Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-00118-01 | Staff Incorrectly Processed Claims When Denying Veterans’ Benefits for Presumptive Disabilities Under the PACT Act | Review | ||
1 Update VA’s Adjudication Procedures Manual on when personnel should request medical disability examinations and opinions.
Closure Date:
2 Reduce examination and medical opinion overdevelopment by establishing a plan to continue the development of examination request tools and evaluate the effectiveness of these efforts for any future enhancements.
Closure Date:
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| 23-03517-230 | Survivors Did Not Always Receive Accurate Retroactive Benefits for Dependency and Indemnity Compensation Claims Reopened Under the PACT Act | Review | ||
1 Correct the two errors involving prematurely denied Dependency and Indemnity Compensation claims.
Closure Date:
2 Conduct a file review of the reopened Dependency and Indemnity Compensation claims granted under the PACT Act from January 1 through August 31, 2023, and take appropriate actions to ensure monetary benefits and notification letters are accurate.
3 Consider whether modifications could be made to the reevaluation request process consistent with the PACT Act and related regulations and, should this result in a policy change, consult with the VA Office of General Counsel.
Closure Date:
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| 23-02682-09 | Veterans Health Administration Initiated Toxic Exposure Screening as Required by the Promise to Address Comprehensive Toxics (PACT) Act but Improvements Needed in the Training Process | National Healthcare Review | ||
1 The Under Secretary for Health ensures Veterans Health Administration leaders assess reasons for noncompliance with training requirements and takes action as warranted.
2 The Under Secretary for Health evaluates whether toxic exposure screening is negatively affecting primary care workload and takes action to mitigate as needed.
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| 23-00547-187 | VBA Did Not Ensure Employees Sent Some Letters Using Its Package Manager Application | Review | ||
1 Implement and periodically monitor the effectiveness of a plan to provide oversight for unsent packages in the Package Manager application.
2 Implement a plan to address existing unsent packages in the Package Manager application.
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| 24-01232-02 | Inspection of Information Security at the Health Eligibility Center in Atlanta, Georgia | Information Security Inspection | ||
1 Improve vulnerability management processes to ensure all vulnerabilities are identified and that plans of action and milestones are created for vulnerabilities that cannot be mitigated by VA deadlines.
2 Implement a more effective system life-cycle process to ensure network devices are running authorized software and operating systems that are configured to approved baselines and free of vulnerabilities.
Closure Date:
3 Ensure all file systems holding veteran information are encrypted in accordance with NIST and VA policy requirements.
Closure Date:
4 Maintain an accurate inventory of personnel with key access to the facility.
Closure Date:
5 Enable improved audit logging capability to monitor administrator access to sensitive information hosted on the Workload Reporting and Productivity Assessing file server.
Closure Date:
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| 23-03526-07 | Heart Transplant Program Review: Facility Leaders Failed to Ensure a Culture of Safety and the Section Chief Engaged in Unprofessional Conduct at the Richmond VA Medical Center in Virginia | Hotline Healthcare Inspection | ||
1 The Richmond VA Medical Center Director ensures completion of a clinical review of patient 2’s cardiothoracic surgical episode of care and takes action as appropriate.
Closure Date:
2 The Under Secretary for Health ensures that consideration to reactivate the heart transplant program at the Richmond VA Medical Center includes a comprehensive analysis of transplant referral volume, leadership competency, and transplant team proficiency.
3 The Under Secretary for Health ensures that VA Mid-Atlantic Health Care Network and Richmond VA Medical Center leaders conduct a rigorous surveillance of quality measures if the heart transplant program is reactivated and emphasize safely meeting program target volumes to maintain clinical experience.
4 The Richmond VA Medical Center Director ensures the chief of surgery conducts a review of the cardiothoracic section chief’s unprofessional behaviors and develops a plan to address complaints.
Closure Date:
5 The Richmond VA Medical Center Director ensures surgical leaders review cardiothoracic staff’s concerns and take action to create a culture of safety, and considers the use of resources such as the National Center for Organization Development.
Closure Date:
6 The VA Mid-Atlantic Health Care Network Director develops a process for ensuring VA Mid-Atlantic Health Care Network staff provide timely and complete responses to facility leaders’ requests for clinical care reviews.
Closure Date:
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| 23-02890-209 | VBA’s and NCA’s Personnel Suitability Programs Need Improved Governance | Audit | ||
1 Execute the compliance plan for the Veterans Benefits Administration’s personnel suitability program.
Closure Date:
2 Ensure the Veteran Benefits Administration’s personnel suitability program oversight verifies background investigations are initiated and adjudicated within prescribed timelines and that documentation is filed as required.
Closure Date:
3 Establish a plan to ensure robust oversight of the National Cemetery Administration’s personnel suitability program that includes verifying background investigations are initiated and adjudicated within prescribed timelines and that documentation is filed as required.
Closure Date:
4 Evaluate resource requirements for the personnel suitability program to ensure that all personnel suitability requirements are being met.
Closure Date:
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| 24-00386-265 | Inspection of Select Vet Centers in Pacific District 5 Zone 1 | Vet Center Inspection Program | ||
1 District leaders and the Everett and Walla Walla Vet Center Directors collaborate with the support VA medical facility to determine reasons for noncompliance with staff participation on the mental health executive council, take action as indicated, and monitor compliance.
Closure Date:
2 District leaders and the Eugene Vet Center Director determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented, and monitor compliance.
Closure Date:
3 District leaders and the Anchorage, Eugene, and Everett Vet Center Directors determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.
Closure Date:
4 District leaders and the Anchorage, Eugene, Everett, and Walla Walla Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.
Closure Date:
5 District leaders and Everett and Walla Walla Vet Center Directors determine reasons for noncompliance with fire or safety annual inspection, ensure completion, and monitor compliance.
Closure Date:
6 District leaders and the Eugene and Everett Vet Center Directors determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.
Closure Date:
7 District leaders and the Eugene and Everett Vet Center Directors determine reasons for noncompliance with annual fire extinguisher servicing, ensure completion, and monitor compliance.
Closure Date:
8 District leaders and the Eugene Vet Center Director determine reasons for noncompliance with having an automated external defibrillator located on-site and ensure compliance with the requirement.
Closure Date:
9 District leaders and the Everett and Walla Walla Vet Center Directors determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.
Closure Date:
10 District leaders and the Everett and Walla Walla Vet Center Directors determine reasons for noncompliance with building evacuation plans posted in a communal area for staff and visitors and ensure compliance with the requirement.
Closure Date:
11 District leaders and the Eugene and Walla Walla Vet Center Directors determine reasons for noncompliance with having an emergency and crisis plan that includes required components, ensure completion, and monitor compliance.
Closure Date:
12 District leaders and the Eugene, Everett, and Walla Walla Vet Center Directors determine reasons for noncompliance with a desktop reference sheet outlining steps for ancillary office staff to follow in case of a suicidal or homicidal client, ensure completion, and monitor compliance.
Closure Date:
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| 24-00388-266 | Inspection of Select Vet Centers in Pacific District 5 Zone 2 | Vet Center Inspection Program | ||
1 District leaders and the Kauai Vet Center Director determine reasons for noncompliance with assigning a licensed mental health professional as a clinical liaison, ensure a process is implemented, and monitor compliance.
Closure Date:
2 District leaders and the Corona, Temecula, Kauai, and Western Oahu Vet Center Directors determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented, and monitor compliance.
3 District leaders and the Western Oahu Vet Center Director determine reasons for noncompliance with Vet Center Director review of 10 percent of active client records monthly for each counselor’s caseload, ensure completion, and monitor compliance.
Closure Date:
4 District leaders and the Corona, Temecula, Kauai, and Western Oahu Vet Center Directors determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.
Closure Date:
5 District leaders and the Western Oahu Vet Center Director determine reasons for noncompliance with completion of a current written outreach plan, ensure completion, and monitor compliance.
Closure Date:
6 The District Director and zone leaders, in conjunction with the Corona, Temecula, and Kauai Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.
Closure Date:
7 District leaders and Western Oahu Vet Center Director determine reasons for noncompliance with fire or safety annual inspection, ensure completion, and monitor compliance.
Closure Date:
8 District leaders and the Corona, Temecula, and Western Oahu Vet Center Directors determine reasons for noncompliance with having an annual risk and vulnerability assessment completed by VA police or local law enforcement, ensure completion, and monitor compliance.
Closure Date:
9 District leaders and the Temecula and Western Oahu Vet Center Directors determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.
Closure Date:
10 District leaders and the Temecula Vet Center Director determine reasons for noncompliance with annual fire extinguisher servicing, ensure completion, and monitor compliance.
Closure Date:
11 District leaders and the Corona, Temecula, and Kauai Vet Center Directors determine reasons for noncompliance with having an automated external defibrillator located on-site and ensure compliance with the requirement.
12 District leaders and the Western Oahu Vet Center Director determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.
Closure Date:
13 District leaders and the Kauai and Western Oahu Vet Center Directors determine reasons for noncompliance with having an updated emergency and crisis plan that includes required components, ensure completion, and monitor compliance.
Closure Date:
14 District leaders and the Western Oahu Vet Center Director determine reasons for noncompliance with a desktop reference sheet outlining steps for ancillary office staff to follow in case of a suicidal or homicidal client, ensure completion, and monitor compliance.
Closure Date:
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| 24-00389-267 | Inspection of Select Vet Centers in Pacific District 5 Zone 3 | Vet Center Inspection Program | ||
1 District leaders and the Phoenix and West Valley Vet Center Director collaborate with the support VA medical facility to determine reasons for noncompliance with staff participation on the mental health executive council, take action as indicated, and monitor compliance.
Closure Date:
2 District leaders and the Antelope Valley, Phoenix, and West Valley Vet Center Directors determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented, and monitor compliance.
Closure Date:
3 District leaders and the West Valley Vet Center Director determine reasons for noncompliance with Vet Center Director review of 10 percent of active client records monthly for each counselor’s caseload, ensure completion, and monitor compliance.
Closure Date:
4 District leaders and the Antelope Valley Vet Center Director determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.
Closure Date:
5 District leaders and the Antelope Valley, Phoenix, Santa Fe, and West Valley Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.
Closure Date:
6 District leaders and the Santa Fe Vet Center Director determine reasons for noncompliance with having an annual risk and vulnerability assessment completed by VA police or local law enforcement, ensure completion, and monitor compliance.
Closure Date:
7 District leaders and the Antelope Valley Vet Center Director determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.
Closure Date:
8 District leaders and the Antelope Valley and Santa Fe Vet Center Directors determine reasons for noncompliance with having an automated external defibrillator located on-site and ensure compliance with the requirement.
Closure Date:
9 District leaders and the Phoenix and Santa Fe Vet Center Directors determine reasons for noncompliance with having an emergency and crisis plan that includes required components, ensure completion, and monitor compliance.
Closure Date:
10 District leaders and the Santa Fe Vet Center Director determine reasons for noncompliance with a desktop reference sheet outlining steps for ancillary office staff to follow in case of a suicidal or homicidal client, ensure completion, and monitor compliance.
Closure Date:
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15039