends that the under secretary for health ensure that responsible VA medical facility personnel account for all prescription drugs set aside for return credit when they leave the medical facility either by following procedures outlined in VHA Directive 1108.07(1) or by adhering to a superseding policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommends that the under secretary for health ensure that responsible VA medical facility personnel maintain inventory management practices to make sure drugs that are returned for credit are returned in a timely manner, so that medical facilities do not miss opportunities to maximize the value of their drug returns or reduce their risk of overspending to replace drugs prematurely returned for credit.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommends that the under secretary for health takes steps to provide all offices and positions with defined national, network, or facility responsibilities for the drug return program or the administration of any future drug return contract(s), to include Pharmacy Benefits Management Services, Veterans Integrated Service Network pharmacist executives, network contracting officers, contracting officer representatives, and medical facility pharmacy chiefs, with the support, such as training, and the authority needed to carry out those responsibilities.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommends that the under secretary for health makes sure that Pharmacy Benefits Management Services reviews the drug return contractor(s) data for accuracy, and uses this data to identify unusual reimbursement patterns and potential improvements for revenue recovery through the last invoices issued as part of the October 2018 Pharma Logistics contract, and for any future drug return contract(s); and coordinate with the National Contract Service on corrective action if inaccurate contractor data is identified.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommends that the under secretary for health implements mechanisms to make sure that contracting officer representatives, if assigned, or Veterans Health Administration network contracting officers, provide oversight to ensure the contractor is performing in accordance with the terms of any future drug return contract(s).
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommends that the under secretary for health, to minimize the risk of errors, makes sure that Veterans Health Administration network contracting officers when writing task orders off any future drug return contract(s) use a template with terms that align with any future drug return contract(s) developed by the National Contract Service.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC),Veterans Health Administration (VHA)
The OIG recommends that the under secretary for health coordinate with the VA Office of Acquisition, Logistics, and Construction’s principal executive director, who should develop a task order template with terms that align with any future drug return contract(s) and require the National Contract Service to disseminate the template to Veterans Health Administration network contracting officers.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 14,907,365.00
Opportunities Exist to Improve Management of Noninstitutional Care through the Veteran-Directed Care Program
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20-02828-174
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Topics:  Patient Care Services Operations

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health establish a process to ensure program personnel document veterans’ quarterly monitoring in their electronic health records, such as by using a standardized template.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health etablish a process to ensure the provider agency list in the Electronic Claims Adjudication Management System is updated as new provider agencies are added to the program.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health etablish a process to ensure proper pricing in the Electronic Claims Adjudication Management System when paying program claims.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health update program guidance on claims submission and processing to make sure provider agencies are aware of the need to include all required information when submitting program claims.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health establish guidance to include processes that medical facilities must follow to determine if veterans are receiving the same personal care services through the Veteran Directed Care program and the Program of Comprehensive Assistance for Family Caregivers, and how to address these situations, as appropriate.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health ensure program personnel determine if veterans enrolled in both the Veteran Directed Care and the Program of Comprehensive Assistance for Family Caregivers are receiving the same personal care services and take action, as appropriate.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The OIG recommended the under secretary for health establish procedures to identify program staffing needs and define program personnel’s roles and responsibilities at the national, network, and local levels.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health update procedures for tracking and reporting demand for and use of program services and use these data to inform yearly cost estimates for the program.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 6,570,395.00
Contracted Residence Programs Need Stronger Monitoring to Ensure Veterans Experiencing Homelessness Receive Services
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19-08267-147
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Topics:  Clinical Care Services Operations

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Establish control mechanisms at the Veterans Integrated Service Network and Contracted Residential Services program levels to ensure Contracted Residential Services staff at medical facilities comply with Veterans Health Administration Handbook 1162.09 requirements for monitoring and documentation.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Direct Network Contracting Offices to establish controls to verify contracting officers meet with contracting officer’s representatives on at least a quarterly basis to evaluate contractor performance and document the meetings.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Direct Network Contracting Offices for all Contracted Residential Services contracts to ensure contracting officers include quality assurance surveillance plans and promptly issue letters of delegation to staff who have been nominated to be contracting officer’s representatives.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Update Veterans Health Administration Handbook 1162.09 to incorporate unannounced site visits to the extent possible during annual inspections and quarterly evaluations.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Update Veterans Health Administration Handbook 1162.09 to include guidance on paying for veteran absences and make certain these requirements are reflected in contracts and surveillance plans.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 35,300,000.00
Inadequate Financial Controls and Payments Related to VA-Affiliated Nonprofit Corporations
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20-03704-165
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Topics:  Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Establish procedures at all facilities with affiliated nonprofit corporations to help ensure VA medical center Research and Development Budget Office staff review nonprofit corporation invoice documentation and confirm services were performed before approving payment.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Establish procedures for Research and Development Budget Office supervisors at all the VA medical centers with affiliated nonprofit corporations that ensure periodic reviews are conducted of invoices authorized for payment, confirming that staff verified services were performed before approving payments.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Ensure the Nonprofit Program Office invoice review procedures incorporate verification that affiliated nonprofit corporations include evidence that services were provided with invoices submitted to VA.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 17,900,000.00
Unreliable Information Technology Infrastructure Cost Estimates for the Electronic Health Record Modernization Program
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20-03185-151
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Topics:  Electronic Health Records Modernization (EHRM) ● System Development and Implementation

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)

Ensure an independent cost estimate is performed for program life-cycle cost estimates related to information technology infrastructure costs.

No. 2
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

Reassess the cost estimate for Electronic Health Record Modernization program-related information technology infrastructure and refine as needed to comply with VA’s cost-estimating standards. 

No. 3
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

Develop procedures for cost-estimating staff that align with VA cost-estimating guidance.

No. 4
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

Ensure costs for all information technology infrastructure upgrades funded by the Office of Information and Technology and the Veterans Health Administration or other sources needed to support the Electronic

No. 5
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

Formalize agreements with the Office of Information and Technology and the Veterans Health Administration identifying the expected contributions from each entity toward information technology infrastructure upgrades in support of the Electronic Health Record Modernization program.

No. 6
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

Establish procedures that identify when life-cycle cost estimates should be updated and ensure those updated estimates are disclosed in the program’s congressionally mandated reports.

VHA Made Inaccurate Payments to Part-Time Physicians on Adjustable Work Schedules
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20-01646-139
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Topics:  Financial Management

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Ensure payroll personnel complete overdue reconciliations of part-time physicians on adjustable work schedule agreements and take any necessary actions to address overpayments and underpayments.
No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Establish oversight procedures to make certain that part-time physicians submit and validate their subsidiary time sheets and that supervisors promptly certify the time sheets.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

Train newly assigned payroll personnel on agreement reconciliation procedures and develop follow-up procedures to prevent missed reconciliations because of staff turnover.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Implement procedures to confirm service chiefs conduct quarterly reviews of all adjustable work hour agreements that include identifying physicians with significant variances from the agreements or indicators that the cap on part-time hours is likely to be exceeded and taking corrective actions.
No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Document oversight procedures for monitoring and validating compliance with the requirements of the part-time physician on adjustable work schedules program.
No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Direct the program office, in coordination with the VA Office of General Counsel, to determine whether medical centers committed Antideficiency Act violations by not correcting underpayments and preventing physicians from working above the annual limit of 1,820 hours.
No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Establish oversight procedures for monitoring and validating their medical centers’ compliance with the requirements of the part-time physician on adjustable work schedules program.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Complete overdue reconciliations of part-time physicians on adjustable work schedule agreements and take any necessary actions to address overpayments and underpayments.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Document oversight procedures for monitoring and validating that all reconciliations and payment corrections are completed when agreements expire or are terminated.
Total Monetary Impact of All Recommendations
Open: $ 16,600,000.00
Closed: $ 0.00
Veterans Cemetery Grants Program Did Not Always Award Grants to Cemeteries Correctly and Hold States to Standards
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20-00176-125

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
The OIG recommended the under secretary for memorial affairs develop controls to ensure state grants are prioritized and awarded in accordance with the Code of Federal Regulations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
The OIG recommended the under secretary for memorial affairs develop and implement written policies and procedures for grant prioritization.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
The OIG recommended the under secretary for memorial affairs evaluate all current national headstone and niche cover contracts for appropriate penalties and clauses for timeliness and quality issues and enforce and amend those contracts as necessary.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
The OIG recommended the under secretary for memorial affairs direct the Improvement and Compliance Service to assign levels of importance to standards and measures used for compliance reviews and test the inscription accuracy of all gravesites sampled.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)

The OIG recommended the under secretary for memorial affairs require all state and tribal cemeteries to submit certified condition and operations performance assessments annually.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
The OIG recommended the under secretary for memorial affairs ensure representatives from all state and tribal cemeteries are provided opportunities to participate in National Cemetery Administration standards training via remote training options and monitor all training to ensure adequate participation.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
The OIG recommended the under secretary for memorial affairs continue to seek an increase in cemetery grant funding in excess of $45 million
No. 8
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
The OIG recommended the under secretary for memorial affairs ensure that the Improvement and Compliance Service follows up with Hawaiian cemeteries after action plans are submitted to ensure deficiencies are corrected.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
The OIG recommended the under secretary for memorial affairs implement controls to ensure cemeteries that receive provisionally compliant or noncompliant scores during reviews are followed up with on a fixed and regular basis until sufficient corrective action plans are submitted.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)

The OIG recommended the under secretary for memorial affairs use accountability measures in the Code of Federal Regulations when appropriate if grantees do not take adequate steps to correct significant long standing deficiencies.

No. 11
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
The OIG recommended the under secretary for memorial affairs work with the State of Hawaii Office of Veterans’ Services to conduct an extensive assessment of all eight Hawaii state veterans cemeteries, including organizational oversight and operations, staffing needs (including training), gravesite marker accuracy, and grounds conditions.
VHA Needs More Reliable Data to Better Monitor the Timeliness of Emergency Care
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20-01141-145
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Topics:  Appointment Scheduling and Wait Times

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health ensure Baltimore VA Medical Center leaders reevaluate their corrective action plan and adjust as needed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health make certain relevant staff receive appropriate training on recording wait times in the software.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health strengthen reliability reviews of Emergency Department Integration Software data to mitigate the risk of inaccurate records.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health establish routine oversight responsibilities for Veterans Integrated Service Network and facility leaders of emergency departments’ efforts to improve the reliability of their emergency department data.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health improve the monitoring of data for patients with the highest Emergency Severity Index levels of one or two receiving emergency care services.
Improvements Needed in Adding Non-VA Medical Records to Veterans’ Electronic Health Records
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19-08658-153
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Topics:  Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Ensure facilities create and implement standard operating procedures that clearly define all Health Information Management and community care staff responsibilities and the procedures for accurately scanning, importing, and indexing non-VA medical records.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Require facility directors ensure that Health Information Management leaders provide or formally delegate training, quality checks, and quality assurance monitoring for community care staff responsible for medical record management.
Entitled Veterans Generally Received Clothing Allowance but Stronger Controls Could Decrease Costs
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20-01487-142

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health revise the Veterans Health Administration handbook to include detailed roles, responsibilities, and procedures for determining entitlement to and monitoring of the clothing allowance benefit.
No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health develop and initiate a plan to reevaluate veterans’ entitlement to recurring clothing allowance benefits in collaboration with the Veterans Benefit Administration.
Total Monetary Impact of All Recommendations
Open: $ 129,709,810.00
Closed: $ 0.00
Program of Comprehensive Assistance for Family Caregivers: IT System Development Challenges Affect Expansion
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20-00178-24
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Topics:  System Development and Implementation

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
The OIG recommended the acting assistant secretary for information and technology, in conjunction with the acting under secretary for health, establish policies and procedures for joint governance by OIT and program offices on all information.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
The OIG recommended the acting assistant secretary for information and technology require the Office of Information and Technology to develop controls for making certain the program management review process is consistently enforced for future information technology projects to deliver and sustain the intended outcomes and to ensure underperforming projects are identified for evaluation by the Program and Acquisition Review Council.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
The OIG recommended the acting assistant secretary for information and technology, in conjunction with the acting under secretary for health, reevaluate the risk determination for the Caregiver Record Management Application and determine if the system should be set to a security categorization level of high based on the personal health information and other sensitive data maintained therein.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
The OIG recommended the acting assistant secretary for information and technology establish VA wide policies and responsibilities for managing VA information technology projects under the Development Operations process.
Compensation and Pension Proceeds Were Generally Handled Accurately but Some Were Delayed
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20-00817-123

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Implement a timeliness requirement or performance measure for handling proceeds.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Develop oversight and monitoring procedures to ensure timely handling of proceeds.
Deficiencies in Reporting Reliable Physical Infrastructure Cost Estimates for the Electronic Health Record Modernization Program
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20-03178-116
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Topics:  Electronic Health Records Modernization (EHRM) ● System Development and Implementation

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)

The executive director for the Office of Electronic Health Record Modernization should ensure an independent cost estimate is performed for program life cycle cost estimates including related physical infrastructure costs funded by the Veterans Health Administration.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)

The VA Assistant Secretary for Management and Chief Financial Officer  should ensure the Office of Programming, Analysis and Evaluation, or another office performing its duties, conducts independent cost 

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

 The director of Special Engineering Projects for the Veterans Health  Administration’s Office of Healthcare Environment and Facilities Programs should develop a  reliable cost estimate for Electronic Health Record Modernization program-related physical  infrastructure in accordance with VA cost-estimating standards and incorporate costs for upgrade  needs identified in facility self-assessments and scoping sessions.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The director of Special Engineering Projects should also continuously update physical infrastructure cost estimates based on emerging requirements and identified project needs.

No. 5
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

Ensure costs for physical infrastructure upgrades funded by the Veterans Health Administration or other sources needed to support the Electronic Health Record Modernization program are disclosed in program life cycle cost estimates presented to Congress.

Federal Information Security Modernization Act Audit for Fiscal Year 2020
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20-01927-104
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Topics:  FISMA

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Assistant Secretary for Information and Technology consistently implement an improved continuous monitoring program in accordance with the NIST Risk Management Framework. Specifically, implement an independent security control assessment process to evaluate the effectiveness of security controls prior to granting authorization decisions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Assistant Secretary for Information and Technology implement improved mechanisms to ensure system stewards and information system security officers follow procedures for establishing, tracking, and updating Plans of Action and Milestones for all known risks and weaknesses including those identified during security control assessments.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Assistant Secretary for Information and Technology implement controls to ensure that system stewards and responsible officials obtain appropriate documentation prior to closing Plans of Action and Milestones.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Assistant Secretary 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.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Assistant Secretary for Information and Technology Implement improved processes for reviewing and updating key security documents such as security plans, risk assessments, and interconnection agreements on an annual basis and ensure the information accurately reflects the current environment.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Assistant Secretary for Information and Technology implement improved processes to ensure compliance with VA password policy and security standards on domain controls, operating systems, databases, applications, and network devices.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Assistant Secretary 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.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Assistant Secretary for Information and Technology enable system audit logs on all critical systems and platforms and conduct centralized reviews of security violations across the enterprise.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Office of Personnel Security strengthen processes to ensure appropriate levels of background investigations are completed for applicable VA employees and contractors and applicable investigation data is accurately tracked within the authoritative system of record.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Office of Personnel Security formalize the Position Descriptions and methodology used within the Human Resource business processes to ensure that employees with similar positions are required to have the same level of background investigation.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Assistant Secretary 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.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Assistant Secretary 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.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Assistant Secretary for Information and Technology maintain a complete and accurate security baseline configuration for all platforms and ensure all baselines are appropriately implemented for compliance with established VA security standards.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Assistant Secretary for Information and Technology implement improved network access controls that restrict medical devices from systems hosted on the general network.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Assistant Secretary 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.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Assistant Secretary for Information and Technology implement improved processes to ensure that all devices and platforms are evaluated using credentialed vulnerability assessments.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Assistant Secretary for Information and Technology implement improved procedures to enforce standardized system development and change control processes that integrates information security throughout the life cycle of each system.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Assistant Secretary for Information and Technology review system boundaries, recovery priorities, system components, and system interdependencies and implement appropriate mechanisms to ensure that established system recovery objectives are met.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Assistant Secretary for Information and Technology ensure contingency plans for all systems and applications are updated and tested in accordance with VA requirements.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Assistant Secretary for Information and Technology implement more effective agency-wide incident response procedures to ensure timely notification, reporting, updating, and resolution of computer security incidents in accordance with VA standards.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Assistant Secretary for Information and Technology ensure that VA’s Cybersecurity Operations Center has full access to all security incident data to facilitate an agency-wide awareness of information security events.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Assistant Secretary for Information and Technology implement improved safeguards to identify and prevent unauthorized vulnerability scans on VA networks.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Assistant Secretary for Information and Technology implement improved measures to ensure that all security controls are assessed in accordance with VA policy and that identified issues or weaknesses are adequately documented and tracked within POA&Ms.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Assistant Secretary for Information and Technology fully develop a comprehensive list of approved and unapproved software and implement continuous monitoring processes to prevent the use of prohibited software on agency devices.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Assistant Secretary for Information and Technology develop a comprehensive inventory process to identify connected hardware, software, and firmware used to support VA programs and operations.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Assistant Secretary for Information and Technology implement improved procedures for monitoring contractor-managed systems and services and ensure information security controls adequately protect VA sensitive systems and data.
Inadequate Oversight of the Medical/Surgical Prime Vendor Program’s Distribution Fee Invoicing
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19-06147-50
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Topics:  Supplies and Equipment ● Financial Management

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Direct the Medical Supplies Program Office to implement procedures requiring chief logistics officers at Veterans Integrated Service Networks to monitor facility processes for verification and certification of distribution fee invoices to ensure invoice accuracy prior to payment by the Financial Services Center.
No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Require Veterans Integrated Service Network directors to ensure their chief logistics officers develop distribution fee monitoring and review procedures for facility logistics audits and compliance reviews to ensure invoices are adequately reviewed, verified, and certified.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Require Veterans Integrated Service Network directors to ensure facility chief logistics officers and contracting officer’s representatives review and update the election forms according to contract requirements and provide copies to the Medical/Surgical Prime Vendors for acknowledgment.
No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Require Veterans Integrated Service Network directors to ensure facility contracting officer’s representatives verify that distribution fee rates match with those on the election forms and pricing schedule by comparing transaction data from the vendors to VHA-maintained transaction data, and reconcile payments as appropriate.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Require the Strategic Acquisition Center to develop and add modifications to the Medical/ Surgical Prime Vendor-Next Generation contract requiring prime vendors to provide reports to VA medical facilities with detailed medical and surgical transaction data, fee amounts, and fee percentage rates applied to each transaction on distribution fee invoices.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Require the Strategic Acquisition Center contracting officer to work with the Medical Supplies Program Office to ensure that Medical/Surgical Prime Vendor contracting officer’s representatives are assigned to each VA medical facility.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Require the Strategic Acquisition Center to appropriately modify the Medical/Surgical Prime Vendor contract to define annual facility purchase as well as adding a provision for paying the annual facility purchase amount based on the estimated total spend until year-end reconciliation.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Require the Strategic Acquisition Center to also appropriately modify the Medical/ Surgical Prime Vendor contract to require the prime vendors—rather than the facility—to reconcile to annual facility purchases at the end of the year.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Require the Medical Supplies Program Office to establish policy that clearly defines the source VA medical facilities should use to estimate their annual facility purchase amounts and determine the year-end amounts.
No. 10
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Require VA medical facilities to review their on-site representative fees paid during fiscal year 2018 and future years to ensure they were paid based on the actual annual facility purchase amounts, consistent with the Medical/Surgical Prime Vendor-Next Generation contract, and reconcile payment discrepancies as appropriate.
Total Monetary Impact of All Recommendations
Open: $ 3,700,000.00
Closed: $ 0.00
The Office of Community Care’s Oversight of Non-VA Healthcare Claims Processed by Its Contractor
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19-06902-23
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Topics:  Community Care

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health ensures the Payment Operations and Management directorate reevaluates all sample claims identified in this audit as not processed in accordance with Office of Community Care guidance, and takes appropriate corrective action as needed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health ensures there is a contract requirement that the contractor’s employees must follow Office of Community Care guidance for processing non-VA care claims.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health ensures the contractor’s standard operating procedures for claims processing are accurate and a mechanism is put in place to keep the contractor’s procedures updated to reflect current Office of Community Care claims processing procedures.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health ensures the Office of Community Care develops and implements clear controls for reviewing and updating, if necessary, the quality assurance surveillance plan requirements at least annually
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health ensures the Payment Operations and Management personnel make full use of the established communication tracking tool.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health ensures the Payment Operations and Management leaders provide timely training and additional guidance to their staff and the contractor’s employees on applying and using standardized denial and rejection reasons, and employees follow procedures to process claims with no authorizations to ensure consistent and accurate claims processing.
Biologic Implant Purchasing, Inventory Management, and Tracking Need Improvement
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19-07053-51
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Topics:  Supplies and Equipment

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Provide clarifying guidance and controls to clinic staff on making determinations to send purchase requests and consult notifications to the appropriate purchasing agents.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Provide clarifying guidance to purchasing agents on how to effectively evaluate biologic implant purchase requests for the correct funding source.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Provide clarifying guidance to prosthetic agents to ensure they receive clinic staff consult notifications on all prosthetic purchases of biologic implants.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Create a biologic implant cost code for general-purpose funds to improve funding accountability and potentially assist in ensuring all biologic implant use is tracked.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Direct the Procurement and Logistics Office to clarify guidance on the use of an approved inventory management system specific to biologic implants and the related VHA network, office, and facility staff responsibilities.
No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Monitor facility compliance with the use of an approved inventory management system for completeness and accuracy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Direct the Procurement and Logistics Office to ensure logistics staff perform inventory reviews of biologic implants, as required.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Monitor medical facility compliance with required reviews of on-site inventory.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

Establish a structure for oversight responsibility that can provide guidance for tracking implanted biologics.

No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

Create policies and procedures for facilities to follow as they implement effective controls for tracking biologic implants.

No. 11
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Establish standardized systems and requirements for facility staff to appropriately record necessary biologic implant attributes for accurate and accessible tracking of recipients to advance patient safety.
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