All Reports

Establish mechanisms to make sure business cases are developed, promptly reviewed, and approved as required by the Office of Management and Budget Circular A‑11 and VA Directive 0011.

Perform periodic reviews to verify that business cases comply with Office of Management and Budget Circular A‑11 requirements by being updated throughout a project’s life cycle to reflect changes in scope, schedule, and cost, and to verify that if changes exceed 10 percent of the initially approved business case, they are reported to the Office of Management and Budget.

Verify that milestones for the Louisville new medical center project are updated to incorporate critical user-requested changes and that these changes are completed in a timely manner to prevent further delays, while keeping the project within its authorized scope, cost, and schedule.

Establish controls to ensure the executive director of the Office of Construction and Facilities Management fulfills the responsibilities in VA Directive 0067 to incorporate National Environmental Policy Act analysis early on in all land acquisition, planning, design, and construction projects.

Conduct a comprehensive review of major construction project obligations to ensure all costs related to each project, including those recorded in separate funding lines, are included in the total estimated project costs reported to Congress, consistent with 38 U.S.C. § 8120, 31 U.S.C. § 1105, Office of Management and Budget Circular A‑11, and volume 8 of VA Financial Policy.

Update the responsibilities section of VA Directive 0067 to reflect the expectation that, before budget authorization, major construction projects must proactively identify advance planning fund requirements to support the initiation of NEPA environmental reviews during project development.

Provide the VA Office of Inspector General with an implementation schedule for an acquisition framework to enable monitoring of major construction project performance.

Assess options to expand and optimize automation tools, including artificial intelligence–based solutions, for request for services processing to reduce manual steps and promote efficiency.

Address system limitations that prevent identification of whether actions specific to requests for services have been taken or are pending, such as the delegated clinician review.

Review and update national standard operating procedures for request for services processing to clarify roles and responsibilities, address inappropriate practices, and reduce processing delays.

Develop processes or controls to help improve the accuracy and consistency of the use of the actual receipt date as the official date the Veterans Health Administration received the request for services to maintain accurate timeliness tracking.

Make sure facilities provide accurate notifications to community providers and notify veterans at key processing stages.

Implement mechanisms to provide routine oversight of the request for services process, including assessing data accuracy and the timeliness of request processing, to reinforce accountability and support corrective action.

In collaboration with the director of Veterans Integrated Service Network 16, verify engineering staff are complying with Veterans Health Administration policies and guidance associated with architectural and engineering design review and inspection procedures.

Verify that all engineering staff understand and are trained on VA design and physical security requirements related to minor and nonrecurring maintenance construction projects.

Verify that engineering staff who develop independent government cost estimates are sufficiently trained on developing a statement of work and how these documents affect the cost estimates.

Ensure engineering staff are documenting their review and acceptance of architectural and engineering designs as required by the Federal Acquisition Regulation before the solicitation of construction contracts.

Develop and implement procedures to maintain stock within the required thresholds as outlined in Veterans Health Administration Directive 1761.

Ensure all relevant supply chain staff receive appropriate and recurring training and require supervisors to perform ongoing monitoring—including periodic inventory reviews and root‑cause analyses—to strengthen controls over VA supplies.

Develop and implement, in collaboration with the Veterans Integrated Service Network, local procedures that require custodial officers to notify supply chain staff when equipment is relocated, and establish protocols to validate and update equipment location and ensure equipment items are properly tagged.

Ensure expendable supplies labeled expired are, in fact, expired and appropriate documentation is completed before turning the supplies in.

Address the physical security issues discussed in this report and provide recurring training on proper physical security controls and procedures to individuals with authorized access to the primary inventory point and warehouses.

Evaluate contractor performance under the contracts awarded for inventory management systems in the Augusta VA Health Care System and take appropriate action to ensure performance in accordance with the contract and to recover funds.

Ensure supply chain management staff effectively address deficiencies identified during Veterans Integrated Service Network quality control reviews.

Confer with the VA Office of General Counsel to determine whether VA should assert a claim to recover the $11.2 million paid for services not received

Evaluate and take any needed actions to make sure policies and procedures require appropriate officials to accurately ascertain information security requirements for contracts that involve sensitive information prior to award.

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

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

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

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

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

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

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

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

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

Consider the need for adjustments to current or for future contractual requirements that would improve mental health appointment timeliness by third-party administrators.

Identify and disseminate best practices used by healthcare systems to contact veterans, evaluate barriers to broader adoption of those practices, and implement a plan that supports consistent use of those best practices to improve scheduling timeliness.

Ensure that systems used to identify available community providers capture the full range of preferences that matter to veterans, so scheduling can better align with their individual needs and expectations for care.

Evaluate whether the third-party administrator’s network adequacy standards for mental health providers meet demand for both in person and telehealth, and if needed, modify the language to explicitly require sufficient availability of both in‑person and telehealth mental health providers to meet veteran demand.

Conduct a review to determine the best approach for increasing external use of available systems by community providers to streamline communication between the Veterans Health Administration and community providers and develop, implement, and monitor an action plan based on the review’s findings.

Assess the need for standardized guidance or contractual requirements that prohibit community mental health providers from requesting additional forms containing information already provided in the Veterans Health Administration referral documentation and implement measures to ensure compliance.

Consult with the VA Office of General Counsel to establish a clear and consistent interpretation of 38 C.F.R. § 4.59, to include clarification of whether pain alone without painful motion is sufficient to warrant a compensable evaluation.

Based on the clarified interpretation of 38 C.F.R. § 4.59, consider revising the Adjudication Procedures Manual to improve consistency of terms, and notify claims processors of the revision.

Assess whether guidance is clear to claims processors regarding the requirement to review all evidence, including both objective and subjective evidence, as well as the proper weight that should be given to each piece of evidence.

Determine what actions are necessary to the evaluation builder tool to mitigate confusion and ensure decision consistency for all musculoskeletal joint conditions.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Develop and communicate guidance that explains what detail should be included in a valid justification for every Veterans Benefits Management System for Rating override.

Develop and implement a plan to reestablish an overrides quality review process that provides individualized feedback for claims processors.

Develop and implement a plan to monitor the effectiveness of override reviews and continue to address areas and trends that are found to need improvement.

Identify the business need for the override review tab and, if there is one, develop and implement requirements for updating and using it.

Develop and implement a plan that addresses the limitations of the aggregate dashboard.