All Reports

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)
Closure Date: 6/16/2022
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)
Closure Date: 6/16/2022
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)
Closure Date: 3/15/2022
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
VBA Overpaid Veterans Due to Delays in Reducing Compensation Benefits
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20-03229-155

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/18/2021
Establish, document, and implement a workload management strategy to distribute and process proposals to reduce benefits that minimizes delays and excessive payments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/18/2021
Develop, document, and implement a formal procedure to routinely monitor the workload management strategy to ensure it minimizes delays and excessive payments.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 348,000,000.00
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)
Closure Date: 11/9/2022

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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2025

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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2025

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)
Closure Date: 5/5/2024

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

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2024

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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2024

Document oversight procedures for monitoring and validating compliance with the requirements of the part-time physician on adjustable work schedules program.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2025

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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2025

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)
Closure Date: 2/8/2022
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)
Closure Date: 2/8/2022
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: $ 0.00
Closed: $ 16,600,000.00
Inadequate Oversight of Contractors’ Personal Identity Verification Cards Puts Veterans’ Sensitive Information and Facility Security at Risk
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20-00345-77
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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: 3/26/2026

The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to ensure contracting officers obtain and maintain evidence of contractor-provided lists of all personal identity verification cards issued to contractor employees.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2026

The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to ensure contracting officers maintain evidence documenting personal identity verification cards were returned to the issuing or designated office when the cards were no longer required and prior to closing the contract.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2026

The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to evaluate the role of contracting officer’s representatives in the personal identity verification card process for contractor employees and assess whether updates to their letter of delegation and standard operating procedures are necessary.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/3/2023
The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to establish policies and procedures outlining specific supervisory responsibilities for contracting officer oversight in accordance with the Government Accountability Office Standards for Internal Controls in the Federal Government.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2025

The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to assess the contract completion statement template to determine whether to include the contractor-related personal identity verification card requirements.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2026

The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to establish procedures within the Procurement Audit Office for periodic reviews of contract files to determine compliance with the personal identity verification card requirements established in the Federal Acquisition Regulation and the Veterans Health Administration procurement manual. Further, require the results of these reviews to be reported to senior management to help determine whether corrective actions are required.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2025

The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to determine whether existing or planned systems can have the functionality to allow management to effectively and routinely monitor contractor employee personal identity verification cards or whether a new system should be established.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2026

The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to assess whether contracting officers should be required to include the contractor-provided list as an explicit requirement in all Veterans Health Administration contracts that require issuance of personal identity verification cards to contractor employees.

No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2025

The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to establish procedures to ensure contracting officers include Federal Acquisition Regulation clause 52.204-9, “Personal Identity Verification of Contractor Personnel,” in contracts when required.

No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2025

The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to consider directing contracting officers to delay final payment to contractors on future contracts until all personal identity verification cards have been returned.

Deficiencies in Emergency Preparedness for Veterans Health Administration Telemental Health Care at VA Clinic Locations Prior to the Pandemic
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19-09808-171
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Topics:  Mental Health ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/18/2022
The Under Secretary for Health ensures the Office of Connected Care Telehealth Services and the Office of Mental Health and Suicide Prevention collaborate to develop a consistent process for facility implementation of telehealth emergency plans tailored for telehealth care and the patient-clinic locations that are inclusive of procedures addressing mental health and medical emergencies and technological disruptions during telemental health care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/18/2022
The Under Secretary for Health verifies the Office of Connected Care Telehealth Services reviews and implements oversight of telehealth emergency plan processes to include expectations for updating and monitoring.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/8/2022
The Under Secretary for Health confirms the Office of Connected Care Telehealth Services develops consistent processes for healthcare systems to define and communicate individual telehealth staff responsibilities during telehealth emergencies, specific to the patient-clinic locations.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/8/2022
The Under Secretary for Health ensures the Office of Connected Care Telehealth Services has a consistent process for healthcare systems to develop, maintain and communicate accurate, patient-clinic location specific telehealth emergency contact information to all telehealth staff, to include remote providers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/2/2022
The Under Secretary for Health collaborates with the Office of Connected Care Telehealth Services to develop a streamlined process to report patient safety events specific to telehealth that clearly identifies the setting and specific service line to allow tracking, trending, and monitoring.
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)
Closure Date: 11/4/2021
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)
Closure Date: 11/4/2021
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)
Closure Date: 11/15/2022
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)
Closure Date: 5/11/2022
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)
Closure Date: 2/7/2024

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)
Closure Date: 5/11/2022
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)
Closure Date: 11/4/2021
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)
Closure Date: 11/4/2021
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)
Closure Date: 11/4/2021
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)
Closure Date: 3/4/2024

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)
Closure Date: 8/16/2023
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)
Closure Date: 2/15/2022
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)
Closure Date: 2/15/2022
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)
Closure Date: 6/6/2022
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)
Closure Date: 4/4/2023
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)
Closure Date: 2/15/2022
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)
Closure Date: 5/8/2023
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)
Closure Date: 5/8/2023
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.
Stronger Financial Management Practices Are Needed at VA's Maryland Health Care System
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19-07719-113
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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: 8/6/2024

The OIG recommended the Maryland Health Care System director implement internal controls for healthcare system staff to submit and document approvals for all equipment requests in the Enterprise Equipment Request Portal before ordering and paying for equipment.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/14/2022
The OIG recommended the Maryland Health Care System director implement a control requiring staff to justify the waiver of any healthcare system approvals ordinarily required to purchase equipment in the Enterprise Equipment Request Portal.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/11/2022
The OIG recommended the Maryland Health Care System director inform the deputy under secretary for health for operations and management for procurement and logistics of the internal control weakness in the Enterprise Equipment Request Portal and request a response regarding whether corrective action is necessary.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2021
The OIG recommended the Maryland Health Care System director require the logistics service to develop a plan for working with the prime vendor to ensure historical and current estimated supply data are timely, accurate, and meet healthcare system supply requirements.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2021
The OIG recommended the Maryland Health Care System director ensure the logistics service implements a plan to monitor for and correct unit conversion factor errors consistently and promptly.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2024

The OIG recommended the Maryland Health Care System director establish processes and controls for cardholders to comply with the record retention requirements in the Federal Acquisition Regulation and VA’s Financial Policy, Volume XVI, “Charge Card Program.”

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2023
The OIG recommended the Maryland Health Care System director ensure all staff are provided clear guidance on overtime approval and payment policies and procedures that meet VA requirements.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/8/2023
The OIG recommended the Maryland Health Care System director implement policies and procedures for supervisors to effectively monitor overtime worked and maintain documentation required to support related payments.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 5,552,000.00
Medical/Surgical Prime Vendor Contract Emergency Supply Strategies Available Before the COVID-19 Pandemic
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20-03075-138
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Topics:  COVID-19

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2023
The under secretary for health direct the Medical Supplies Program Office to provide Veterans Integrated Service Network and VA medical facility chief logistics officers guidance on how to use and monitor the emergency and continuous supply strategies offered in prime vendors’ contingency plans to help mitigate acute emergency and continuous supply shortages during the current pandemic and future emergencies.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 1/6/2023
The Office of Acquisition, Logistics, and Construction direct the Strategic Acquisition Center’s Medical/Surgical Prime Vendor Program contracting officer to provide guidance to Veterans Integrated Service Network and VA medical facilities’ program contracting officer’s representatives on the emergency and continuous supply provisions in the contracts, and ensure contracting officers’ representatives inform network and facility managers of the strategies offered by the prime vendors.
Review of VHA’s Financial Oversight of COVID-19 Supplemental Funds
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20-02967-121
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Topics:  COVID-19

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2023
The OIG recommends that the Principle Deputy Under Secretary for Health coordinate with VA’s Office of Management to implement internal control procedures to ensure the completeness and accuracy of the data in VA’s reports to the Office of Management and Budget and to Congress.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2023
The OIG recommends that the Principle Deputy Under Secretary for Health coordinate with VA’s Office of Management to execute data validation procedures to make certain that reports to the Office of Management and Budget and to Congress can be traced back efficiently to the source transactions.
Inconsistent Human Resources Practices Inhibit Staffing and Vacancy Transparency
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20-00541-133
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Topics:  Staffing

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No. 1
Open Recommendation Image, Square
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
The OIG recommended the acting assistant secretary for human resources and administration/operations, security, and preparedness develop and implement an enterprise wide plan to independently examine and validate the HR Smart position inventory.
No. 2
Open Recommendation Image, Square
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
The OIG recommended the acting assistant secretary for human resources and administration/operations, security, and preparedness establish standard guidance to ensure positions are consistently approved, created, and maintained.
No. 3
Open Recommendation Image, Square
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
The OIG recommended the acting assistant secretary for human resources and administration/operations, security, and preparedness implement enterprise wide oversight mechanisms to monitor position management on a regular basis and ensure the HR Smart position inventory is properly maintained.
No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The OIG recommended the acting under secretary for health develop and implement a standardized national policy and procedures for the documentation and communication of staffing level approvals at VA medical facilities.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/31/2023
The OIG recommended the acting under secretary for health publish detailed and prescriptive guidance establishing authoritative position management documents.
Use and Oversight of the Emergency Caches Were Limited during the First Wave of the COVID-19 Pandemic
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20-03326-124
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Topics:  COVID-19 ● Supplies and Equipment

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2023
The OIG recommended that the under secretary for health initiate efforts to revise or amend VHA Directive 1047 to clarify when changes to emergency cache activation procedures are appropriate, and develop the communication and documentation requirements for these situations to ensure all relevant parties—including medical facility directors and pharmacy chiefs—are aware of and comply with any changes to routine activation protocols as well as the responsibilities they maintain.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2023
The OIG recommended that the under secretary for health establish minimum time frames, for example by assessing Emergency Pharmacy Service’s data on the typical length of time it takes to replenish emergency cache inventory items, by which the Emergency Pharmacy Service initiates resupply orders to make sure caches are fully stocked with unexpired inventory.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2023
The OIG recommended that the under secretary for health make sure that the Emergency Pharmacy Service and the Watch Office are maintaining accurate and complete records of emergency cache activations.
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)
Closure Date: 11/8/2021
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)
Closure Date: 11/8/2021
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)
Closure Date: 11/8/2021
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)
Closure Date: 11/8/2021
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)
Closure Date: 10/14/2021
Implement a timeliness requirement or performance measure for handling proceeds.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/27/2021
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)
Closure Date: 11/9/2022

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)
Closure Date: 11/9/2022

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)
Closure Date: 7/26/2022

 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)
Closure Date: 1/20/2022

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.

The Office of Field Operations Did Not Adequately Oversee Quality Assurance Program Findings
|
20-00049-122

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 Benefits Administration (VBA)
Closure Date: 1/10/2023
Develop and implement a written plan to strengthen oversight of the quality assurance program for disability compensation benefits and monitor the plan to ensure identified deficiencies are adequately addressed.
Federal Information Security Modernization Act Audit for Fiscal Year 2020
|
20-01927-104
|
Topics:  FISMA

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/13/2022
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)
Closure Date: 4/13/2022
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)
Closure Date: 4/13/2022
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)
Closure Date: 4/13/2022
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)
Closure Date: 4/13/2022
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)
Closure Date: 4/13/2022
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)
Closure Date: 4/13/2022
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)
Closure Date: 4/13/2022
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)
Closure Date: 4/13/2022
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)
Closure Date: 4/13/2022
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)
Closure Date: 4/13/2022
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)
Closure Date: 4/13/2022
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)
Closure Date: 4/13/2022
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)
Closure Date: 4/13/2022
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)
Closure Date: 4/13/2022
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)
Closure Date: 4/13/2022
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)
Closure Date: 4/13/2022
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)
Closure Date: 4/13/2022
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)
Closure Date: 4/13/2022
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)
Closure Date: 4/13/2022
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)
Closure Date: 4/13/2022
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)
Closure Date: 4/13/2022
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)
Closure Date: 4/13/2022
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)
Closure Date: 4/13/2022
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)
Closure Date: 4/13/2022
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)
Closure Date: 4/13/2022
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.
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