All Reports

Review of Alleged Lack of Access Controls for VA's Project Management Accountability System (PMAS) Dashboard
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15-02459-260

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/3/2018
We recommended the Assistant Secretary for Information and Technology create read-only access capability for the Project Management Accountability System.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/3/2018
We recommended the Assistant Secretary for Information and Technology assess the current level of each user’s access to the Project Management Accountability System Dashboard to ensure each user’s access is based on the least privilege needed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/3/2018
We recommended the Assistant Secretary for Information and Technology develop Project Management Accountability System Dashboard access logs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/3/2018
We recommended the Assistant Secretary for Information and Technology periodically review Project Management Accountability System Dashboard access logs to ensure users have a need for system access.
Combined Assessment Program Summary Report – Evaluation of Safe Medication Storage Practices in Veterans Health Administration Facilities
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16-00693-269

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities’ policies include automated dispensing machine user training and competency assessment requirements and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that employees perform and document monthly inspections of all medication storage areas and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when employees identify deficiencies during medication storage area inspections, they document corrective actions and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities have oral syringes available for medication administration and clearly label and store them separately from parenteral syringes and that facility managers monitor compliance.
Review of Claims-Related Documents Pending Destruction at VA Regional Offices
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15-04652-146

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/14/2019
We recommended the Acting Under Secretary for Benefits revise Veterans Benefits Administration’s Policy on Management of Veterans’ and Other Governmental Paper Records to ensure documents printed from Veterans Benefits Management System are clearly identified.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/5/2018
We recommended the Acting Under Secretary for Benefits revise Veterans Benefits Administration’s Policy on Management of Veterans’ and Other Governmental Paper Records to include detailed, standardized procedures for the collection and review of material by records management staff at VA Regional Offices.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/5/2018
We recommended the Acting Under Secretary for Benefits implement a plan to ensure all claims-related documents receive the mandated levels of review to comply with Veterans Benefits Administration’s policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/15/2017
We recommended the Acting Under Secretary for Benefits implement a plan that requires supervisors to conduct periodic reviews of employees’ red boxes and track all shredding policy violations they identify.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/5/2018
We recommended the Acting Under Secretary for Benefits implement a plan to ensure records management staff comply with Veterans Benefits Administration’s policy to track all shredding violations they identify.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/23/2017
We recommended the Acting Under Secretary for Benefits implement a plan to ensure management and staff receive refresher training on the proper handling of both claims-related and non-claims-related documents.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/23/2017
We recommended the Acting Under Secretary for Benefits develop specific procedures regarding the maintenance and disposition of congressional correspondence.
Combined Assessment Program Summary Report - Evaluation of Emergency Airway Management in Veterans Health Administration Facilities
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16-00969-257

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure facilities’ policies include plans for managing difficult airways.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facility clinical managers provide all required initial training for designated employees who will perform airway management and ensure initial competency assessment includes all required testing and demonstration and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facility clinical managers include all required elements in airway management competency reassessments and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility clinical managers ensure competent clinicians provide emergency airway management during all hours of patient care unless the facility is exempt and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facility clinical managers conduct root cause analyses when clinicians without demonstrated airway management competency perform emergency intubations and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility clinical managers ensure scopes of practice for non-licensed independent practitioners who perform airway management include a statement related to airway management and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility Chiefs of Staff ensure clinicians complete required training and experience within a short timeframe after recommending airway management privileges and that facility managers monitor compliance.
Review of Alleged Noncompliance With Section 508 of the Rehabilitation Act on MyCareer@VA Web Site
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15-02781-153

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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: 8/31/2016
We recommended the Assistant Secretary for Human Resources and Administration correct all Section 508 compliance issues with the MyCareer@VA Web site and seek certification of Section 508 compliance from the appropriate component within VA Section 508.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 8/31/2016
We recommended the Assistant Secretary for Human Resources and Administration develop and implement a process to ensure their products conform with Section 508 requirements prior to their deployment, which includes defining what support is required to document a product¿s compliance with Section 508 requirements.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 8/31/2016
We recommended the Assistant Secretary for Human Resources and Administration provide and require training for all individuals involved in developing and maintaining products to ensure they are aware of the requirements and expectations for conformance with Section 508 requirements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 2/22/2019
We recommended the Assistant Secretary for Information and Technology strengthen policy to ensure Electronic and Information Technology products are compliant with Section 508 prior to their deployment, which includes providing an expectation of when to establish compliance, how to document compliance, and what specifically constitutes compliance with Section 508.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 34,011.00
Audit of VA's Conference Management for Fiscal Year 2014
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15-01227-129

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 1/13/2017
We recommended the Interim Assistant Secretary for Management update existing guidance to address if and when a Conference Package may be used to summarize the budgets for multiple events and how to present the budget for each event to ensure adequate line item detail for each event.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 1/13/2017
We recommended the Interim Assistant Secretary for Management update existing guidance to address how to present line item detail of expenditures in the Final Conference Reports if the approved Conference Package was for multiple events to ensure traceability to source documents.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 1/31/2017
We recommended the Interim Assistant Secretary for Management establish review procedures that ensure Conference Packages and Final Conference Reports comply with law and VA policy and report the results to the Deputy Secretary or VA Chief of Staff.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 1/31/2017
We recommended the Interim Assistant Secretary for Management update existing policy to provide adequate accountability to ensure that VA organizations comply with conference policies.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 1/31/2017
We recommended the Interim Assistant Secretary for Management update existing policy to reinstate the Conference Certifying Official as the reviewer of the Conference Package instead of the Responsible Conference Executive.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 1/31/2017
We recommended the Interim Assistant Secretary for Management update existing policy to reinstate the Corporate Travel Reporting Office review of Conference Packages with a budget of $100,000 or more before submitting the package for Deputy Secretary or Secretary approval.
VA’s Federal Information Security Modernization Act Audit for Fiscal Year 2015
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15-01957-100

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the 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 modified repeat recommendation from prior years.)
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology formally authorize Health Eligibility Center systems to operate in accordance with VA information security standards. (This is a new recommendation.)
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology implement clear roles, responsibilities, and accountability for developing, maintaining, completing, and reporting Plans of Action and Milestones. (This is a repeat recommendation from prior years.)
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology implement mechanisms to ensure Plans of Action and Milestones are updated to accurately reflect current status information. (This is a repeat recommendation from prior years.)
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology implement mechanisms to ensure sufficient supporting documentation is captured in the central Governance Risk and Compliance tool to justify closure of Plans of Action and Milestones. (This is a repeat recommendation from last year.)
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology implement improved processes to ensure that all identified weakness are incorporated into Governance Risk and Compliance tool, in a timely manner, and corresponding POA&Ms are developed to track corrective actions and remediation. (This is a new recommendation.)
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the 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 update Enterprise Operation¿s version of the tool to reflect NIST 800-53 Revision 4 controls. (This is a new recommendation.)
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the 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 last year.)
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the 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 last year.)
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the 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. 11
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology implement periodic access 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. 12
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology enable system audit logs and conduct centralized reviews of security violations on mission-critical systems. (This is a repeat recommendation from prior years.)
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology fully implement two-factor authentication for all local and remote access methods throughout the agency. (This is a repeat recommendation from prior years.)
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology implement mechanisms to ensure all remote access computers have updated security patches and antivirus definitions prior to connecting to VA information systems. (This is a repeat recommendation from prior years.)
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology implement more effective automated mechanisms to continuously identify and remedy security deficiencies on VA¿s network infrastructure, database platforms, and Web application servers. (This is a repeat recommendation from last year.)
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the 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 work stations. (This is a repeat recommendation from last year.)
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology maintain complete and accurate baseline configurations and ensure all baselines are appropriately implemented and checked for compliance with established VA security standards. (This is a modified repeat recommendation from last year.)
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology implement improved network access controls to ensure medical devices and non-OI&T managed networks are appropriately segregated from general networks and mission-critical systems. (This is a repeat recommendation from last year.)
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology consolidate the security responsibilities for non-OI&T networks present under a common control for each site and ensure vulnerabilities are remedied in a timely manner. (This is a modified repeat recommendation from last year.)
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology implement 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 last year.)
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology implement processes to ensure information system contingency plans are updated with the required information. (This is a repeat recommendation from last year.)
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology develop and implement a process for ensuring the encryption of backup data prior to transferring the data offsite for storage. (This is a repeat recommendation from prior years.)
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology implement improved processes for the testing of contingency plans and failover capabilities for major applications and general support systems to ensure that critical components can be recovered at an alternate site in the event of a system failure or disaster. (This is a new recommendation.)
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology perform and document a Business Impact Analysis for all systems and incorporate the results into an overall strategy development effort for contingency planning. (This is a new recommendation.)
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology implement more effective agency-wide incident response procedures to ensure timely resolution of computer security incidents in accordance with VA set standards. (This is a repeat recommendation from prior years.)
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology identify all external network interconnections and implement improved processes for monitoring all VA internal networks, systems, and exchanges for unauthorized activity. (This is a repeat recommendation from last year.)
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology implement improved safeguards to prevent data exfiltration from VA networks. (This is a new recommendation.)
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology fully develop a comprehensive list of approved and unapproved software and implement continuous monitoring processes to identify and 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 Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the 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 Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology implement procedures for overseeing contractor-managed cloud-based systems and ensuring information security controls adequately protect VA sensitive systems and data. (This is a repeat recommendation from last year.)
No. 31
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology implement mechanisms for updating the Federal Information Security Modernization Act systems inventory, including contractor-managed systems and interfaces, and annually review the systems inventory for accuracy. (This is a repeat recommendation from last year.)
No. 32
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology update all applicable position descriptions to better describe position sensitivity levels, and improve documentation of personnel records of ¿Rules of Behavior¿ and annual privacy training certifications.
No. 33
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology ensure appropriate levels of background investigations be completed for all personnel in a timely manner, implement processes to monitor and ensure timely reinvestigations on all applicable employees and contractors, and monitor the status of the requested investigations.
No. 34
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology reduce wireless security vulnerabilities by ensuring sites have up-to-date mechanisms to protect against interception of wireless signals and unauthorized access to the network, and ensure the wireless network is segmented from the general network.
No. 35
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/21/2017
We recommended the Assistant Secretary for Information and Technology identify and deploy solutions to encrypt sensitive data and resolve clear text protocol vulnerabilities.
Follow-Up Audit of VBA's Internal Controls Over Disability Benefits Questionnaires
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14-02384-45

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: 12/15/2017
We recommended the Acting Under Secretary for Benefits evaluate options for electronically capturing and analyzing information contained on completed Disability Benefits Questionnaires and implement the most cost effective option. (Similar to recommendation from 2012 Office of Inspector General audit report)
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/5/2017
We recommended the Acting Under Secretary for Benefits revise the remaining 59 public-use Disability Benefits Questionnaires to provide veterans and clinicians adequate notification regarding verification of submitted information.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/14/2016
We recommended the Acting Under Secretary for Benefits establish policies and procedures for determining if clinicians who prepare public-use Disability Benefits Questionnaires are private or Veterans Health Administration clinicians.
No. 4
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 3/2/2018
We recommended the Acting Under Secretary for Benefits revise policies and procedures to include steps for obtaining missing public-use Disability Benefits Questionnaires clinician information and verifying clinicians have an active medical license. (Similar to recommendation from 2012 Office of Inspector General audit report)
No. 5
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 2/25/2016
We recommended the Acting Under Secretary for Benefits revise Veterans Affairs Regional Office quality assurance review methodologies to review appropriate samples of claims including public-use Disability Benefits Questionnaires.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
We recommended the Acting Under Secretary for Benefits revise local quality assurance reviews to evaluate Veterans Affairs Regional Office compliance with Disability Benefits Questionnaires’ special-issue indicator requirements.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/4/2016
We recommended the Acting Under Secretary for Benefits revise local quality assurance reviews to evaluate Veterans Affairs Regional Office compliance with public-use Disability Benefits Questionnaires’ clinician information completeness requirements.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/26/2016
We recommended the Acting Under Secretary for Benefits establish procedures requiring Compensation Service Disability Examination Management staff to analyze local quality assurance review results to identify systemic issues related to compliance with Disability Benefits Questionnaires’ special-issue indicator and clinician information completeness requirements.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/14/2018
We recommended the Acting Under Secretary for Benefits establish procedures requiring Veterans Affairs Regional Office staff to receive recurring training on systemic issues identified during analyses of local quality assurance review results related to compliance with Disability Benefits Questionnaires’ special-issue indicator and clinician information completeness requirements.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/20/2017
We recommended the Acting Under Secretary for Benefits require Veterans Benefits Administration’s Compensation Service Disability Examination Management staff to conduct annual validation reviews that select samples from a complete universe of claims with public-use Disability Benefits Questionnaires and focus on public-use Disability Benefits Questionnaires that pose an increased risk of fraud. (Similar to recommendation from 2012 Office of Inspector General audit report)
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/11/2016
We recommended the Acting Under Secretary for Benefits revise policies and procedures to include follow-up actions for inadequate public-use Disability Benefits Questionnaires.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/11/2016
We recommended the Acting Under Secretary for Benefits revise the Systematic Technical Accuracy Review checklists and local quality assurance reviews to evaluate whether claims processors use adequate public-use Disability Benefits Questionnaires instead of obtaining unnecessary Veterans Health Administration compensation and pension examinations.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/11/2016
We recommended the Acting Under Secretary for Benefits establish procedures requiring Compensation Service Disability Examination Management staff to analyze local quality assurance review results to identify systemic issues related to public-use Disability Benefits Questionnaires, including unnecessary Veterans Health Administration compensation and pension examinations.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/14/2018
We recommended the Acting Under Secretary for Benefits establish procedures requiring Veterans Affairs Regional Office staff to receive recurring training on systemic issues identified during analyses of local quality assurance review results related to public-use Disability Benefits Questionnaires, including unnecessary Veterans Health Administration compensation and pension examinations.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 24,000,000.00
Audit of VHA’s Non-VA Medical Care Obligations
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14-02465-47

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 4/4/2018
We recommended that the Under Secretary for Health improve cost estimation tools to ensure adequate Non-VA Care cost estimates are produced consistently.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/28/2016
We recommended that the Under Secretary for Health implement a mechanism to ensure that VA medical facilities perform ongoing reviews and adjust cost estimates for individual authorized services to better reflect actual costs.
No. 3
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 4/4/2018
We recommended that the Under Secretary for Health update Fee Basis Claims System software to ensure inpatient authorizations can be periodically adjusted when the scope of patient care is fully known.
No. 4
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 4/4/2018
We recommended that the Under Secretary for Health update Fee Basis Claims System software to allow the system to automatically deobligate unused funds when Non-VA Care staff indicate payments for the authorized services are complete.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2016
We recommended that the Under Secretary for Health implement a mechanism to monitor how effectively VA medical facilities are estimating Non-VA Care obligations.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 358,000,000.00
Combined Assessment Program Summary Report – Evaluation of Magnetic Resonance Imaging Safety in Veterans Health Administration Facilities
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15-03804-38

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 Health Administration (VHA)
Closure Date: 8/3/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that employees consistently conduct initial magnetic resonance imaging patient safety screenings.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Level 2 magnetic resonance imaging personnel consistently document when they review the second magnetic resonance imaging patient safety screening forms.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Level 2 magnetic resonance imaging personnel document resolution of all identified potential contraindications prior to the magnetic resonance imaging exam.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities routinely conduct contrast reaction drills in magnetic resonance imaging areas.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/2/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that all designated Level 1 ancillary employees receive annual level-specific magnetic resonance imaging safety training.
Combined Assessment Program Summary Report – Evaluation of Acute Ischemic Stroke Care in Veterans Health Administration Facilities
|
15-03803-26

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/30/2016
We recommended that the Under Secretary for Health improve the availability of expertise in stroke treatment across the system.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/6/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure compliance with stroke care requirements, including prompt and thorough assessment, treatment, and patient education, and ensure the gathering and reporting of required stroke data elements.
Audit of the Seismic Safety of VA’s Facilities
|
14-04756-32

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 11/2/2017
We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction establish policy requiring medical facilities to conduct detailed seismic studies for all critical and essential buildings located in high and very high seismic zones that have not already undergone detailed seismic studies.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 4/21/2016
We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction revise its Facility Condition Assessment guidance to require Facility Condition Assessment contractors to review structural design documents for buildings that have completed seismic retrofit projects.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 4/21/2016
We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction revise its Facility Condition Assessment guidance to ensure conditions of seismically unsafe buildings are properly reported on assessment reports.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2016
We recommended the Under Secretary for Health ensure medical facilities submit construction project applications, in a timely manner, for all identified seismically unsafe structural and nonstructural deficiencies.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 4/21/2016
We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction ensure that Facility Condition Assessment contractors include specific and detailed descriptions of nonstructural seismic deficiencies in their assessments.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 4/21/2016
We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction ensure its contracting officers obtain copies of seismic certificates or plans to mitigate seismic deficiencies from lessors prior to executing lease agreements or renewals.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended the Under Secretary for Health ensure its contracting officers obtain copies of seismic certificates or plans to mitigate seismic deficiencies from lessors prior to executing lease agreements or renewals.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/2/2017
We recommended the Acting Assistant Secretary for Management revise VA Directive 7415 to mandate that enhanced use lease agreements require developers to certify the seismic safety of buildings or to have a plan for mitigating identified seismic deficiencies prior to renewal or execution of new facility use agreements with VA organizations.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2020
We recommended the Under Secretary for Health develop policies and procedures requiring VHA medical facilities to develop and test Continuity of Operations Plans, to include documenting the testing performed, in accordance with Federal Continuity Directive 1 requirements.
Healthcare Inspection – Alleged Program Inefficiencies and Delayed Care, Veterans Health Administration’s National Transplant Program
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15-00187-25

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2016
We recommended that the Under Secretary for Health review the extent of delays in responses to referrals for transplant evaluations; assess the risk, if any, posed by those delays; and, take appropriate action to ensure timely responses to referrals for liver transplant evaluations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2016
We recommended that the Under Secretary for Health review the extent of delays in initial patient evaluations for transplantation; assess the risk, if any, posed by those delays; and, take appropriate action to ensure timely initial patient evaluations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2016
We recommended that, after reviewing the circumstances of delays in responses to referrals and initial patient evaluations for transplantation, the Under Secretary for Health take action to confirm that any patients who experienced delayed care that presented risks received appropriate care.
Review of Patient-Centered Community Care (PC3) Health Record Coordination
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15-00574-501

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/23/2016
We recommended the Under Secretary for Health implement a mechanism to ensure payments are not made to Patient-Centered Community Care contractors until all required clinical documentation is received.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2016
We recommended the Under Secretary for Health enforce Patient-Centered Community Care contract performance requirements to ensure that contractors return complete clinical documentation timely.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/23/2016
We recommended the Under Secretary for Health implement a mechanism to verify contractors¿ performance without relying on contractors¿ self-reported data.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/30/2016
We recommended the Under Secretary for Health complete a review of TriWest's performance and apply penalties if it is determined there is a lack of performance related to the timely return of clinical documentation.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2016
We recommended the Under Secretary for Health review the contract disincentives applied to HealthNet and determine if additional funds need to be recouped from the contractor and pursue collection if disincentives were under applied.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2016
We recommended the Under Secretary for Health ensure that Patient-Centered Community Care contractors annotate on all diagnostic imaging reports and non-imaging-related critical findings submitted to VA the name of the VA person contacted, and the date and time of the contact.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/30/2016
We recommended the Under Secretary for Health implement procedures to verify whether Patient-Centered Community Care contractors and their network providers correctly and timely report critical findings to VA and impose financial penalties or other remedies when contractors fall below the contract performance threshold.
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