All Reports

Audit of VHA’s Alleged Improper Payments to Providers After Veterans’ Reported Deaths
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16-00252-137

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2017
We recommended the Under Secretary for Health recover the reported improper payments for outpatient services that could not have been rendered to deceased veterans.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2017
We recommended the Under Secretary for Health ensure medical facilities adhere to VHA Procedure Guide 1601F.02 and update non-VA care authorization end dates for deceased veterans.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 505,000.00
Healthcare Inspection - Evaluation of the Veterans Health Administration Veterans Crisis Line
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16-03985-181

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2018
We recommended that the Under Secretary for Health implement an automated transcription function for callers’ phone numbers in the Veterans Crisis Line call documentation recording system.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2018
We recommended that the Under Secretary for Health ensure that Veterans Crisis Line policies and procedures, staff education, Information Technology support, and monitoring are in place for audio call recording.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2017
We recommended that the Under Secretary for Health implement a Veterans Crisis Line governance structure that ensures cooperation and collaboration between VHA Member Services and the Office of Suicide Prevention.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2017
We recommended that the Under Secretary for Health develop clear guidelines that delineate clinical and administrative decision-making, assuring that clinical staff make decisions directly affecting clinical care of veterans in accordance with sound clinical practice.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2018
We recommended that the Under Secretary for Health ensure processes are in place for routinely reviewing backup center data, establish wait-time targets for call queuing and rollover, and ensure plans are in place for corrective action when wait-time targets are exceeded.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/8/2017
We recommended that the Under Secretary for Health ensure processes are in place to require contracted backup centers to have the same standards as the Veterans Crisis Line related to call queuing and wait-time targets.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2018
We recommended that the Under Secretary for Health ensure that VHA Member Services leadership, Veterans Crisis Line leadership, VHA Contracting Officers, and Contracting Officer Representatives implement the quality control plan and conduct ongoing oversight to ensure contractor accountability in accordance with their roles as specified in the contract with backup call centers.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/8/2017
We recommended that the Under Secretary for Health ensure that training is provided to Veterans Crisis Line quality management staff in the skills needed to provide leadership to promote quality and safety of care.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2018
We recommended that the Under Secretary for Health ensure the development of structured oversight processes for tracking, trending, and reporting of clinical quality performance measures.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2018
We recommended that the Under Secretary for Health ensure processes for Veterans Crisis Line quality management staff to collect and review adverse outcomes so that established cohorts of severe adverse outcomes are analyzed.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2018
We recommended that the Under Secretary for Health direct the Veterans Health Administration Assistant Deputy Under Secretary for Health for Quality, Safety, and Value to review existing Veterans Crisis Line policies and determine whether the policies incorporate the appropriate Veterans Health Administration policies for veteran safety and risk management, and if not, establish appropriate action plans.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/8/2017
We recommended that the Under Secretary for Health ensure that Veterans Crisis Line quality management staff incorporate call audio recording into quality management data analysis.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2017
We recommended that the Under Secretary for Health ensure that processes are in place to analyze performance and quality data from the Atlanta Call Center separately from the Canandaigua Call Center data.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2018
We recommended that the Under Secretary for Health ensure that quality assurance monitoring policies and procedures are in place and consistent for both Social Service Assistants and responders.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2018
We recommended that the Under Secretary for Health ensure that supervisors certify Social Service Assistant training prior to engaging in independent assistance with rescues.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2018
We recommended that the Under Secretary for Health ensure a process is in place to establish, maintain, distribute, and educate staff on all Veterans Crisis Line policies and directives that includes verifying the use of current versions when policies and directives are modified.
Combined Assessment Program Summary Report – Evaluation of Inpatient Flow in Veterans Health Administration Facilities
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16-03805-20

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities revise discharge policies to include encouraging physicians to schedule discharges early in the day.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities develop or revise policies addressing overflow patients in temporary bed locations and include priority placement for inpatient beds given to patients in temporary bed locations, upholding standard of care while patients are in temporary bed locations, medication administration, and meal provision.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/2/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when resident physicians complete discharge notes or instructions, supervising physicians co-sign the residents’ notes.
Evaluation of Human Immunodeficiency Virus Screening in Veterans Health Administration Outpatient Clinics
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15-04925-469

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinical staff offer HIV screening as part of routine medical care and that managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians document informed consent for HIV testing and that managers monitor for compliance. VA Office
Audit of VBA’s Automated Burial Payments
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15-01436-456

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/27/2017
We recommended the Principal Deputy Under Secretary for Benefits, Performing the Duties of Under Secretary for Benefits, review the improper payments identified in this report and take appropriate corrective actions when warranted.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
We recommended the Principal Deputy Under Secretary for Benefits, Performing the Duties of Under Secretary for Benefits, strengthen controls to ensure intended recipients meet entitlement requirements before authorizing automated burial payments.
No. 3
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 2/8/2017
We recommended the Principal Deputy Under Secretary for Benefits, Performing the Duties of Under Secretary for Benefits, initiate action to ensure policies and procedures are consistent with the requirement under the United States Code of Federal Regulations that proof of death be submitted prior to the release of automated burial payments.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/27/2017
We recommended the Principal Deputy Under Secretary for Benefits, Performing the Duties of Under Secretary for Benefits, initiate action to ensure policies and procedures are consistent with United States Code of Federal Regulations related to automated burial payments and recipients’ entitlement requirements prior to authorizing payments.
No. 5
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 6/13/2017
We recommended the Principal Deputy Under Secretary for Benefits, Performing the Duties of Under Secretary for Benefits, ensure quality assurance reviews determine whether staff inappropriately discontinued veterans’ disability benefits and assess whether spouses met entitlement requirements to receive automated burial payments.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 28,000,000.00
Review of Alleged Waste of Funds on a Cloud Brokerage Service Contract
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15-02189-336

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/1/2017
We recommended the Assistant Secretary for Information and Technology implement improved controls to ensure the effective oversight of information technology projects and compliance with information technology project management procedures in order to ensure delivery of value.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/1/2017
We recommended the Assistant Secretary for Information and Technology enforce the use of the Project Management Accountability System or Veteran-focused Integration Process on all Office of Information and Technology software development projects to ensure that such efforts will provide an adequate return on investment.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/1/2017
We recommended the Assistant Secretary for Information and Technology establish oversight mechanisms to ensure all VA-developed software costs are funded with Information Technology Systems appropriations.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 5,300,000.00
Review of VHA’s Implementation of the Veterans Choice Program
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15-04673-333

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2018
We recommended the Under Secretary for Health streamline processes and procedures for accessing care under the Veterans Choice Program.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2019
We recommended the Under Secretary for Health develop accurate forecasts of demand for care purchased in the community.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/14/2017
We recommended the Under Secretary for Health simplify requirements for network providers to bill for services under the Veterans Choice Program.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2018
We recommended the Under Secretary for Health ensure eligible veterans are not financially liable for the full cost of treatment authorized under the Veterans Choice Program.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2018
We recommended the Under Secretary of Health ensure community providers are paid in a timely manner under the Veterans Choice Program.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/14/2017
We recommended the Under Secretary for Health review the Veterans Choice Program to determine if growth of provider networks is being limited by allowing reimbursement below Medicare rates.
Audit of VA’s Recruitment, Relocation, and Retention Incentives
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14-04578-371

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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: 7/9/2020
We recommended the Assistant Secretary for Human Resources and Administration review and update procedures and add internal controls for Administrations to ensure recruitment and relocation incentives are fully justified and authorized before being included on vacancy announcements for hard-to-fill positions or before the final selectee is identified in cases where a position is not filled through a vacancy announcement.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 1/5/2017
We recommended the Assistant Secretary for Human Resources and Administration review and update procedures and add internal controls for the Corporate Senior Executive Management Office to ensure Senior Executive Service recruitment and relocation incentives are fully justified and authorized before being included on vacancy announcements for hard-to-fill positions or before the final selectee is identified in cases where a position is not filled through a vacancy announcement.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 7/9/2020
We recommended the Assistant Secretary for Human Resources and Administration review and update procedures and add internal controls for Administrations to monitor compliance with its employee certification requirement before relocation incentives are authorized for payment.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 1/5/2017
We recommended the Assistant Secretary for Human Resources and Administration review and update procedures and add internal controls to monitor the Corporate Senior Executive Management Office’s compliance with the employee certification requirement before Senior Executive Service relocation incentives are authorized for payment.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 3/1/2018
We recommended the Assistant Secretary for Human Resources and Administration review and update procedures and add internal controls for Administrations to monitor facilities’ compliance with developing workforce and succession plans to reduce the risk of long-term reliance on retention incentives.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 11/22/2017
We recommended the Assistant Secretary for Human Resources and Administration review and update procedures and add internal controls to monitor the Corporate Senior Executive Management Office’s compliance with developing workforce and succession plans to reduce the risk of long-term reliance on retention incentives for Senior Executives.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 9/19/2017
We recommended the Assistant Secretary for Human Resources and Administration monitor the Corporate Senior Executive Management Office to ensure its technical review and recommendations to the VA Chief of Staff regarding Senior Executive Service incentives are prudent and in full compliance with VA Handbook 5007/46.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 1/5/2017
We recommended the Assistant Secretary for Human Resources and Administration assess the feasibility of limiting the number of consecutive years employees in specific occupations or groups of employees in specific occupations can receive retention incentive payments.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 5/18/2018
We recommended the Assistant Secretary for Human Resources and Administration review and update procedures and add internal controls for Administrations to monitor facilities’ compliance with VA Handbook 5007/46 requirements to initiate debt collection from individuals who did not fulfill their recruitment, relocation, or retention incentive service obligations.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 5/18/2018
We recommended the Assistant Secretary for Human Resources and Administration examine the capabilities of the HR Smart personnel system to determine the extent to which it is possible to develop an incentive-specific automated alert that notifies Human Resources personnel when employees have outstanding recruitment, relocation, or retention incentive service obligations.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 162,600,000.00
Healthcare Inspection – Review of Antimicrobial Stewardship Programs in VHA Facilities
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15-04247-111

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2017
We recommended that the Under Secretary for Health implement procedures to ensure that facilities comply with Veterans Health Administration Directive 1031 requirements, including the completion of annual evaluations, designation of provider and pharmacy champions, staff education, and the provision of adequate dedicated staffing and resources.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2017
We recommended that the Under Secretary for Health require that Veterans Health Administration facilities track and generate clinical outcome reports on antibiotic use.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/15/2016
We recommended that the Under Secretary for Health consider implementing standardized tools and definitions for antimicrobial stewardship data and a uniform reporting system to permit analysis of comparable information over time.
Review of Alleged Wasted Funds at Consolidated Patient Account Centers for Windows Enterprise Licenses
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16-00790-417

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 11/9/2020
We recommended the Assistant Secretary for Information and Technology implement a policy to ensure cost-effective utilization of information technology equipment, installed software, and services and ensure coordination of acquisitions with affected VA organizations. This will help ensure VA’s operating framework and organizational needs are considered prior to acquisitions.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 7,200,000.00
Audit of VHA’s Consolidated Mail Outpatient Pharmacy Program
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15-05255-422

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2016
We recommended the Under Secretary for Health ensure the Consolidated Mail Outpatient Pharmacies¿ Logistics Officer and Director or Associate Director review all inventory adjustments and approve adjustment documentation monthly as required by CMOP Inventory Management and Control national policy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2016
We recommended the Under Secretary for Health ensures Consolidated Mail Outpatient Pharmacy National Office implements a mechanism to validate self-reported data to ensure the reliability of its core quality metrics.
Audit of VBA's Post-9/11 G.I. Bill Tuition and Fee Payments
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14-05118-147

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/19/2017
We recommended the Acting Under Secretary for Benefits improve outreach by periodically requiring Education Liaison Representatives to review Post-9/11 G.I. Bill and Yellow Ribbon Program requirements, the School Certifying Official Handbook, and other available Veterans Benefits Administration training resources with School Certifying Officials to help them submit accurate and complete tuition and fee certifications.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/9/2018
We recommended the Acting Under Secretary for Benefits develop risk profiles for schools that are prone to certification problems, improper payments, and missed recoupments; and implement a process to periodically review and verify the certification information submitted by these schools.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/9/2018
We recommended the Acting Under Secretary for Benefits incorporate improper payment and missed recoupment risk factors into Veterans Benefits Administration’s risk-based system for the prioritization and completion of compliance surveys.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/23/2017
We recommended the Acting Under Secretary for Benefits revise the School Certifying Official Handbook to clarify guidance on allowable book and supply fees.
No. 5
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 10/25/2017
We recommended the Acting Under Secretary for Benefits review and strengthen Education Service policies and controls regarding the discontinuance and recoupment of payments, repeated classes, and satisfactory academic progress to ensure compliance with Federal regulations and prevent possible education benefits abuse.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/21/2017
We recommended the Acting Under Secretary for Benefits ensure that mitigating circumstances are properly verified and supporting documentation is obtained before tuition repayments are forgiven.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/9/2018
We recommended the Acting Under Secretary for Benefits initiate action to recover identified improper payments when collections are deemed appropriate and reasonable.
No. 8
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 9/30/2016
We recommended the Acting Under Secretary for Benefits review the identified missed recoupments to determine if collections would be appropriate and reasonable.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 2,270,000,128.00
Review of VBA’s Special Monthly Compensation Housebound Benefits
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15-02707-277

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/29/2016
We recommended the then Acting Under Secretary for Benefits establish a plan to update the electronic system to prevent staff from completing a decision without considering potential eligibility to statutory housebound benefits any time a veteran has a single 100 percent evaluation.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/27/2018
We recommended the then Acting Under Secretary for Benefits conduct a review of all veterans being paid compensation at the housebound rate with a combined evaluation of 90 percent or less and provide certification of completion of the review to the Office of Inspector General.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/5/2017
We recommended the then Acting Under Secretary for Benefits establish a plan to conduct periodic reviews of high-risk cases in which housebound benefits are being paid.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/5/2017
We recommended the then Acting Under Secretary for Benefits implement a plan to provide all decision-makers the updated special monthly compensation training and monitor the effectiveness of the training.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/9/2016
We recommended the then Acting Under Secretary for Benefits establish a plan to update the electronic system to ensure staff discontinue temporary housebound benefits when the criteria are no longer met.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/15/2017
We recommended the then Acting Under Secretary for Benefits remind staff of the requirements to use the Special Monthly Compensation Calculator in all special monthly compensation cases and include the results in the file, and implement a plan to ensure compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/9/2016
We recommended the then Acting Under Secretary for Benefits clarify the meaning of the term substantially confined for housebound in-fact benefits.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 154,400,000.00
OIG Determination of VHA Occupational Staffing Shortages
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16-00351-453
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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: 1/4/2018
We restated our previous recommendation that the Under Secretary for Health ensure that the Veterans Health Administration develops staffing models for critical need occupations, and we further recommend that the Veterans Health Administration sets forth milestones and a timetable for further critical need occupations’ staffing model development, piloting, and implementation.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
We restated our previous recommendation that the Under Secretary for Health review data on regrettable losses and consider implementing measures to reduce such losses.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
We recommended that the Under Secretary for Health consider incorporating data that predicts changes in veteran demand for health care into its staffing model.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
We recommended that the Under Secretary for Health assess the Veterans Health Administration’s resources and expertise in developing staffing models and determine whether exploration of external options to develop the above staffing model is necessary.
Combined Assessment Program Summary Report – Evaluation of Advance Directives in Veterans Health Administration Facilities
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16-03960-428

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/8/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that employees consistently ask inpatients whether they want to discuss advance directives and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/8/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when inpatients request a discussion about advance directives, clinicians consistently document that the discussion occurred using only the two Veterans Health Administration standardized note titles for advance directive discussions and that facility managers monitor compliance.
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