All Reports

Emergency Cache Program: Ineffective Management Impairs Mission Readiness
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18-01496-301

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2020
The Executive in Charge, Veterans Health Administration, should develop requirements for medical facilities with emergency caches to perform at least annually a wall-to-wall inventory of all cache drugs and supplies, and develop processes to (1) label all expired or excess drugs that are purposefully maintained to respond to drug shortages or for the purposes of Shelf Life Extension testing, and (2) remove and rectify cases of other expired, missing, or excess drugs.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2020
The Executive in Charge, Veterans Health Administration, should conduct an assessment to determine if the cost saving benefits of the Shelf Life Extension Program outweigh the risks expired drugs pose to the emergency cache’s mission and to take corrective action as appropriate.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2019
The Executive in Charge, Veterans Health Administration, should improve emergency cache inventory management processes to ensure emergency cache national inventory data sorted by location is reliable and accurately identifies the expiration dates of all cache contents, including Shelf Life Extension Program drugs, and that this information is electronically accessible to each facility.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2020
The Executive in Charge, Veterans Health Administration, should initiate steps to update and reissue the Veterans Health Administration directives specifying oversight responsibilities for the Emergency Cache Program with a requirement for inventory to be timely rotated into the emergency cache after it is received.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2020
The Executive in Charge, Veterans Health Administration, should assess whether the Emergency Cache Program is properly aligned within VA and coordinate with other VA offices as necessary to determine the appropriate roles and responsibilities by program office, and then review, update, and reissue Emergency Cache Program requirements to include (1) robust annual cache inspection and activation exercise requirements, (2) processes to ensure cache inspection and activation requirements are met, (3) processes to ensure that violations identified during annual cache inspections are timely addressed, and (4) specific accountability measures for the program offices and local facility personnel responsible for program oversight.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2019
The Executive in Charge, Veterans Health Administration, should conduct a comprehensive assessment of the cache inventory to identify drugs and supplies that can be readily used in medical facilities’ general operations and develop a mechanism to monitor and ensure medical facilities are maximizing the use of these items before they expire.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2020
The Executive in Charge, Veterans Health Administration, should initiate steps to update and reissue the Veterans Health Administration directives specifying oversight responsibilities for the Emergency Cache Program to reflect the Office of Public Health’s reorganization and reassign responsibilities as needed.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 34,263,584.00
Timeliness of Final Competency Determinations
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17-05535-292

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/22/2019
The Under Secretary for Benefits ensures cases requiring final competency determinations are entered into the Beneficiary Fiduciary Field System as soon as the cases are established in the Veterans Benefits Management System.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/15/2019
The Under Secretary for Benefits reminds Veterans Benefits Administration staff of their responsibility to notify Fiduciary Hubs when waivers are received of the due process notification period for cases with proposed incompetency, and implements a plan to ensure compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/22/2019
The Under Secretary for Benefits implements a plan to ensure the processing of final competency determinations under the jurisdiction of the Fiduciary Hubs meet Veterans Benefits Administration’s established timeliness standard.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/3/2019
The Under Secretary for Benefits implements a plan to prioritize the processing of final competency determinations under the jurisdiction of Veterans Service Centers and Pension Management Centers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/7/2019
The Under Secretary for Benefits ensures the National Work Queue distributes final competency determinations according to the Veterans Benefits Administration policy for processing these cases.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/15/2019
The Under Secretary for Benefits implements a plan to ensure Fiduciary Hub staff who complete final competency determinations have access to documents containing federal taxpayer information in the Legacy Content Manager.
VA Policy for Administering Traumatic Brain Injury Examinations
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16-04558-249

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/10/2018
The Under Secretary for Benefits coordinate with the Under Secretary for Health to determine whether veterans who had received initial TBI medical examinations by VHA-contracted examiners and not by one of the four designated specialists, were unintentionally excluded from equitable relief. If additional veterans are identified, the OIG requests that those cases be referred to the VA Secretary for consideration of equitable relief.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/13/2019
The Under Secretary for Benefits confirm whether the names of veterans who were not on the initial list of veterans entitled to equitable relief and later identified by VBA staff and referred for potential equitable relief were submitted to the VA Secretary for consideration. The OIG requests an update of the current status and disposition of those cases.
Review of Accuracy of Reported Pending Disability Claims Backlog Statistics
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16-02103-265

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/3/2019
The OIG recommended the Under Secretary for Benefits consider revising which claims are included in VBA’s reported disability claims backlog and provide a clear definition to all stakeholders.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/28/2019
The OIG recommended the Under Secretary for Benefits implement a plan to provide consistent oversight and training of Claims Assistants through national performance and training plans.
Bulk Payments Made under Patient-Centered Community Care/Veterans Choice Program Contracts
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17-02713-231

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2019
The Executive in Charge, Office of the Under Secretary for Health, continue to support processes to prevent duplicate payments made to third-party administrators through the bulk payment process and ensure that proper controls are in place to prevent duplicate payments to third-party administrators through all other current payment methodologies and under future Community Care contracts.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2019
The Executive in Charge, Office of Under Secretary for Health, ensure that Office of Community Care staff and members of VA’s Office of General Counsel continue to work collaboratively with relevant government authorities to review and determine an appropriate process for reimbursement of overpayments by the third-party administrators.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 101,400,000.00
Accuracy of Effective Dates for Reduced Evaluations Needs Improvement
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17-05244-226

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/29/2018
The Under Secretary for Veterans Benefits Administration implement a plan to ensure staff timely process cases with reduced evaluations, after the decision, to prevent rework and improper payments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/12/2020
The Under Secretary for Veterans Benefits Administration establish a plan to modify the Veterans Benefits Management System to apply correct effective dates for cases with reduced evaluations for conditions that were no longer service-connected and alert staff when the assigned effective dates are improper.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/29/2018
The Under Secretary for Veterans Benefits Administration remind VA Regional Office staff of the system defect that causes effective dates to be one month later than required for conditions that are no longer being classified as service-connected, until the Veterans Benefits Administration could implement a system change.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/28/2019
The Under Secretary for Veterans Benefits Administration implement a plan to provide refresher training on the proper processing of reduced evaluations to staff who process rating reductions and monitor the effectiveness of that training.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/7/2019
The Under Secretary for Veterans Benefits Administration provide updated guidance to include provisions for when amended proposal letters are necessary.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/8/2021
The Under Secretary for Veterans Benefits Administration implement a plan to conduct periodic reviews for veterans who had evaluations reduced after the first of the month following the final notification letter and before the first of the month following 60 days after the final notification letter, take corrective actions as needed, and provide certification of completion to the Office of Inspector General.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 37,900,000.00
Use of Not Otherwise Classified Codes for Prosthetic Limb Components
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16-01913-223

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2020
The Executive in Charge, Veterans Health Administration, should review the Prosthetic and Sensory Aids Service Ottobock microprocessor knee instructions (August 2011, March 2013, and August 2013), coordinate with appropriate officials to determine which Centers for Medicare and Medicaid Services’ Healthcare Common Procedure Coding System Level II L codes are appropriate to classify these items for reimbursement, and issue revised guidance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2019
The Executive in Charge, Veterans Health Administration, should coordinate with appropriate officials to establish a formal oversight and reporting structure that defines the roles and the responsibilities of the Prosthetic and Sensory Aids Service Orthotic and Prosthetic L Code Committee, as well as who has the authority to approve recommendations for the use of the Centers for Medicare and Medicaid Services’ Healthcare Common Procedure Coding System Level II L codes to classify specific prosthetic components for reimbursement.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2020
The Executive in Charge, Veterans Health Administration, should develop and implement effective processes and procedures to monitor the use of Not Otherwise Classified codes and communicate these procedures to the Veterans Integrated Service Networks to ensure compliance with Veterans Health Administration Directive 1045, Healthcare Common Procedure Coding System (HCPCS) List for Prosthetic Limb and/or Custom Orthotic Device Prescription (December 30, 2013) and the Centers for Medicare and Medicaid Services’ Healthcare Common Procedure Coding System Level II Coding Procedures.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2019
The Executive in Charge, Veterans Health Administration, should coordinate with the appropriate officials to develop and implement processes and procedures to ensure any pricing guidance with regard to the pricing of prosthetic items classified using a Not Otherwise Classified code is developed and concurred with by VA Office of General Counsel and Veterans Health Administration’s Procurement and Logistics Office prior to issuance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2020
The Executive in Charge, Veterans Health Administration, should issue corrected guidance to replace the Prosthetic and Sensory Aids Service Ottobock microprocessor knee instructions (March 2013 and August 2013) and the prosthetic limb contract template issued in August 2014, by coordinating with appropriate officials to develop and implement pricing guidance to ensure VA pays a fair and reasonable price for items classified using a Not Otherwise Classified code.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 21,300,000.00
Processing Inaccuracies Involving Veterans' Intent to File Submissions for Benefits
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17-04919-210

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/18/2019
The OIG recommended the Under Secretary for Benefits take steps to prioritize the modernization of functionality within the Veterans Benefits Management System to assist rating personnel with assigning correct effective dates related to intent to file.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/26/2019
The OIG recommended the Under Secretary for Benefits implement a plan to conduct a special review of claims with intent to file submissions from March 24, 2015, through September 30, 2017, during which payment changes occurred, to determine whether rating personnel assigned correct effective dates when awarding compensation benefits.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 72,500,000.00
Denied Posttraumatic Stress Disorder Claims Related to Military Sexual Trauma
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17-05248-241

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No. 1
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 3/26/2021
The Under Secretary for Benefits reviews all denied military sexual trauma related claims since the beginning of FY 2017, determines whether all required procedures were followed, takes corrective action based on the results of the review, renders a new decision as appropriate, and reports the results back to the Office of Inspector General.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/2/2019
The Under Secretary for Benefits focuses processing of military sexual trauma related claims to a specialized group of Veterans Service Representatives and Rating Veterans Service Representatives.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/8/2020
The Under Secretary for Benefits requires an additional level of review for all denied military sexual trauma related claims and holds the second level reviewers accountable for accuracy.
No. 4
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 3/26/2021
The Under Secretary for Benefits conducts special focused quality improvement reviews of denied military sexual trauma related claims and takes corrective action as needed.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/26/2021
The Under Secretary for Benefits updates the current training for processing military sexual trauma related claims, monitors the effectiveness of the training, and takes additional actions as necessary.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/8/2019
The Under Secretary for Benefits updates the development checklist for military sexual trauma related claims to include specific steps claims processors must take in evaluating such claims in accordance with applicable regulations, and requires claims processors to certify that they completed all required development action for each military sexual trauma-related claim.
Program of Comprehensive Assistance for Family Caregivers: Management Improvements Needed
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17-04003-222

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2019
The Executive in Charge, Veterans Health Administration, will establish a governance environment for the Program of Comprehensive Assistance for Family Caregivers to ensure medical facilities process veteran applications within the required 45-day timeliness standard, consistently monitor veterans and their caregivers, adequately document the results and changes in veterans’ health status, and adjust the level of support provided or discharge veterans and their caregivers, as appropriate.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2019
The Executive in Charge, Veterans Health Administration, will take steps to ensure caregiver support coordinators are properly applying eligibility criteria with processes, such as pre- or post-approval reviews, to ensure the accuracy of all veteran eligibility determinations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2019
The Executive in Charge, Veterans Health Administration, will update Directive 1152, Caregiver Support Program, to include a well-defined process for documenting changes in veterans’ health conditions during monitoring sessions to determine if those changes warrant a reassessment of the need for care or the level of care.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2020
The Executive in Charge, Veterans Health Administration, will establish assessment guidelines that caregiver support coordinators should follow when a veteran’s need for care changes.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2019
The Executive in Charge, Veterans Health Administration, will make sure that Veterans Integrated Service Network directors designate program leads at the network level with responsibility for Program of Comprehensive Assistance for Family Caregivers oversight.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/3/2019
The Executive in Charge, Veterans Health Administration, will assess the extent to which current staffing levels at medical facilities are adequate to implement the Program of Comprehensive Assistance for Family Caregivers, as intended.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 41,572,914.00
Misuse of Time and Resources within the Veterans Engineering Resource Center in Indianapolis, Indiana
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17-04156-234

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/8/2019
The Principal Deputy Under Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against Employee 1.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2019
The Principal Deputy Under Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against Employee 2.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2022
The Principal Deputy Under Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against Employee 3.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/8/2019
The Principal Deputy Under Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against other OSI VERC employees identified by the OIG for misusing government time and resources associated with this endeavor.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2019
The Principal Deputy Under Secretary assesses the adequacy of oversight and training for OSI VERC employees regarding the appropriate use of VA time and resources and addresses any deficiencies.
Unwarranted Medical Reexaminations for Disability Benefits
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17-04966-201

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No. 1
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 8/29/2022
The Under Secretary for Benefits establishes internal controls sufficient to ensure that a reexamination is necessary prior to employees ordering it, and modifies VBA procedures as appropriate to reflect these improved business processes.
No. 2
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 3/28/2019
The Under Secretary for Benefits takes steps to prioritize the design and implementation of system automation reasonably designed to minimize unwarranted reexaminations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/7/2019
The Under Secretary for Benefits enhances VBA’s quality assurance reviews to evaluate whether employees correctly requested reexaminations and categorize unwarranted reexaminations as errors.
No. 4
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 8/29/2022
The Under Secretary for Benefits conducts a special focused quality improvement review of cases with unwarranted reexaminations to develop data sufficient to understand and redress the causes of any avoidable errors.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 100,600,000.00
OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages FY 2018
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18-01693-196
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Topics:  Staffing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2020
The Under Secretary for Health refines and formalizes VHA’s position categorization of individuals (clinical and nonclinical) who are necessary to VHA’s mission of delivering health care by looking at various dimensions of each occupation, including staff skill set and function, enabling identification of positions based on the specific role a person would fill.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/28/2019
The Under Secretary for Health ensures the consistent implementation and use of the position categorization approach across all facilities.
VA’s Compliance with the Improper Payments Elimination and Recovery Act for FY 2017
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17-05460-169

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2020
The Executive in Charge, Office of the Under Secretary for Health, develops a timeline to reduce improper payments under the 10 percent threshold for the Beneficiary Travel; Communications, Utilities, and Other Rents; Medical Care Contracts and Agreements; Prosthetics; Purchased Long Term Services and Support; Supplies and Materials; and VA Community Care Programs and activities. This is a repeat finding and recommendation for the Purchased Long Term Services and Support and VA Community Care programs from our FY 2015 and 2016 reports.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The Executive in Charge, Office of the Under Secretary for Health, implements steps to achieve stated reduction targets for the Beneficiary Travel; Civilian Health and Medical Program of the Department of Veterans Affairs; Purchased Long Term Services and Support; Supplies and Materials; and VA Community Care Programs and activities. This is a repeat finding for all five programs from our FY 2016 report.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/14/2020
The Executive in Charge, Veterans Benefits Administration, implements steps to achieve reduction targets for the Pension and Post-9/11 GI Bill Programs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2019
The OIG recommended the Executive in Charge, Office of the Under Secretary for Health, implement procedures to ensure thorough testing of sample items used to estimate improper payments for Supplies and Materials purchases under indefinite delivery contracts.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/7/2020
The OIG recommended the Executive in Charge, Veterans Benefits Administration, continue working with the Department of Defense to increase the frequency of drill pay adjustments from annually to monthly. This is a repeat recommendation from our FY 2016 report.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/22/2020
The OIG recommended the Executive in Charge, Veterans Benefits Administration, continue to report statutory barriers preventing complete resolution of drill pay improper payments in future Agency Financial Reports until resolved.
Audit of the Beneficiary Travel Program, Special Mode of Transportation, Eligibility and Payment Controls
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15-00022-139

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2019
The OIG recommended the Under Secretary for Health require Veterans Integrated Service Networks to implement periodic reviews to ensure clinicians and Beneficiary Travel Office staff comply with Veterans Health Procedure Guide 1601B.05 eligibility requirements for authorizing Special Mode of Transportation services.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2019
The OIG recommended the Under Secretary for Health modify Veterans Health Administration Procedure Guide 1601B.05 to require the Beneficiary Travel Office staff to verify beneficiaries attended medical appointments prior to approving payment of Special Mode of Transportation vendor invoices.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2019
The OIG recommended the Under Secretary for Health require Veterans Integrated Service Networks to implement periodic reviews to ensure VA Medical Centers comply with Veterans Health Administration policies for verifying beneficiaries listed on vendor invoices had been properly authorized for Special Mode of Transportation services or attended medical appointments prior to approving payment of Special Mode of Transportation vendor invoices.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2019
The OIG recommended the Under Secretary for Health ensure the Improper Payments Elimination and Recovery Act reports provided to Veterans Integrated Service Networks are modified to include Special Mode of Transportation information specific to vendor payments by VA Medical Centers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2023
The OIG recommended the Under Secretary for Health implement use of Centers for Medicare and Medicaid Services Rates when savings can be achieved for Special Mode of Transportation ambulance services in accordance with 38 U.S.C. Section 111(b)(3)(C).
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2019
The OIG recommended the Under Secretary for Health implement controls to prevent beneficiaries using Special Mode of Transportation services from also obtaining mileage reimbursement for the same appointment(s).
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 173,829,000.00
Alleged Contracting and Appropriation Irregularities at the Office of Transition, Employment, and Economic Impact
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16-04555-138

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/31/2019
The OIG recommended the Executive in Charge for Benefits coordinate with the Head of VA Contracting Activity and the Office of General Counsel to determine what actions need to be taken to remedy the unauthorized commitment.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/7/2018
The OIG recommended the Executive in Charge for Benefits obtain appropriate funding for all future information technology costs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/3/2020
The OIG recommended the Executive in Charge for Benefits coordinate with the Office of Information Technology, the Office of Management, and the Office of General Counsel to make accounting adjustments to debit the information technology account that should have been used and credit the general operating expense account that was inappropriately used, determine whether Antideficiency Act violations occurred, and report the violations as appropriate.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 11,700,000.00
Healthcare Inspection - Testosterone Replacement Therapy Initiation and Follow-Up Evaluation in VA Male Patients
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15-03215-154

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2020
The Under Secretary for Health ensures that providers establish clinical signs and symptoms consistent with androgen deficiency, prior to testing patients’ testosterone level for confirmation in alignment with Veterans Health Administration guidance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2019
The Under Secretary for Health ensures that providers biochemically confirm hypogonadism through repeated testosterone testing prior to initiation of testosterone replacement therapy in alignment with Veterans Health Administration guidance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2019
The Under Secretary for Health ensures that providers determine whether the etiology of hypogonadism is primary or secondary, prior to testosterone replacement therapy initiation in alignment with Veterans Health Administration guidance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2019
The Under Secretary for Health ensures that providers discuss and document the risks and benefits of testosterone therapy with patients prior to initiation in alignment with Veterans Health Administration guidance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2019
The Under Secretary for Health ensures that providers assess and document patients’ symptoms improvement and adverse effects within 3–6 months of initiation before continuing testosterone replacement therapy in alignment with Veterans Health Administration guidance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2019
The Under Secretary for Health ensures that providers monitor patients’ hematocrit levels within 3–6 months of initiation, before continuing testosterone replacement therapy in alignment with Veterans Health Administration guidance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2019
The Under Secretary for Health ensures that providers assess and document patients’ adherence to therapy and perform testosterone level test within 3–6 months of initiation, before continuing testosterone replacement therapy in alignment with Veterans Health Administration guidance.
VA’s Federal Information Security Modernization Act Audit for Fiscal Year 2017
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17-01257-136

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 Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology fully implement an agency-wide risk management governance structure, along with mechanisms to identify, monitor, and manage risks across the enterprise. (This is a repeat recommendation from prior years.)
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement mechanisms to ensure sufficient supporting documentation is captured to justify closure of Plans of Action and Milestones. (This is a repeat recommendation from prior years.)
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement improved processes to ensure that all identified weaknesses are incorporated into the Governance Risk and Compliance tool, in a timely manner, and corresponding Plans of Actions and Milestones are developed to track corrective actions and remediation. (This is a repeat recommendation from prior years.)
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement clear roles, responsibilities, and accountability for developing, maintaining, completing, and reporting on Plans of Action and Milestones. (This is a repeat recommendation from prior years.)
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge 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. (This is a modified repeat recommendation from prior years.)
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement improved processes for reviewing and updating key security documents such as risk assessments and security control assessments on an annual basis and ensure the information accurately reflects the current environment. (This is a modified repeat recommendation from prior years.)
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement mechanisms to enforce VA password policies and standards on all operating systems, databases, applications, and network devices. (This is a repeat recommendation from prior years.)
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge 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. (This is a repeat recommendation from prior years.)
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology enable system audit logs on all critical systems and platforms and conduct centralized reviews of security violations across the enterprise. (This is a repeat recommendation from prior years.)
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology fully implement two-factor authentication for all network access methods throughout the agency. (This is a repeat recommendation from prior years.)
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge 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. (This is a repeat recommendation from prior years.)
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge 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. (This is a repeat recommendation from prior years.)
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology maintain a complete and accurate security baseline configurations for all platforms and ensure all baselines are appropriately implemented for compliance with established VA security standards. (This is a modified repeat recommendation from prior years.)
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement improved network access controls to ensure medical devices and networks, not managed by the Office of Information and Technology, are appropriately segregated from general networks and mission-critical systems. (This is a repeat recommendation from prior years.)
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge 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. (This is a repeat recommendation from prior years.)
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement improved processes to ensure that all devices and platforms are evaluated using credentialed vulnerability assessments. (This is a repeat recommendation from prior years.)
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement improved procedures to enforce a standardized system development and change control framework that integrates information security throughout the life cycle of each system. (This is a repeat recommendation from prior years.)
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement improved processes for ensuring the encryption of backup data prior to transferring the data offsite for storage. (This is a repeat recommendation from prior years.)
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement improved processes for the testing of contingency plans and failover capabilities for critical systems to ensure that all components can be recovered at the assigned sites and within stated timeframes. (This is a modified repeat recommendation from prior years.)
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology identify all external network interconnections and implement improved processes for monitoring VA networks, systems, and connections for unauthorized activity. (This is a repeat recommendation from prior years.)
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement more effective agency-wide incident response procedures to ensure timely reporting, updating, and resolution of computer security incidents in accordance with VA standards. (This is a repeat recommendation from prior years.)
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology ensure that VA’s Network Security and Operations Center has full access to all security incident data to facilitate an agency-wide awareness of information security events. (This is a repeat recommendation from prior years.)
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement improved safeguards to identify and prevent unauthorized vulnerability scans and data exfiltrations from VA networks. (This is a repeat recommendation from prior years.)
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology fully develop a comprehensive list of approved and unapproved software and implement continuous monitoring processes to prevent the use of unauthorized software on agency devices. (This is a repeat recommendation from prior years.)
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology develop a comprehensive software inventory process to identify major and minor software applications used to support VA programs and operations. (This is a repeat recommendation from prior years.)
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement improved procedures for overseeing contractor-managed cloud-based systems and ensure information security controls adequately protect VA sensitive systems and data. (This is a repeat recommendation from prior years.)
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/11/2018
We recommended the Executive in Charge for Information and Technology implement mechanisms for updating systems inventory, including contractor-managed systems and interfaces, and provide this information in accordance with Federal reporting requirements. (This is a repeat recommendation from prior years.)
Review of Timeliness of the Appeals Process
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16-01750-79

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: 3/28/2018
The OIG recommended the acting Under Secretary for Benefits continue to monitor the effectiveness of the Veterans Benefits Administration’s appeals realignment and increased resources, towards meeting its established targets related to appeals processing timeliness.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/28/2018
The OIG recommended the acting Under Secretary for Benefits monitor the effectiveness of the Caseflow application to ensure Board of Veterans’ Appeals decisions are timely controlled and assigned to the appropriate VA Regional Office or the Appeals Resource Center.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/28/2018
The OIG recommended the acting Under Secretary for Benefits implement a plan to amend Veterans Benefits Administration’s procedures for closing appeals records to prevent appeals being closed prematurely.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/21/2018
The OIG recommended the acting Under Secretary for Benefits remind staff of their responsibilities when processing remands and recertifying appeals to the Board of Veterans’ Appeals, and implement a plan to ensure compliance.
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