Date Issued
|
Report Number
13-01738-385
All Reports
Date Issued
|
Report Number
14-04307-399
Date Issued
|
Report Number
11-01391-377
Date Issued
|
Report Number
14-04819-394
Date Issued
|
Report Number
11-02258-378
Date Issued
|
Report Number
11-04093-379
Date Issued
|
Report Number
12-01041-381
Date Issued
|
Report Number
12-01081-382
Date Issued
|
Report Number
12-03705-383
Date Issued
|
Report Number
13-01419-384
Date Issued
|
Report Number
13-03380-386
Date Issued
|
Report Number
14-02790-393
Date Issued
|
Report Number
15-04231-223
Date Issued
|
Report Number
16-01613-326
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/29/2016
We recommended that the Under Secretary for Health ensure that the Veterans Health Administration establishes system-wide requirements for competency assessment and validation, including frequency, for nursing employees who provide post-anesthesia care after operational hours.
Date Issued
|
Report Number
13-02255-276
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 9/13/2017
We recommended the Acting Under Secretary for Benefits review the data on Federal incarcerations from May 2008 through June 2015 and issue bills of collection to recover improper payments made to veterans while they were incarcerated.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 9/13/2017
We recommended the Acting Under Secretary for Benefits review the data on Federal incarcerations from May 2008 through June 2015 and take action to make appropriate benefits adjustments and issue bills of collection to recover improper payments for veterans currently incarcerated in Federal penal institutions.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 9/13/2017
We recommended the Acting Under Secretary for Benefits increase the priority placed on the Federal incarceration adjustment workload by using monthly data on Federal incarcerations to make appropriate and timely compensation and pension benefits adjustments.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 9/24/2016
We recommended the Acting Under Secretary for Benefits monitor the terms of the current agreement with the Bureau of Prisons and take timely action to extend the agreement when appropriate.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 9/13/2017
We recommended the Acting Under Secretary for Benefits increase the priority placed on state and local incarceration adjustment workload by initiating timely development action after receiving notifications of incarceration from the Social Security Administration.
No. 6
to Veterans Benefits Administration (VBA)
Closure Date: 9/13/2017
We recommended the Acting Under Secretary for Benefits increase priority of state and local incarceration adjustment workload by making timely incarceration adjustments and issue bills of collection to recover improper payments, as appropriate, after providing due process notification to veterans.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 307,900,000.00
Date Issued
|
Report Number
15-01296-203
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/25/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic staff complete diagnostic assessments for patients with a positive alcohol screen and that managers monitor for compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/27/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic staff document the offer of further treatment to patients diagnosed with alcohol dependence and that managers monitor for compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/27/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that that clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care and that managers monitor for compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 4/21/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 4/21/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic providers and clinical associates receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Date Issued
|
Report Number
16-01040-324
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/1/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Risk Managers invite clinicians involved in Level 2 or 3 peer reviews to submit comments to and/or appear before the Peer Review Committee.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/25/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network managers, ensure Facility Directors review all privilege forms annually and document the review.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/10/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Medical Staff Coordinators complete the conversion from six-part to two-part credentialing and privileging folders and ensure non-allowed information is not placed in the folders.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 11/10/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Chiefs of Surgery discuss surgical deaths with identified problems in Surgical Work Group meetings.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 11/10/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities designate a committee to oversee safe patient handling activities, track patient handling injury data, and share data with safe patient handling champions.
Date Issued
|
Report Number
15-03700-283
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to National Cemetery Administration (NCA)
Closure Date: 5/14/2018
We recommended the Interim Under Secretary for Memorial Affairs rescind and replace Chapters 6 and 7 from Manual 40-2, National Cemeteries, Administration, Operation, and Maintenance.
No. 2
to National Cemetery Administration (NCA)
Closure Date: 1/17/2018
We recommended the Interim Under Secretary for Memorial Affairs recertify or rescind Directive 3170/1, Ceremonies and Special Events at VA National Cemeteries.
No. 3
to National Cemetery Administration (NCA)
Closure Date: 5/14/2018
We recommended the Interim Under Secretary for Memorial Affairs incorporate National Cemetery Administration’s three interim guidance documents into directives or handbooks.
No. 4
to National Cemetery Administration (NCA)
Closure Date: 11/4/2016
We recommended the Interim Under Secretary for Memorial Affairs develop mechanisms to ensure staff begin the process of updating guidance and compensate for the time needed to draft guidance and obtain staff concurrence.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 2/3/2017
We recommended the Under Secretary for Health recertify or rescind Veterans Health Administration’s three religious belief guidance documents that need to be updated.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 6/12/2017
We recommended the Under Secretary for Health develop mechanisms to ensure staff begin the process of updating guidance and compensate for the time needed to draft guidance and obtain staff concurrence.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 2/3/2017
We recommended the Under Secretary for Health provide staff a means to request senior official assistance, when necessary, to obtain timely agency-level concurrences.
Date Issued
|
Report Number
16-01489-311
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/14/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facility clinicians consistently include ‘inpatient’ in the inpatient consult title and that facility managers monitor compliance.
Date Issued
|
Report Number
15-04252-284
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/6/2017
We recommended the Under Secretary for Health ensure implementation of the corrective action plans included in VA’s Agency Financial Report to make procurement practices for the VA Community Care and Purchased Long Term Services and Support programs compliant with laws and regulations.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/15/2017
We recommended the Under Secretary for Health implement steps to achieve reduction targets or appropriately adjust them for the VA Community Care, Purchased Long Term Services and Support, Beneficiary Travel, and Supplies and Materials programs.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 2/2/2017
We recommended the Acting Under Secretary for Benefits implement steps to achieve reduction targets or appropriately adjust them for the Compensation, Education Chapter 1606, and Education Chapter 1607 programs.
No. 4
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 2/2/2017
We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction, implement steps to achieve reduction targets for the Disaster Relief Act-Hurricane Sandy program.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/15/2017
We recommended the Under Secretary for Health implement additional training for personnel who evaluate Improper Payment Elimination and Recovery Act samples for the Supplies and Materials program.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/27/2017
We recommended the Under Secretary for Health provide contracting expertise to the Improper Payment Elimination and Recovery Act review team, as needed.
No. 7
to Veterans Benefits Administration (VBA)
Closure Date: 3/3/2017
We recommended the Acting Under Secretary for Benefits develop a solution for correcting the concurrent payment of Compensation and Pension benefits and military drill pay and seek Office of Management and Budget assistance in coordinating a future resolution of the matter.