All Reports

Audit of VHA’s Non-VA Medical Care Obligations
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14-02465-47

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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

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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
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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
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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.
Review of VHA's Patient-Centered Community Care (PC3) Provider Network Adequacy
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15-00718-507

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2016
We recommended the Under Secretary for Health ensure the establishment of an adequate governance structure to oversee and improve Patient-Centered Community Care management and operations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2016
We recommended the Under Secretary for Health ensure adequate implementation and performance monitoring plans are developed for future high-dollar, complex health care initiatives.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2016
We recommended the Under Secretary for Health assess where Patient-Centered Community Care provider networks are inadequate and develop action plans to improve provider networks that are unable to provide health care services at the specific geographic locations identified.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2016
We recommended the Under Secretary for Health ensure the Patient-Centered Community Care Quality Assurance Surveillance Plan is revised to address the monitoring and measurement of network adequacy.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/7/2016
We recommended the Under Secretary for Health require the input of National Provider Identifier information for rendering providers in the Fee Basis Claims System to ensure adequate data are available for program evaluation and planning.
Administrative Investigation: Inappropriate Use of Position and Misuse of Relocation Program and Incentives in VBA
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15-02997-526

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/20/2016
We recommended the Deputy Secretary review the Department's request and approval process for the Appraised Value Option program and make improvements as deemed appropriate.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 3/22/2017
We recommended the Deputy Secretary review the Department’s request and approval process for temporary quarters subsistence expense allowance and make improvements as deemed appropriate.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/20/2016
We recommended the Deputy Secretary consult with the Office of General Counsel to determine whether Ms. Rubens should be issued a bill of collection for $123.50 to recoup the improper reimbursements paid to her for alcoholic beverages and unauthorized meals and tips.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/9/2017
We recommended the Deputy Secretary strengthen the approval process to include requiring an independent review of the Department’s Permanent Change of Station program to ensure moves and expenses are appropriate and justified.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 3/27/2017
We recommended the Deputy Secretary require the Veterans Benefits Administration to establish policies and procedures to standardize its practices regarding annual salary increases when reassigning Senior Executives’ positions.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 3/17/2016
We recommended the Deputy Secretary consult with the Office of General Counsel to determine whether bills of collection should be issued to recover unjustified relocation incentives paid by the Veterans Benefits Administration for Senior Executive reassignments.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 3/27/2017
We recommended the Deputy Secretary consult with the Office of General Counsel to determine what actions may be taken to hold the appropriate Senior Officials accountable for processing and approving payments of unjustified relocation incentive payments.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/20/2016
We recommended the Deputy Secretary confer with the Office of Human Resources and Administration, the Office of Accountability Review, and the Office of General Counsel to determine the appropriate administrative action to take, if any, against Ms. Rubens.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 3/17/2016
We recommended that the Deputy Secretary consult with the Office of General Counsel to determine whether a bill of collection should be issued to Ms. Rubens to recoup the $274,019 paid for expenses related to her relocation.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/20/2016
We recommended the Deputy Secretary confer with the Office of Human Resources and Administration, the Office of Accountability Review, and the Office of General Counsel to determine the appropriate administrative action to take, if any, against Ms. Graves.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 3/17/2016
We recommended that the Deputy Secretary consult with the Office of General Counsel to determine whether a bill of collection should be issued to Ms. Graves to recoup the $129,468 paid for expenses related to her relocation.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/20/2016
We recommended the Deputy Secretary confer with the Office of Human Resources and Administration, the Office of Accountability Review, and the Office of General Counsel to determine the appropriate administrative action to take, if any, against Ms. Hickey, Mr. Pummill, and Ms. McCoy.
Follow-up Review of VA’s Veterans Benefits Management System
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13-00690-455

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No. 1
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA),Information and Technology (OIT)
Closure Date: 9/14/2015
We recommended the Executive in Charge for the Office of Information and Technology, in conjunction with the Under Secretary for Benefits, implement improved cost controls and stabilize Veterans Benefits Management System functionality requirements for the remainder of planned system development to restrict further cost increases.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA),Information and Technology (OIT)
Closure Date: 5/13/2016
We recommended the Executive in Charge for the Office of Information and Technology, in conjunction with the Under Secretary for Benefits, perform a formal budget versus cost analysis to identify actual costs expended in support of the Veterans Benefits Management System development effort.
No. 3
Not Implemented Recommendation Image, X character'
to Information and Technology (OIT)
Closure Date: 9/14/2015
We recommended the Executive in Charge for the Office of Information and Technology perform market analyses on all future Space and Naval Warfare Systems Command Atlantic task orders to determine whether the continued use of the interagency agreements is in the best interest of the Department.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA),Information and Technology (OIT)
Closure Date: 2/21/2018
We recommended the Executive in Charge for the Office of Information and Technology, in conjunction with the Under Secretary for Benefits, establish a clear strategy and plan to decommission legacy systems, eliminate redundant systems operations, and reduce system maintenance costs.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA),Information and Technology (OIT)
Closure Date: 8/9/2016
We recommended the Executive in Charge for the Office of Information and Technology, in conjunction with the Under Secretary for Benefits, fully develop and implement Veterans Benefits Management System electronic workflow and workload brokering functionality to facilitate more efficient claims processing.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA),Information and Technology (OIT)
Closure Date: 3/23/2016
We recommended the Executive in Charge for the Office of Information and Technology, in conjunction with the Under Secretary for Benefits, provide adequate training with each Veterans Benefits Management System release to ensure VA Regional Office users fully benefit from the enhanced functionality provided.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/23/2016
We recommended the Executive in Charge for the Office of Information and Technology implement an improved Veterans Benefits Management System network infrastructure to mitigate single points of failure and reduce the network performance issues across the enterprise.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA),Information and Technology (OIT)
Closure Date: 3/23/2016
We recommended the Executive in Charge for the Office of Information and Technology, in conjunction with the Under Secretary for Benefits, develop sufficient Veterans Benefits Management System performance metrics to demonstrate the system is improving VA¿s ability to efficiently process claims as compared to legacy practices.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/13/2016
We recommended the Executive in Charge for the Office of Information and Technology minimize the use of manual requirements tracking processes and maximize the use of automated application lifecycle management tools to manage requirements traceability in accordance with industry best practices.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 27,000,000.00
Review of Alleged Mismanagement at the Health Eligibility Center
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14-01792-510

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2016
We recommended the Under Secretary for Health provide guidance concerning how long applications may remain pending before reaching a final determination.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/22/2016
We recommended the Under Secretary for Health assign an accountable official responsible to implement a plan to correct current data integrity issues in the Enrollment System.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/25/2016
We recommended the Under Secretary for Health develop and execute a project management plan to ensure that Enrollment System data are fully evaluated and properly categorized.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2016
We recommended the Under Secretary for Health implement controls to ensure that future enrollment data are accurate and reliable before being entered in the Enrollment System.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2016
We recommended the Under Secretary for Health implement effective policies and procedures to accurately and timely identify deceased individuals with records in the Enrollment System and record their changed status in the system.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/25/2016
We recommended the Under Secretary for Health establish appropriate policies and procedures to ensure Health Eligibility Center workload data are not deleted or changed without appropriate management review, approval, and audit trails.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/22/2016
We recommended the Under Secretary for Health implement mechanisms to ensure that privileges and access rights to Health Eligibility Center workload data are based upon specific job duties and the need to know.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2016
We recommended the Under Secretary for Health confer with the Office of Human Resources and the Office of General Counsel to fully evaluate the implications of the first three allegations, determine if administrative action should be taken against any senior Veterans Health Administration officials involved, and ensure that appropriate action is taken.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/22/2016
We recommended that the Assistant Secretary for Information and Technology implement adequate security controls to enforce separation of duties and role-based access control for Workload Reporting and Productivity tool developers and administrators.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/21/2016
We recommended that the Assistant Secretary for Information and Technology implement adequate security controls to enforce separation of duties and role-based access control for Workload Reporting and Productivity tool developers and administrators.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/21/2016
We recommended that the Assistant Secretary for Information and Technology develop a monthly schedule to test whether Health Eligibility Center workload data are backed up properly and to provide the results of such testing to the Chief Business Office.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/29/2016
We recommended the Assistant Secretary for Information and Technology confer with the Office of Human Resources and the Office of General Counsel to fully evaluate the implications of the lack of controls over the Workload Reporting and Productivity tool, determine if administrative action should be taken against any senior Office of Information Technology officials involved, and ensure that appropriate action is taken.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/22/2016
We recommended the Under Secretary for Health perform monthly comparisons between Workload Reporting and Productivity reports and enrollment records to ensure the timely processing of applications and related documents.
OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages
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15-03063-511
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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: 9/28/2016
We recommended that the Under Secretary for Health ensure that the Veterans Health Administration further develops staffing models for critical need occupations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2016
We recommended that the Under Secretary for Health review the data on regrettable losses in this report and Veterans Integrated Service Network Workforce Succession Strategic Plans and, if appropriate, consider implementing measures to reduce such losses.
Audit of Fiduciary Program Controls Addressing Beneficiary Fund Misuse
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13-03922-453

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/27/2015
We recommended the Under Secretary for Benefits revise policy to require timely removal of a fiduciary from all assigned beneficiaries when an individual case of misuse has been determined.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/27/2017
We recommended the Under Secretary for Benefits retroactively establish debts for all fiduciaries who VBA determined misused beneficiary funds during calendar year 2013.
No. 3
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 8/27/2015
We recommended the Under Secretary for Benefits revise policy to include clear timeliness standards from the time the hubs determine misuse occurred to the time Pension and Fiduciary Service completes the negligence determination.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/7/2017
We recommended the Under Secretary for Benefits ensure the processing of all misuse actions are incorporated into quality reviews of Fiduciary Program operations.
Audit of VHA’s Efforts To Improve Veterans’ Access to Outpatient Psychiatrists
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13-03917-487

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2016
We recommended the Under Secretary for Health ensure Veteran Integrated Service Networks and facilities incorporate the Office of Mental Health Operations staffing model to determine the appropriate number of psychiatrists needed for outpatient care, and work with those facilities to attain appropriate staffing levels or identify alternative options to meet veteran demand for psychiatrists.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/1/2016
We recommended the Under Secretary for Health develop clinic management business rules to ensure facilities consistently monitor the use of clinical time and number of veterans per psychiatrist, in conjunction with monitoring psychiatrists’ productivity.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/1/2016
We recommended the Under Secretary for Health reassess the appropriateness of the Veterans Health Administration’s productivity target for psychiatrists.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 567,000,000.00
Administrative Investigation, Improper Use of Web-based Collaboration Technology, Office of Information and Technology
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13-03054-463

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2016
We recommend that the VA Chief of Staff confer with the Offices OIT, OPIA, and General Counsel (OGC) to ensure that VA Yammer is formally evaluated, approved, and/or disapproved for VA use. If approved, ensure it meets all Federal laws and regulations, as well as VA policy and guidance. If disapproved, ensure that all VA employees cannot access it from VA-issued equipment or VA's network.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2016
We recommend that the VA Chief of Staff confer with the Offices of Human Resources (OHR), Accountability Review (OAR), and OGC to determine the appropriate administrative action to take, if any, against accountable OIT and OPIA officials, as well as other VA and contractor employees involved in this particular matter.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommend that the VA Chief of Staff ensure that all VA employees are made fully aware of which Web-based collaboration technologies VA has approved for their use and which are prohibited.
Review of Alleged Mismanagement of VHA's Service-Oriented Architecture Research and Development Pilot Project
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14-00545-343

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2015
We recommended the Under Secretary for Health establish an oversight mechanism to ensure the use of proper appropriations for Veterans Health Administration information technology projects.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2017
We recommended the Under Secretary for Health remedy all Medical Support and Compliance appropriations used to pay for Service-Oriented Architecture Research and Development.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2016
We recommended the Under Secretary for Health confer with VA’s Office of Accountability Review regarding administrative actions against Veterans Health Administration senior officials, beyond those individuals who have left VA employment, who were involved with Service-Oriented Architecture Research and Development funding decisions and ensure that action is taken, if appropriate.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/16/2016
We recommended the Executive in Charge, Office of Information and Technology, obtain Chief Financial Officer certifications from responsible VA Administrations or Staff Offices that proper appropriations will be used before using any non-Information Technology Systems appropriations for any information technology project, including projects managed by the Project Management Accountability System.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 2,600,000.00
Healthcare Inspection – Review of the Operations and Effectiveness of VHA Residential Substance Use Treatment Programs
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15-01579-457

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: 6/20/2016
We recommended that Mental Health Services liaison with internal and external entities regarding standardized data collection from screening processes to core outcome measures to improve program monitoring and by which Mental Health Services can develop collaborative treatment initiatives.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2016
We recommended that Mental Health Services ensure system-wide use of the 596 stop code.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2016
We recommended that Mental Health Services review the consistency of current processes and provides specific guidance on reducing inflow of contraband into residential substance use treatment programs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2016
We recommended that Mental Health Services consider requiring programs to document patients' physical status in addition to presence when completing physical bed checks.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2016
We recommended that Mental Health Services clarify the intent of the requirement for and use of closed circuit television with respect to residential substance use programs.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2016
We recommended that Mental Health Services review and evaluate whether reversal agents such as naloxone are readily available at each residential substance use treatment program.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2016
We recommended that Mental Health Services encourage more widespread incorporation of programming with a specialized focus on mental health comorbidities.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2016
We recommended that Mental Health Services encourage discussion of addiction focused pharmacotherapy with residential substance use treatment program patients.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2016
We recommended that Mental Health Services ensure that active mental health comorbidities are addressed in residential substance use rehabilitation treatment program interdisciplinary treatment plans.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2016
We recommended that Mental Health Services ensure documentation of post-discharge aftercare appointment arrangements for mental health comorbidities.
Improper Use of Title 38 Section 8153 Contracts to Fund Educational Costs of the Graduate Medical Education Programs of Affiliated Schools of Medicine
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14-04259-409

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: 7/7/2015
We recommend that the Interim Under Secretary for Health rescind VHA Handbook 1400.10.
No. 2
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 7/7/2015
We recommend that the Interim Under Secretary for Health terminate existing contracts for indirect educational costs awarded under the guidance of VHA Handbook 1400.10.
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