Date Issued
|
Report Number
20-01249-259
|
Topics: Staffing
All Reports
Date Issued
|
Report Number
18-06039-229
|
Topics: Clinical Care Services Operations
● Appointment Scheduling and Wait Times
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/1/2021
The OIG recommended the Under Secretary for Health consider developing an oversight mechanism that includes the VISN Surgery Integrated Clinical Community Chair in the monitoring of medical facility operating room efficiency and surgical support element problems and ensures VISN Directors hold medical facilities accountable when these problems persist and reduce operating room efficiency.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/1/2021
The OIG recommended the Under Secretary for Health consider periodically analyzing two to three years of operating room efficiency data to identify medical facilities that have not consistently met National Surgery Office efficiency goals and assess surgical support element problems impacting patients and operating room efficiency.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/1/2021
The OIG recommended the Under Secretary for Health consider requiring the National Surgery Office clarify the intent of the current utilization measure and assess other utilization measures other than staffing.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/17/2020
The OIG recommended the Under Secretary for Health consider requiring the National Surgery Office gather as part of its capacity measure information about operating room closures or reduced usage, including the reasons for the closures or curtailment of surgeries.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/4/2022
The OIG recommended the Under Secretary for Health consider identifying surgical support element best practices used by efficient facilities and ensure less efficient medical facilities, where appropriate, implement these practices to address problems, reduce surgical cancellations and delays, and minimize patient risks.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/1/2021
The OIG recommended the Under Secretary for Health consider requiring medical facility surgical work groups to discuss the National Surgery Office Efficiency goals and their facility’s performance with support services, such as logistics, sterile processing service, and environment management service, at least quarterly and ensure they all work proactively and collaboratively to address surgical support element problems.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 30,000,000.00
Date Issued
|
Report Number
19-00227-226
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 7/5/2022
The under secretary for benefits ensures the adjudication procedures manual is updated for consistency with all applicable laws, regulations, and policies related to permanent and total determinations in consultation with the office of general counsel.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 8/2/2022
The under secretary for benefits ensures decision-making staff support their permanent and total status decisions in the Reasons for Decision section of the rating decision by describing the evidence used to support their conclusions.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 2/9/2022
The under secretary for benefits replaces the title and standardized language of “Dependents’ Educational Assistance under 38 U.S.C. Chapter 35” in rating decisions to clearly state that permanent and total status is being considered.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 1/9/2023
The under secretary for benefits ensures appropriate training is provided to decision-making staff based on the changes made to permanent and total procedures related to Recommendations 1, 2 and 3, and monitor the effectiveness of that training.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 122,000,000.00
Date Issued
|
Report Number
18-03800-232
|
Topics: Financial Management
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/10/2025
The OIG recommended the executive in charge, Office of the Under Secretary for Health, establish financial controls, such as key performance indicators, that align with medical center operations and can be used to assess the efficient use of operating funds.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/2/2020
Specify the accountable Veterans Health Administration office responsible for establishing financial controls to ensure Veterans Health Administration’s financial management activities promote the efficient use of funds at Veterans Integrated Service Networks.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/6/2021
The OIG recommended the executive in charge, Office of the Under Secretary for Health, require the Veterans Health Administration to establish and publish organizational charts that identify the appropriate financial management reporting lines of authority and to develop familiarization training on the reporting lines of authority at the VISN and medical center levels, as appropriate.
Date Issued
|
Report Number
20-02794-218
|
Topics: COVID-19
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The OIG recommended the under secretary for health develop and clearly communicate a well defined strategic plan to all medical facilities for rescheduling patients and provide oversight particularly to those facilities with the highest rates of canceled appointments with no evidence of follow up or tracking.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The OIG recommended the under secretary for health develop a mechanism to monitor facilities’ progress with following up on all cancellations to ensure facilities are not solely relying on COVID annotations or cancellation source classifications when rescheduling.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The OIG recommended the under secretary for health ensure that facilities take appropriate follow up action on canceled or discontinued consults.
Date Issued
|
Report Number
19-07062-230
|
Topics: Claims and Appeals
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 11/16/2020
The OIG recommended that the under secretary for benefits direct the Compensation Service to formalize the Hot Topics list into an annual report submitted to the Office of Field Operations detailing all recurring deficiencies and action items identified throughout the inspection year from its site visit program.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 4/7/2021
The OIG recommended that the under secretary for benefits require the Office of Field Operations to initiate a recurring plan to correct all recurring deficiencies and action items identified by the Compensation Service throughout the inspection year from its site visit program annual report.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 4/7/2021
The OIG recommended that the under secretary for benefits direct the Office of Field Operations to establish a follow-up process to monitor compliance with the new requirement and hold regional office managers accountable for making corrections and addressing action items in a timely manner.
Date Issued
|
Report Number
19-08095-198
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 8/5/2020
We recommended the under secretary for benefits implement a plan to incorporate the system-generated instructions for medical providers directly into the heart disability questionnaire (instead of separately on the examination request) and determine whether additional revisions are necessary to ensure medical providers’ findings are sufficient for evaluation purposes.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 1/13/2021
We recommended the under secretary for benefits implement a plan to ensure medical providers who complete heart disability benefits questionnaires are made aware of common problem areas related to the questionnaire format and system-generated instructions and are provided guidance on how to avoid giving conflicting or insufficient information.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 1/13/2021
We recommended the under secretary for benefits implement a plan to make certain that Veterans Benefits Administration decision makers receive refresher training on identifying and resolving heart disability benefits questionnaires that are insufficient for evaluation purposes and monitor the effectiveness of the training.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 61,800,000.00
Date Issued
|
Report Number
19-07059-169
|
Topics: Claims and Medical Exams
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 9/7/2021
Improve the current second-review process for quality reviews when STAR analysts identify claims-processing deficiencies and consider requiring senior reviewers to conduct a comprehensive review of all issues assessed by the analyst.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 9/7/2021
Establish a formal second-review process for quality reviews when STAR analysts do not identify claims-processing deficiencies.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 1/5/2021
Assess the current training requirements for STAR staff and establish a formal training plan that promotes claims-processing expertise and accuracy.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 3/30/2022
Implement a plan to ensure STAR analysts place more emphasis on and assess all procedural deficiency elements included on the quality review checklist.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 6/25/2021
Establish adequate policies, procedures, and monitoring to ensure corrections are completed timely and accurately.
No. 6
to Veterans Benefits Administration (VBA)
Closure Date: 6/25/2021
Ensure STAR develops a plan to provide usable data and meaningful feedback to assist regional offices in improving the quality of decision-making.
Date Issued
|
Report Number
19-07054-174
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 6/4/2021
The OIG recommends that the under secretary for benefits assess the current peer review process and determine whether a more in depth review should be required to ensure claims processing errors are identified.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 6/4/2021
The OIG recommends that the under secretary for benefits establish a process where a sampling of non error quality reviews undergo peer review to ensure claims processing errors are identified.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 6/4/2021
The OIG recommends that the under secretary for benefits revise the QRT specialist performance review process to include more objectivity to ensure constructive feedback is provided to promote competency.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 12/12/2022
The OIG recommends that the under secretary for benefits revise the error reconsideration process to ensure objectivity and adherence to current VBA procedures.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 6/4/2021
The OIG recommends that the under secretary for benefits improve oversight procedures for monitoring the timeliness of error corrections.
Date Issued
|
Report Number
20-02562-188
|
Topics: Financial Management
Date Issued
|
Report Number
19-06451-165
|
Topics: Healthcare Infrastructure
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/27/2021
The Under Secretary for Health establish a formal process for requesting and obtaining the approval of the VA Secretary for research studies that use canine subjects to comply with applicable restrictions on the use of appropriated funds.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/30/2022
The Under Secretary for Health develop and implement processes for documenting and maintaining records of the VA Secretary’s approval of canine research studies, including the study at the Richmond VAMC that was not included in the Secretary’s August 30, 2019, approval document.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/27/2021
The Under Secretary for Health establish controls for ensuring appropriate funds are not spent for canine research studies before obtaining the VA Secretary’s approval.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 7/7/2022
The Under Secretary for Health review local accounting records and cost allocations to determine the total amount of FY 2018 and 2019 funds spent on canine research before the VA Secretary approved the studies and report this information to the House and Senate appropriations committees.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/27/2021
The Under Secretary for Health work with the VA Secretary and the chief financial officer to take the steps required by OMB Circular A-11 to determine whether an Antideficiency Act violation occurred and, if so, take appropriate action for the funds obligated and expended for research studies involving canine subjects.
Date Issued
|
Report Number
19-07281-105
|
Topics: Financial Management
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/13/2021
The OIG recommended the Under Secretary for Health conduct a formal analysis of VHA’s Office of Community Care prescription drug programs to determine what steps VA would need to take to require drug manufacturers to provide Big 4 prices for covered prescription drugs purchased for CHAMPVA and any other VA Community Care programs that use a retail pharmacy.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/13/2021
The OIG recommended the Under Secretary for Health collaborate with the Office of Regulatory and Administrative Affairs and, if determined appropriate, pursue any proposed statutory or other changes needed to provide VA with the appropriate legal authority to purchase all prescription drugs through retail pharmacies at the Big 4 prices.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 345,100,000.00
Date Issued
|
Report Number
19-08728-166
|
Topics: Education and Loan Guaranty
Date Issued
|
Report Number
18-06292-117
|
Topics: Community Care
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/23/2020
The Office of Community Care completes a review of the OIG identified employees who had no claims processing production or activity in the Fee Basis Claims System during overtime hours to determine whether the employees’ conduct requires disciplinary or other corrective action, as appropriate.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/17/2021
The Office of Community Care establishes and implements controls for Payment Operations and Management supervisors to effectively monitor and assess staff productivity during overtime hours to mitigate the risk of overtime abuse.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/23/2020
The Payment Operations and Management directorate clarifies and communicates nurse productivity standards and requirements.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/23/2020
The Payment Operations and Management directorate develops and implements formal guidance for its staff on the appropriate use of overtime, and the controls needed for monitoring compliance.
Date Issued
|
Report Number
18-00711-141
|
Topics: Financial Management
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/13/2021
The San Francisco VA Healthcare System director establishes procedures to ensure the Research and Development Budget Office staff review VA-affiliated nonprofit corporation invoices to confirm services were performed or goods were received in accordance with Intergovernmental Personnel Act agreements before approving invoices for payment.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/24/2021
The San Francisco VA Healthcare System director establishes procedures to ensure the Research and Development Budget Office supervisor conducts periodic reviews of the VA-affiliated nonprofit corporation invoices authorized for payment by staff as required by VA Financial Policies and Procedures, Volume VIII, Chapter 1A.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 25,940,000.00
Date Issued
|
Report Number
19-06249-94
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 1/28/2021
The OIG recommended the under secretary for benefits correct disability compensation benefits for the veterans identified in the sample whose benefits were not adjusted or were incorrectly adjusted.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 9/2/2020
The OIG recommended the under secretary for benefits develop and implement a plan to ensure all VA regional offices generate and process the weekly Admission Report for Service Connected Veterans and maintain coordinators’ logs to complete required benefit adjustments.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 9/2/2020
The OIG recommended the under secretary for benefits continue to develop and implement a plan to nationally generate and process the Admission Report for Service Connected Veterans.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 9/2/2020
The OIG recommended the under secretary for benefits determine if a statutory or regulatory change is required to ensure lawful, consistent, and timely processing of benefits for veterans entitled to temporary increases of benefits to 100 percent.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 11/17/2020
The OIG recommended the under secretary for benefits develop and implement a plan to ensure staff receive refresher training when needed to properly process temporary disability compensation benefit adjustments for veterans hospitalized for more than 21 days that includes monitoring the effectiveness of the training.
No. 6
to Veterans Benefits Administration (VBA)
Closure Date: 8/6/2021
The OIG recommended the under secretary for benefits develop a plan to determine which veterans required adjustment of compensation benefits for hospitalization for a service connected condition, using the Admission Report for Service Connected Veterans for fiscal years 2018 and 2019, and make the required adjustments.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 40,000,000.00
Date Issued
|
Report Number
20-00541-149
|
Topics: Staffing
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 12/8/2020
The assistant secretary for human resources and administration/ operations, security, and preparedness should ensure VA time to hire percentages are reported using the Office of Personnel Management’s target as required by Section 505(a)(1)(D) of the MISSION Act.
No. 2
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 1/5/2021
The assistant secretary for human resources and administration/ operations, security, and preparedness should confer with the VA Office of General Counsel to ensure that changes to the reporting methodology comply with Section 505 of the MISSION Act.
Date Issued
|
Report Number
19-09563-142
|
Topics: Financial Management
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/28/2021
The Executive in Charge, Veterans Health Administration, implement appropriate IPERA testing procedures to ensure evidence is sufficient to verify that services were received for the Purchased Long-Term Services and Supports program.
Date Issued
|
Report Number
19-08980-95
|
Topics: Electronic Health Records Modernization (EHRM)
● System Development and Implementation
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/1/2020
Establish an infrastructure-readiness schedule for future deployment sites thatincorporates lessons learned from DoD.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/1/2020
Reassess the enterprise-wide deployment schedule to ensure projected milestones arerealistic and achievable, considering the time needed for facilities to completeinfrastructure upgrades.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/21/2021
Implement tools to comprehensively monitor the status and progress of medical devicesat the enterprise level.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021
Standardize infrastructure requirements in conjunction with VHA and the OIT and ensurethose requirements are disseminated to all necessary staff.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 11/9/2022
Evaluate physical infrastructure for consistency with OEHRM requirements and monitorcompletion of those evaluations.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 9/12/2022
Fill infrastructure-readiness team vacancies until optimal staffing levels are attained.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 11/9/2022
Ensure physical security assessments are completed and addressed at future electronichealth record deployment sites.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 10/1/2020
Ensure all access points to physical infrastructure are secured and inaccessible tounauthorized individuals.
Date Issued
|
Report Number
19-06382-111