Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 21-02401-190 | The Fugitive Felon Benefits Adjustment Process Needs Better Monitoring | Review | ||
1 Improve monitoring procedures and demonstrate progress toward ensuring all felony referrals are processed.
Closure Date:
2 Update fugitive felon letters and ensure they are consistently sent with all required information.
Closure Date:
3 Review unprocessed felony referrals identified in this report, take corrective action as needed, and report the efforts taken to the OIG.
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| 22-00210-191 | VA Needs to Improve Governance of Identity, Credential, and Access Management Processes | Review | ||
1 Designate roles and responsibilities for all program offices involved in VA’s identity, credential, and access management program.
Closure Date:
2 Provide appropriate oversight and ensure coordination between designated program offices to implement a comprehensive identity, credential, and access management policy.
Closure Date:
3 Update and publish a VA directive and handbook associated with identity and access management that includes current National Institute of Standards and Technology requirements.
Closure Date:
4 Update and publish VA directives and handbooks associated with the Homeland Security Presidential Directive 12 Program and VA’s personnel security and suitability program as required by VA’s enterprise directives management procedures.
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| 21-01351-151 | VBA Improperly Created Debts When Reducing Veterans’ Disability Levels | Review | ||
1 Implement a formal procedure to ensure all improperly created debts identified by the review team are corrected, and certify the results to the OIG.
Closure Date:
2 Enact a formal procedure to review all VBA compensation awards not already reviewed by the OIG that were completed since January 1, 2020, with debts due to reduced disability levels, take corrective action as appropriate, and report the results to the OIG.
3 Develop and demonstrate progress toward implementing a plan to update the electronic system to make employees aware of each period in which an award creates a debt.
Closure Date:
4 Develop a mechanism to review the effectiveness of the recommendations periodically and a process for determining what additional measures, if any, are needed.
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| 22-00066-184 | Financial Efficiency Review of the VA Black Hills Health Care System in South Dakota | Financial Inspection | ||
1 The OIG made the following recommendation to the director of the VA Black Hills Health Care System: Ensure finance office staff conduct reviews on all inactive open obligations as required by VA Financial Policy, vol. 2, chap. 5, “Obligations Policy.”
Closure Date:
2 Establish procedures to ensure cardholders comply with processing requirements as stated in VA’s Financial Policy, vol. XVI, chap. 1B, “Government Purchase Card for Micro-Purchases.”
Closure Date:
3 Establish controls to confirm approving officials and purchase cardholders review their purchases and make sure contracting is used when it is in the best interest of the government.
Closure Date:
4 Develop measures to confirm that completed VA Form 0242 submissions are accurate and updated for all cardholders.
Closure Date:
5 Ensure the supply chain management staff implement a plan to monitor and correct unit conversion factor errors consistently and promptly to improve data reliability in the Generic Inventory Package.
Closure Date:
6 Develop and implement a plan to achieve an inventory turnover rate closer to the Veterans Health Administration-recommended level.
Closure Date:
7 Establish measures to improve compliance with the VHA directive to avoid end-of-year pharmaceutical purchases.
Closure Date:
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| 21-03339-208 | Deficiencies in Facility Leaders’ Oversight and Response to Allegations of a Provider’s Sexual Assaults and Performance of Acupuncture at the Beckley VA Medical Center in West Virginia | Hotline Healthcare Inspection | ||
1 The Capital Health Care Network Director reviews and evaluates the March 2021 Administrative Investigation Board action plan to identify open actions and ensures completion.
Closure Date:
2 The Beckley VA Medical Center Director ensures a review of Veterans Health Administration and Beckley VA Medical Center policies related to professional practice evaluations, including supervisory roles, review periods, and service-specific data collection, and takes action as appropriate.
Closure Date:
3 The Beckley VA Medical Center Director reviews and evaluates Veterans Health Administration and Beckley VA Medical Center policies related to disclosures and quality management actions such as look-back reviews and patient safety reporting to ensure such actions are timely, objective, and documentation is sufficient to address the issue under review.
Closure Date:
4 The Beckley VA Medical Center Director ensures staff education of Veterans Health Administration and Beckley VA Medical Center policies related to employee misconduct and monitors compliance.
Closure Date:
5 The Beckley VA Medical Center Director evaluates processes for reporting providers to the state licensing boards, including initial and comprehensive reviews, and monitors compliance.
Closure Date:
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| 21-02732-153 | Airborne Hazards and Open Burn Pit Registry Exam Process Needs Improvement | Review | ||
1 Ensure the program office and VA’s Office of Information and Technology work together to revise the questionnaire to make it clearer and easier for veterans to more quickly complete the questionnaire and schedule exams.
Closure Date:
2 Improve controls to ensure the registry website maintains accurate contact information for environmental health coordinators.
Closure Date:
3 Assess the feasibility of veteran-centric guidance that assigns medical facility follow-up responsibilities and identifies processes for determining whether unscheduled veterans with an interest in an exam still want to be scheduled, and then track responses and completions.
Closure Date:
4 Implement a mechanism to ensure medical facilities meet the 90-day timeliness standard for the completion of requested exams, including performance metrics.
Closure Date:
5 Ensure Veterans Integrated Service Network and facility environmental health personnel routinely review their performance data and address any challenges with scheduling registry exams with directors.
Closure Date:
6 Ensure the program office reviews registry exam data and continues to work with VA’s Office of Information and Technology to ensure all facilities and veterans are included and properly coded.
Closure Date:
7 Establish procedures for medical facilities to transfer assigned veterans to receive an exam at a closer facility or as otherwise appropriate.
Closure Date:
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| 21-02704-135 | Veterans Prematurely Denied Compensation for Conditions That Could Be Associated with Burn Pit Exposure | Review | ||
1 Take any needed corrective actions on the four errors involving the improperly granted conditions based on burn pit exposure.
Closure Date:
2 Review all denials of compensation claims identified as burn pit claims completed from May 1, 2020, to May 1, 2021, for conditions claimed by eligible veterans to be due to burn pit exposure; correct any errors identified; and provide certification of completion of the review to the Office of Inspector General.
3 Review all denials of compensation claims not identified as burn pit claims completed from May 1, 2020, to May 1, 2021, for conditions of bronchial asthma, chronic bronchitis, allergic rhinitis, sleep apnea, and chronic obstructive pulmonary disease submitted by veterans who served where and when burn pits were used even if not specifically cited in the claim; correct any errors identified; and provide certification of completion of the review to the Office of Inspector General.
4 Update the Adjudications Procedures Manual to provide separate and specific guidance for when claims should be considered based on burn pit exposure and proper development for these claims.
Closure Date:
5 Modify the examination request web-based application to add specialty language into medical opinion requests for burn pit exposure claims, to include the contents from the fact sheet for burn pit claims.
Closure Date:
6 Implement a plan to develop controls that review the accuracy of rating decisions going forward to minimize improper denials for burn pit claims, correct any errors identified, and address error trends.
Closure Date:
7 Update training materials and ensure they are consistent with the adjudication procedures manual guidance for developing burn pit exposure claims.
Closure Date:
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| 21-01081-155 | Inadequate Acceptance of Supplies and Services at Regional Procurement Office West Led to $12.8 Million in Questioned Costs | Review | ||
1 Establish controls to ensure contracting officers’ representatives upload required documentation of acceptability of supplies and services to the electronic contracting officer representative file prior to payment.
Closure Date:
2 Establish a requirement and a process for branch chiefs to consistently monitor contract administration documentation.
Closure Date:
3 Assess existing contracts that require an electronic contracting officer representative file and take corrective actions to ensure compliance.
Closure Date:
4 Establish controls to ensure contracting officers create an electronic contracting officer representative file for all contracts requiring a contracting officer’s representative.
Closure Date:
5 Assess existing contracts to ensure contracting officers have completed contracting officer’s representative delegation memorandums, if required.
Closure Date:
6 Establish controls to ensure contracting officers and contracting officer’s representatives have a completed contracting officer’s representative delegation memorandum in the electronic contracting officer representative file, if required.
Closure Date:
7 Establish a quality assurance process to ensure compliance with contract administration requirements for establishing an electronic contracting officer representative file, completing contracting officer’s representative delegation memorandums, and
maintaining acceptance documentation.
Closure Date:
8 Assess whether additional training is needed to clarify officials’ roles and responsibilities for documenting acceptance of supplies and services.
Closure Date:
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| 21-02194-198 | Review of Veterans Health Administration’s Response to a Medication Recall | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health evaluates current guidance regarding the monitoring and reporting of medication recall adverse drug events and makes changes as necessary.
Closure Date:
2 The Under Secretary for Health reviews vulnerabilities in the medication recall process due to variances in Veterans Health Administration medical facility processes and makes changes as necessary.
Closure Date:
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| 22-01137-204 | The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm | National Healthcare Review | ||
1 The Deputy Secretary reviews the process that led to Oracle Cerner’s failure to inform VA of the unknown queue and takes action as indicated.
Closure Date:
2 The Deputy Secretary evaluates the unknown queue technology and mitigation process and takes action as indicated.
Closure Date:
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