All Reports

Audit of the VHA's Health Care Enrollment Program at Medical Facilities
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16-00355-296

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
We recommended the Acting Under Secretary for Health develop standardized national policy and procedures for the health care enrollment program at VA medical facilities.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2019
We recommended the Acting Under Secretary for Health implement national oversight of the health care enrollment program to continually review operations and performance of VHA medical facilities.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2019
We recommended the Acting Under Secretary for Health provide mandatory and standardized training on eligibility and enrollment to ensure health care applications are processed accurately and timely.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/20/2020
We recommended the Acting Under Secretary for Health develop and execute a process to distinguish new applications for health care enrollment in VistA from other registration data.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/20/2020
We recommended the Acting Under Secretary for Health implement a plan to correct current data integrity issues in VistA to improve the accuracy and timeliness of enrollment data.
Audit of VHA's Consolidated Patient Account Center Controls To Prevent Improper Billings for Service-Connected Conditions
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16-00589-264

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2018
We recommended the Under Secretary for Health require Consolidated Patient Account Centers review a statistical sample of bills issued during fiscal years 2015 and 2016 for the treatment of service-connected veterans to identify erroneously billed amounts that require refunds, and use these results to address internal control deficiencies and assess what additional efforts can be taken to identify and refund erroneously billed amounts.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2018
We recommended the Under Secretary for Health require Consolidated Patient Account Center management to provide billing staff read-only access to the Veterans Benefits Management System to identify potential service-connected bills that require review by Revenue Utilization Review nurses.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2018
We recommended the Under Secretary for Health require Consolidated Patient Account Center management establish oversight procedures to review statistical samples of prescriptions prior to generating bills to veterans and to address any identified systemic or facility-specific billing problems.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2018
We recommended the Under Secretary for Health require Consolidated Patient Account Center management to revise quality assurance reviews to include reviews of pharmacy bills and evaluate whether Revenue Utilization Review nurses correctly validate or make service-connection determinations for veterans’ medical treatment based upon staffing and workload.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2017
We recommended the Under Secretary for Health require Consolidated Patient Account Center management to revise policy and procedure to require Consolidated Patient Account Center staff to adequately provide and document training for VA medical facility staff regarding specific service-connection determination errors.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2018
We recommended the Under Secretary for Health require Consolidated Patient Account Center management to track and monitor incorrect medical provider service-connection determinations and coordinate training to ensure identified issues are appropriately addressed.
Review of VA’s Readiness To Implement the Digital Accountability and Transparency Act
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16-02454-250

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Establish milestones to monitor VA’s system modernization efforts. Coordination with the shared service provider should continue to incorporate current and upcoming DATA Act requirements to ensure that they will be met going forward.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Obtain procurement and grants management system capability that is integrated with the financial system as part of VA’s transition to a shared service provider to the extent feasible.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Improve communication with, and accountability of, administrations and offices and their points of contact who are responsible for providing data and documentation. Accountability should include timely, complete, and accurate submissions to the Project Management Office.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Continue working with the points of contact to ensure program information for all funds is submitted as required.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Identify internal controls and develop standard operating procedures for the processes used to obtain, extract, classify, and summarize data from VA’s financial and management systems to comply with the DATA Act schema.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: In conjunction with VA’s component organizations, perform an assessment of how business, accounting, and payment processes interact with one another for the purpose of establishing relevant policies and procedures to improve VA’s data quality. This assessment should include VA’s subsidiary systems and their interface status with the general ledger system, that is Financial Management System.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Ensure complete reconciliations are performed between the subsidiary and general ledger systems. Differences should be researched and resolved to improve data quality.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Continue to work on minimizing the use of the Management Information Exchange to record journal vouchers that are not linked to obligation and expenditure data by object class or program activity, or devise a mechanism to track such information when recording Management Information Exchange journal vouchers.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Perform reconciliations between VA’s procurement systems (Electronic Contract Management System and Integrated Funds Distribution, Control Point Activity, Accounting and Procurement system) and Financial Management System to ensure consistency, accuracy, and completeness of financial and procurement data.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Provide resources for data storage capabilities to improve auditability of data. Specifically, VA should establish a data storage mechanism such as a shared drive to store data received from points of contact or developed internally by the Project Management Office. Such information should be secured, readily available for analysis and requests, validated, and auditable.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Ensure proper segregation of duties between staff responsible for processing data for submission to the data broker and staff responsible for validating the accuracy and completeness of data prior to submission to the data broker.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Provide necessary resources to the VA DATA Act Project Management Office to ensure that the office can coordinate the data inventory, mapping, and validation for the required DATA Act Schema data elements.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Require administration points of contact to respond timely to Project Management Office data requests to ensure that the data elements can be inventoried, mapped, and validated and that gap analyses are performed thoroughly.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Use the data inventory and mapping to support VA’s move to a shared service provider and ensure full compliance with the DATA Act.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
In addition to recommendations made in Findings Number 1 and Number 2, we recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Establish procedures for data edits and validations to ensure that DATA Act submissionsare accurate and complete. At a minimum, management should selectively test internalcontrols related to the preparation of data submissions.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
In addition to recommendations made in Findings Number 1 and Number 2, we recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Assess the impact of the internal control weaknesses, as reported by VA’s financialstatement audit, on DATA Act data, and develop alternative processes to address data quality issues.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
In addition to recommendations made in Findings Number 1 and Number 2, we recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Continue to maintain communication with the Office of Management and Budget andTreasury regarding VA’s data reporting limitations and progress, and document suchcommunication.
Healthcare Inspection - Opioid Prescribing to High-Risk Veterans Receiving VA Purchased Care
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17-01846-316

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/28/2017
We recommended that the Acting Under Secretary for Health require that all participating VA purchased care providers receive and review the evidence-based guidelines outlined in the Opioid Safety Initiative.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/28/2017
We recommended that the Acting Under Secretary for Health implement a process to ensure all purchased care consults for non-VA care include a complete up-to-date list of medications and medical history until a more permanent electronic record sharing solution can be implemented.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/28/2017
We recommended that the Acting Under Secretary for Health require non-VA providers to submit opioid prescriptions directly to a VA pharmacy for dispensing and recording of the prescriptions in the patient’s VA electronic health record.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2019
We recommended that the Acting Under Secretary for Health ensure that if facility leaders determine that a non-VA provider’s opioid prescribing practices are in conflict with Opioid Safety Initiative guidelines, immediate action is taken to ensure the safety of all veterans receiving care from the non-VA provider.
Healthcare Inspection Review of VHA’s “Our Doctors” Website Accuracy
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16-01436-270

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/14/2018
We recommended that the Acting Under Secretary for Health ensure that the Veterans Health Administration develops and implements a policy defining the purpose, responsibilities, and requirements for credentials information on the Our Doctors website.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2018
We recommended that the Acting Under Secretary for Health ensure that the Veterans Health Administration develops and implements an oversight process for accuracy of the information posted on the Our Doctors website.
VA's Federal Information Security Modernization Act Audit for Fiscal Year 2016
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16-01949-248

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting Assistant Secretary for Information and Technology implement improved processes to ensure all VA systems and devices are formally “Authorized to Operate” and system security controls are evaluated before allowing such systems to connect to VA’s general network or the Internet. (This is a new recommendation.)
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting Assistant Secretary 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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting Assistant Secretary 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. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting Assistant Secretary for Information and Technology implement improved processes to ensure that all identified weakness 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. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting Assistant Secretary for Information and Technology implement system enhancements to the Governance Risk and Compliance tool to prevent the automatic re-opening of closed Plans of Action and Milestones and such actions are updated to accurately reflect their current status. (This is a repeat recommendation from prior years.)
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting Assistant Secretary 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. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting Assistant Secretary for Information and Technology develop mechanisms to ensure system security plans reflect current operational environments, including accurate system interconnections, boundary, control, and ownership information. (This is a repeat recommendation from prior years.)
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting Assistant Secretary for Information and Technology implement improved processes for reviewing and updating key security documents such as risk assessments, privacy impact assessments, and security control assessments on an annual basis and ensure all required information accurately reflects the current environment. (This is a repeat recommendation from prior years.)
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting Assistant Secretary 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. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting 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. (This is a repeat recommendation from prior years.)
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting Assistant Secretary for Information and Technology enable system audit logs on all systems and platforms and conduct centralized reviews of security violations across the enterprise. (This is a modified repeat recommendation from prior years.)
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting Assistant Secretary for Information and Technology fully implement two-factor authentication for all network access methods throughout the agency. (This is a modified repeat recommendation from prior years.)
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting 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. (This is a repeat recommendation from prior years.)
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting 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. (This is a repeat recommendation from prior years.)
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting Assistant Secretary for Information and Technology maintain complete and accurate baseline configurations and ensure all baselines are appropriately implemented for compliance with established VA security standards. (This is a modified repeat recommendation from prior years.)
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting Assistant Secretary for Information and Technology implement improved network access controls to ensure medical devices and networks, not managed by OI&T, are appropriately segregated from general networks and mission-critical systems. (This is a repeat recommendation from prior years.)
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting Assistant Secretary for Information and Technology consolidate the security responsibilities for networks, not managed by OI&T, 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. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting Assistant Secretary for Information and Technology implement improved processes to ensure that all devices and platforms are evaluated using credentialed vulnerability assessments. (This is a new recommendation.)
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting Assistant Secretary 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 modified repeat recommendation from prior years.)
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting Assistant Secretary for Information and Technology implement improved processes to ensure information system contingency plans are updated with the required information. (This is a modified repeat recommendation from prior years.)
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting Assistant Secretary 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 modified repeat recommendation from prior years.)
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting Assistant Secretary 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 an alternate site in the event of a system failure or disaster. (This is a modified repeat recommendation from prior years.)
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting Assistant Secretary for Information and Technology document a Business Impact Analysis for all systems and incorporate applicable Recovery Point Objectives for those systems. (This is a modified repeat recommendation from prior years.)
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting Assistant Secretary 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. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting Assistant Secretary 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. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting Assistant Secretary for Information and Technology ensures that VA’s Network Security and Operations Center has full access of all security incident data to facilitate an agency-wide awareness of information security events. (This is a new recommendation.)
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting Assistant Secretary for Information and Technology implement improved safeguards to identify and prevent unauthorized vulnerability scans and data exfiltrations from VA networks. (This is a modified repeat recommendation from prior years.)
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting 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 unauthorized software on agency devices. (This is a repeat recommendation from prior years.)
No. 29
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting Assistant Secretary 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. 30
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting Assistant Secretary for Information and Technology implement 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. 31
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2018
We recommended the Acting Assistant Secretary 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 modified repeat recommendation from prior years.)
Review of VHA Care and Privacy Standards for Women Veterans
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15-03303-206

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2017
We recommended that the Acting Under Secretary for Health ensure that the Office of Women’s Health Services routinely reviews and when appropriate, strengthens the requirements for women’s health provider designation and facilitates the updating of requirements for all designated women health providers with supporting documentation that details how the requirements were satisfied.
Review of Alleged Mismanagement of VA's Human Resources and Administration Contract Funds
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16-00327-209

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 6/1/2017
We recommended the Acting Assistant Secretary for Human Resources and Administration assign responsibility to an office to assess hosting solution options for the Dashboard Tool.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 5/7/2018
We recommended the Acting Assistant Secretary for Human Resources and Administration evaluate funding a hosting solution needed to test and use its estimated $3.7 million Dashboard Tool investment.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 3,700,000.00
Evaluation of Suicide Prevention Programs in Veterans Health Administration Facilities
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16-03808-215

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Suicide Prevention Coordinators provide at least five outreach activities per month and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians complete Suicide Prevention Safety Plans for all high-risk patients, include in the plans the contact numbers of family or friends for support, and give the patient and/or caregiver a copy of the plan, and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when clinicians, in consultation with Suicide Prevention Coordinators, identify inpatients as at high risk for suicide, they place Patient Record Flags in the patients' electronic health records and notify the Suicide Prevention Coordinator of each patient's admission, and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that a Suicide Prevention Coordinator or mental health provider evaluates inpatients identified as at high risk for suicide at least four times during the first 30 days after discharge, and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when clinicians identify outpatients as at high risk for suicide, they review the Patient Record Flags every 90 days and document the review and their justification for continuing or discontinuing the Patient Record Flags, and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians complete suicide risk management training within 90 days of hire and that facility managers monitor compliance.
Review of VA’s Compliance With the Improper Payments Elimination and Recovery Act for FY 2016
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16-04416-231

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No. 1
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 3/13/2018
We recommended the Acting Under Secretary for Health develop a timeline to reduce improper payments under 10 percent for the VA Community Care and Purchased Long Term Services and Support Programs.
No. 2
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 3/13/2018
We recommended the Acting Under Secretary for Health implement steps to achieve reduction targets for the VA Community Care, Purchased Long Term Services and Support, Beneficiary Travel, Civilian Health and Medical Program of the Department of Veterans Affairs, State Home Per Diem Grants, and Supplies and Materials Programs.
No. 3
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA),Acquisitions, Logistics, and Construction (OALC)
Closure Date: 3/13/2018
We recommended the Acting Under Secretary for Health, in coordination with the Principal Executive Director, Office of Acquisition, Logistics, and Construction, implement additional training with respect to identifying unauthorized commitments and verifying pricing for personnel who evaluate Improper Payment Elimination and Recovery Act samples for the Supplies and Materials Program.
No. 4
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA),Acquisitions, Logistics, and Construction (OALC),Office of Management (OM)
Closure Date: 3/13/2018
We recommended the Acting Under Secretary for Health, in coordination with the Acting Secretary for Management and Acting Chief Financial Officer, and the Principal Executive Director, Office of Acquisition, Logistics, and Construction, develop appropriate testing procedures for direct to patient and Federal Supply Schedule contract payments.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/13/2018
We recommended the Acting Under Secretary for Veterans Benefits Administration implement steps to identify and report a reliable improper payment estimate for the Post-9/11 G.I. Bill Program.
No. 6
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA),Office of Management (OM)
Closure Date: 3/13/2018
We recommended the Acting Under Secretary for Health, in coordination with the Acting Assistant Secretary for Management and Acting Chief Financial Officer, provide the Improper Payment Elimination and Recovery Act team guidance to achieve the expected level of precision for the improper payment estimates for the VA Community Care and Purchased Long Term Services and Support Programs.
No. 7
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 3/13/2018
We recommended the Acting Under Secretary for Benefits continue working with the Department of Defense to increase the frequency of drill pay adjustments from annually to monthly.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/13/2018
We recommended the Acting Under Secretary for Benefits report any statutory barrier preventing complete resolution to drill pay improper payments in its Agency Financial Report.
Combined Assessment Program Summary Report – Evaluation of Compounded Sterile Product Practices in Veterans Health Administration Facilities
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16-03807-223

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/9/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that for employees who prepare compounded sterile products, facilities include in their competency assessment requirements gloved fingertip sampling and the required number of gloved fingertip samplings for initial competency assessment.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/9/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities include in the competency assessment checklists of employees who prepare compounded sterile products donning of personal protective equipment in the required order and performance of appropriate hand hygiene after personal protective equipment removal.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/9/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility managers ensure competency assessments for employees who prepare compounded sterile products include gloved fingertip sampling, written tests, and visual observation or “hands-on” skill assessment of aseptic technique at the required risk level frequency.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/9/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility managers ensure sterile chemotherapy-type gloves are available in areas where hazardous compounded sterile products are prepared.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility managers ensure employees clean sterile compounding area floors daily and storage shelving monthly and document the cleaning.
Evaluation of Computed Tomography Radiation Monitoring in Veterans Health Administration Facilities
|
16-03920-197

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2019
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure a medical physicist inspects computed tomography scanners after completion of repairs or modifications that affect the dose or image quality prior to returning the scanners to clinical service.
Audit of VHA's Patient Advocacy Program
|
15-05379-146

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/5/2018
We recommended the Under Secretary for Health update patient advocate policies and procedures to ensure they meet current needs.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/5/2018
We recommended the Under Secretary for Health develop procedures to ensure pertinent program information is recorded in a standardized format in the Patient Advocate Tracking System.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2018
We recommended the Under Secretary for Health ensure responsible officials and staff perform patient complaint processing activities in accordance with policies and procedures, such as assuring required program information is recorded and trended at the local and national level.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA),Information and Technology (OIT)
Closure Date: 6/5/2018
We recommended the Under Secretary for Health work with the Assistant Secretary for Information and Technology to ensure its Patient Advocate Tracking System meets current program requirements for efficient complaint processing and reporting.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2021
We recommended the Under Secretary for Health establish controls to ensure that patient advocate staffing levels are sufficient to support patient advocate workload estimates.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2017
We recommended the Under Secretary for Health provide patient advocates with periodic formal documented training concerning their responsibilities and utilizing the Patient Advocate Tracking System.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/5/2018
We recommended the Under Secretary for Health implement mechanisms to ensure that privileges and access rights to the Patient Advocate Tracking System are regularly reviewed and extended based upon specific job duties and the need to know.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA),Information and Technology (OIT)
Closure Date: 9/19/2017
We recommended the Assistant Secretary for Information and Technology work with the Under Secretary for Health to fully assess the Patient Advocate Tracking System security and operational risks and to initiate appropriate corrective actions, including requesting the authority to operate the Patient Advocate Tracking System, if appropriate.
Evaluation of the Quality, Safety, and Value Program in Veterans Health Administration Facilities Fiscal Year 2016
|
16-03743-193

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/29/2019
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure clinical managers evaluate licensed independent practitioners’ ongoing professional performance regularly according to the frequency required by facility policy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network managers and facility senior managers, ensure clinical managers implement the improvement actions recommended by the Peer Review Committee.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/18/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure Utilization Managers complete at least 75 percent of all required reviews and designated Physician Utilization Management Advisors document their review decisions in the Veterans Health Administration’s utilization management database.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/18/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure Patient Safety Managers enter all patient incidents into the Veterans Health Administration’s web-based patient incident database, complete the minimum number of root cause analyses, provide feedback about the root cause analyses findings to the individuals or departments who reported the incidents, and submit patient safety reports to facility leaders at least annually.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/18/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure committees and teams consistently implement and evaluate corrective actions from quality, safety, and value activities.
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