All Reports

Date Issued
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Report Number
21-00797-248
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2024

The Under Secretary for Health ensures that Intimate Partner Violence Assistance Program protocols are developed at all medical centers consistent with the national requirement.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2024

The Under Secretary for Health evaluates the sufficiency of current guidance and operational status regarding Intimate Partner Violence Assistance Program coordinators’ dedicated time and population needs, and takes action as warranted.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2024

The Under Secretary for Health determines the appropriate guidance for dedicated administrative staff support in consideration of the Intimate Partner Violence Assistance Program coordinators’ responsibilities, and takes action as warranted.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2024

The Under Secretary for Health considers the establishment of standardized Intimate Partner Violence staff training content and format as well as the evaluation of training efficacy, and takes action as warranted.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2024

The Under Secretary for Health develops intimate partner violence screening requirements based on the current guidance and patient population needs, and takes action as warranted.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2024

The Under Secretary for Health expedites standardized program evaluation processes with oversight and reporting responsibilities to ensure identification of implementation and program deficiencies and monitoring of corrective action and performance improvement plans.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2024

The Under Secretary for Health evaluates the current guidance and operational status related to the roles and oversight functions of the Veterans Integrated Service Network Intimate Partner Violence Assistance Program champions and lead coordinators and clarifies expectations and requirements.

Date Issued
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Report Number
21-02641-229
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Topics:  Leases and Major Contracts

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 8/15/2024

Assess compliance weaknesses identified by VA Office of Procurement Policy, Systems and Oversight internal reviews, and implement corrective actions determined appropriate.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 5/23/2024

Require contracting officers responsible for Buy American Act compliance deficiencies identified by contract file reviewers and VA Office of Procurement Policy, Systems and Oversight internal reviews to attend refresher Buy American Act–specific training.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2023
Evaluate the contract file review procedures to make certain they require the use of the Definitions of Comment Categories, and presolicitation and preaward checklists, and document that use, to strengthen compliance.
Date Issued
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Report Number
22-00971-217
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Topics:  Information Technology and Security

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 9/22/2022
Implement a more effective process to maintain consistent inventory information for all network segments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 9/22/2022
Improve the vulnerability and flaw remediation program to accurately identify vulnerabilities and enforce flaw remediation.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/17/2023
Implement effective configuration control processes that ensure network devices maintain vendor support.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/28/2025

Perform security control assessments of the video surveillance system and obtain an authorization to operate in accordance with set policy.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/25/2023
Ensure installation of distributed network infrastructure equipment that meets VA installation standards, to include proper equipment mounting and clearance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 9/22/2022
Ensure routine maintenance is conducted on uninterruptible power supplies.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 9/22/2022
Implement database authentication processes that comply with VA security requirements.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/17/2023
Implement a physical access control system for the data center and core switch room that is supportable and can meet VA logging requirements.
Date Issued
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Report Number
21-03061-209
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Topics:  Claims and Appeals

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/20/2023
Centralize all Camp Lejeune-related claims processing at the Louisville VA Regional Office, or implement a plan and report progress mitigating the error rate disparity between the Louisville Regional Office and other regional offices.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/20/2023
Conduct and report to the Office of Inspector General the results of targeted quality reviews of Camp Lejeune-related claims from all regional offices processing these claims until the accuracy rate meets or exceeds the Veterans Benefits Administration’s overall national accuracy goal for disability compensation claims.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 13,800,000.00
Date Issued
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Report Number
21-02668-182
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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)
Closure Date: 9/30/2024

Establish clear oversight roles and responsibilities of the program office and of regional network telehealth and medical facility leads to monitor medical facility social worker and telehealth staff compliance with the “Digital Divide Standard Operating Procedure” for conducting assessments, ordering, and scheduling.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/10/2024

Develop and implement a mechanism to alert the requesting clinic that a patient has a loaned device and can now be scheduled for a VA Video Connect appointment.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2022
Clarify timeliness goals for the digital divide consult, and video device order placement.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2023

Update the digital divide consult training to include procedure updates and ensure social workers and facility telehealth and Remote Order Entry System coordinators who process digital divide consults and video device orders complete the training and take refresher training as needed.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/10/2024

Implement procedures to require responsible staff to check for duplicate devices before submitting a device order consult.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2024

Establish an alert in the Remote Order Entry System to notify the responsible staff member that a patient already has an issued device before ordering another, and initiate retrieval activities for duplicate devices.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2024

Delegate in the “Digital Divide Standard Operating Procedure” facility staff to monitor the tablet dashboard for VA Video Connect appointment activity and device use, and clearly define regional network telehealth leads’ oversight responsibilities to ensure facilities initiate retrieval activities when warranted.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/10/2024

Establish an automated mechanism using the tablet dashboard to routinely identify the devices that meet retrieval priorities and also initiate retrieval of those that already meet retrieval requirements.

No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2023
Augment tracking mechanisms for packages sent to patients to ensure VA receipt of the retrieval kit so that devices are accurately recorded in inventory and available for refurbishment and reissue.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2024

Address restrictions in the refurbishment process, implement accessible and trackable reporting of devices waiting to be refurbished, and implement a structured purchasing model to guide new device purchases and maintain an appropriate inventory level.

Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 14,478,000.00
Date Issued
|
Report Number
21-02401-190

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/9/2022
Improve monitoring procedures and demonstrate progress toward ensuring all felony referrals are processed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/3/2022
Update fugitive felon letters and ensure they are consistently sent with all required information.
No. 3
Open Recommendation Image, Square
to Veterans Benefits Administration (VBA)
Review unprocessed felony referrals identified in this report, take corrective action as needed, and report the efforts taken to the OIG.
Date Issued
|
Report Number
22-00210-191
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Topics:  Information Technology and Security

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/25/2023
Designate roles and responsibilities for all program offices involved in VA’s identity, credential, and access management program.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 12/12/2024

Provide appropriate oversight and ensure coordination between designated program offices to implement a comprehensive identity, credential, and access management policy.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 12/12/2024

Update and publish a VA directive and handbook associated with identity and access management that includes current National Institute of Standards and Technology requirements.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 9/29/2025

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.

Date Issued
|
Report Number
21-01351-151
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Topics:  Claims and Appeals

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/17/2024

Implement a formal procedure to ensure all improperly created debts identified by the review team are corrected, and certify the results to the OIG.

No. 2
Open Recommendation Image, Square
to Veterans Benefits Administration (VBA)
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.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/31/2023
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.
No. 4
Open Recommendation Image, Square
to Veterans Benefits Administration (VBA)
Develop a mechanism to review the effectiveness of the recommendations periodically and a process for determining what additional measures, if any, are needed.
Date Issued
|
Report Number
21-02194-198
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2022
The Under Secretary for Health evaluates current guidance regarding the monitoring and reporting of medication recall adverse drug events and makes changes as necessary.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2022
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.
Date Issued
|
Report Number
22-01137-204
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Topics:  Electronic Health Records Modernization (EHRM) ● Patient Safety

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No. 1
Not Implemented Recommendation Image, X character'
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 9/28/2022

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.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 2/13/2023

The Deputy Secretary evaluates the unknown queue technology and mitigation process and takes action as indicated.

Date Issued
|
Report Number
21-02599-156
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Topics:  Contract Integrity

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2023
Establish procedures for consistent quality assurance reviews to ensure all contract closeout requirements, such as identifying and deobligating excess funds, closing out contracts timely, and properly completing and uploading closeout documentation, are performed in accordance with the Federal Acquisition Regulation and the Veterans Health Administration procurement manual. Further, update Veterans Health Administration policies and procedures to provide guidance on conducting and documenting the reviews.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2022
Assess and determine how to effectively distribute contracting officer workload and address imbalances among staff to help ensure contract closeouts are completed in accordance with the Federal Acquisition Regulation and the Veterans Health Administration procurement manual.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2022
Clarify the Veterans Health Administration procurement manual to indicate when simplified acquisition procedures closeout processes are to be used and the documentation requirements for each contract closeout step.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2022
Determine whether setting aside specific time weekly to focus on contract administration tasks, such as contract closeout, and using contractors to perform closeout procedures could improve contract closeout compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2022
Ensure the contract files for the 81 sampled contracts have complete closeout documentation in accordance with the Federal Acquisition Regulation and the Veterans Health Administration procurement manual.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 4,400,000.00
Date Issued
|
Report Number
21-03853-174
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Topics:  Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2022
Ensure that healthcare system finance office staff are made aware of policy requirements and that reviews are conducted on all inactive open obligations, and deobligate any identified excess funds as required by VA Financial Policy, vol. 2, chap. 5, “Obligations Policy.”
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
Ensure cardholders comply with record retention requirements as stated in VA’s Financial Policy, vol. XVI, “Charge Card Programs.”
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
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.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2022
Require purchase cardholders to submit a request for ratification for any unauthorized commitments identified.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2022
Ensure quarterly purchase card audits are performed as required by the Veterans Health Administration’s standard operating procedure, “Internal Audits—Purchase Cards and Convenience Checks.”
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2023
Ensure supply chain management staff implement a plan to improve data reliability within the Generic Inventory Package system.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2023
Ensure the chief of supply chain management signs quarterly physical inventory memorandums of “A” classified items and makes them available to Veterans Integrated Service Network personnel as required in the VHA’s Directive 1761 Supply Chain Management Operations.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
Develop and implement a plan to increase inventory turnover to meet the level recommended by the Veterans Health Administration Pharmacy Benefits Management Office.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 379,439.00
Date Issued
|
Report Number
21-03080-142
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Topics:  Information Technology and Security

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 10/25/2022
The OIG recommends the Assistant Secretary for Information and Technology develop controls to help ensure minor applications are not misclassified as assets and undergo the appropriate security accreditation and certification process.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT),Veterans Benefits Administration (VBA)
Closure Date: 8/7/2023
The OIG recommends the Assistant Secretary for Information and Technology in conjunction with the Under Secretary for Benefits, make certain that appropriate security and privacy controls are implemented during the development of information technology systems before being hosted on VA’s network.
No. 3
Open Recommendation Image, Square
to Information and Technology (OIT),Veterans Benefits Administration (VBA)
The OIG recommends the Under Secretary for Benefits, in conjunction with the Assistant Secretary for Information and Technology, establish a mechanism to gain assurance that proper Office of Information Technology project management processes and protocols are followed when establishing information technology systems and applications.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/25/2022
The OIG recommends the Under Secretary for Benefits establish policies and procedures to ensure the Mission Accountability Support Tracker is used appropriately and does not contain unnecessary personally identifiable information.
Date Issued
|
Report Number
21-01237-127
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Topics:  Claims and Medical Exams

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/24/2023
Assess and modify contracts and any renewals to ensure that vendors can be heldaccountable for unsatisfactory performance by applying monetary disincentives.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/5/2023
Assess and modify contracts and any renewals to ensure procedures are established for vendors to correct errors identified by the Medical Disability Examination Office.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/5/2023
Implement procedures requiring the Medical Disability Examination Office tocommunicate exam errors to the Office of Field Operations and the regional officesand demonstrate progress in correcting the identified errors.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/10/2022
Implement procedures requiring the Medical Disability Examination Office toanalyze all available error data and provide systemic exam issues and error trends tovendors.