All Reports

Combined Assessment Program Summary Report - Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2012
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12-01480-183

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/24/2013
We recommended that the Under Secretary for Health, in conjunction with VISN senior managers, ensures that facility directors and Patient Safety Officers sit on the high-level committees that review QM results.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/24/2013
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that completed corrective actions related to protected peer review are reported to the PRC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/31/2013
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that FPPEs for newly hired licensed independent practitioners are initiated and completed and that results are reported to the MEC.
-Interim Report - Participation in VBA's Veterans Retraining Assistance Program
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12-04524-171

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/10/2013
We recommend the Under Secretary for Benefits continue to issue certificates of eligibility until either 99,000 veterans have enrolled in an approved training program or until October 1, 2013, whichever occurs first.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/10/2013
We recommend the Under Secretary for Benefits revise the Veterans Retraining Assistance Program certificate of eligibility letter to inform veterans that Veterans Benefits Administration will only pay benefits to a limited number of veterans.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/10/2013
We recommend the Under Secretary for Benefits contact the veterans currently holding a certificate of eligibility, who have not yet enrolled in the approved training, and inform them that VBA will pay benefits only to a limited number of veterans. Inform the veterans they will need to check the VRAP Web site or contact VBA to confirm benefits are still available before enrolling in an approved training program.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/10/2013
We recommend the Under Secretary for Benefits provide retroactive benefits to VRAP participants (not to exceed the FY 2012 authorization) who were enrolled in an approved training program in FY 2012, but did not receive benefits before October 1, 2012.
Healthcare Inspection - Evaluation of Cataract Surgeries and Outcomes in VHA Facilities
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11-02487-158

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2013
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, monitor and ensure consistent verification and documentation of preoperative intraocular lens implant verification in the electronic health record for all cataract surgeries.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2013
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure the analysis of OSOD data and dissemination of associated quality improvement processes to VA cataract surgery facilities.
Healthcare Inspection - Improper Conduct During Merit Review Proceedings
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12-02317-144

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/3/2013
To ensure the integrity of the Merit Review process and the appropriateness of funding Dr. Y's research, we recommend that ORD conduct an Administrative Board of Investigation into Dr. X's actions and their consequent effects on the outcome of the review process, and to take appropriate actions, as indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/3/2013
We recommend that ORD consider making modifications to the review process such as: (a) prohibiting SRG members from attending meetings where a spouse's (or immediate family member's) proposal is scheduled for discussion; (b) not posting reviewers' identities prior to the formal SRG group discussion; (c) blinding proposals so that reviewers cannot easily identify the author; and (d) requesting SRG members specify the proposals they are competent to review, but not asking for preferences or selection of primary, secondary, or tertiary reviewer roles.
Review of VA’s Compliance with the Improper Payments Elimination and Recovery Act for FY 2012
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12-04241-138

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2013
We recommended the Under Secretary for Health implement its corrective action plan, as described in the Performance and Accountability Report, for reducing improper payments in the Non-VA Care Fee program.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2013
We recommended the Under Secretary for Health develop achievable reduction targets for the Non-VA Care Fee program.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2013
We recommended the Under Secretary for Health implement an improper payments estimation methodology that will achieve the required statistical precision for reporting on performance in meeting requirements of the Improper Payments Elimination and Recovery Act.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/26/2013
We recommended the Under Secretary for Benefits develop and implement a statistically valid estimation methodology for the Compensation, Pension, and Vocational Rehabilitation and Employment programs for reporting on performance in meeting requirements of the Improper Payments Elimination and Recovery Act.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/13/2013
We recommended the Under Secretary for Benefits develop a process to collect and report the required improper payments recapture information.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/13/2013
We recommended the Executive in Charge for the Office of Management and Chief Financial Officer complete planned activities to improve compliance with the Improper Payments Elimination and Recovery Act and use this information to develop and issue additional guidance.
Healthcare Inspection - Management of Disruptive Patient Behavior at VA Medical Facilities
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11-02585-129

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/27/2013
We recommended that the Under Secretary for Health ensure that VHA program officials provide additional guidance on what constitutes disruptive behavior and establish common terminology.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2015
We recommended that the Under Secretary for Health ensure that VHA program officials develop guidelines for what information VHA facilities should document regarding disruptive incidents and where this information should be documented.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2013
We recommended that the Under Secretary for Health ensure that VHA program officials provide guidance to VHA facilities on collecting and analyzing data on disruptive incidents.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/24/2013
We recommended that the Under Secretary for Health consider implementing a national reporting system or data collection template for disruptive patient incidents.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/27/2013
We recommended that the Under Secretary for Health ensure that VHA facilities implement procedures to ensure more timely assignment of Category I PRFs.
Review of Alleged Transmission of Sensitive VA Data Over Internet Connections
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12-02802-111

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No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommend the Assistant Secretary for Information and Technology require that OIT personnel complete specialized training emphasizing the importance of encrypting sensitive VA data transmitted across public Internet connections.
Healthcare Inspection – Foot Care for Patients with Diabetes and Additional Risk Factors for Amputation
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11-00711-74

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/20/2014
We recommended that the Under Secretary for Health implement a plan to ensure compliance with VHA's requirement that patients who are at moderate or high risk for amputation be examined by a foot care specialist at least once each year.
Audit of VHA's Physician Staffing Levels for Specialty Care Services
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11-01827-36

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2013
The Office of Inspector General recommends that the Under Secretary for Health approve a plan by the end of FY 2013 that ensures all specialty care services have productivity standards within 3 years.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2013
The Office of Inspector General recommends that the Under Secretary for Health establish productivity standards for at least five specialty care services by the end of FY 2013 and ensure medical facility personnel compare physician workload against these standards.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2013
The Office of Inspector General recommends that the Under Secretary for Health provide medical facility directors with more specific guidance on how to develop staffing plans and ensure medical facility management review them at least annually to ensure optimal efficiency.
Audit of Vocational Rehabilitation and Employment Program's Self-Employment Services at Eastern and Central Area Offices
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11-00317-37

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/15/2014
We recommended the Under Secretary for Benefits implement procedures to improve the accuracy of data in Corporate WINRS.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/15/2013
We recommended the Under Secretary for Benefits perform a data integrity review comparing Corporate WINRS to active self-employment Counseling/Evaluation/Rehabilitation files and take corrective action as needed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/15/2015
We recommended the Under Secretary for Benefits develop and implement performance measures that evaluate the success of self-employment services.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/11/2012
We recommended the Under Secretary for Benefits provide training to Eastern and Central area Vocational Rehabilitation and Employment staff to ensure they understand the criteria used to determine rehabilitation status for participants in self-employment services.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/2/2013
We recommended the Under Secretary for Benefits include guidance in Veterans Benefits Administration's Manual M28 to clarify when it is appropriate to provide services for veterans with an established business under a self-employment plan.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/11/2012
We recommended the Under Secretary for Benefits revise Veterans Benefits Administration's Manual M28, Part IV, to ensure Veterans Benefits Administration's guidance aligns with Title 38, Code of Federal Regulations, for approval of self-employment plans.
Healthcare Inspection - Inpatient and Residential Programs for Female Veterans with Mental Health Conditions Related to Military Sexual Trauma
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12-03399-54

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/18/2013
We recommended that the Under Secretary for Health review existing VHA policy pertaining to authorization of travel for veterans seeking MST related MH treatment at specialized inpatient/residential programs outside of the facilities where they are enrolled.
Audit of VA’s Office of Information Technology Strategic Human Capital Management
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11-00324-20

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/12/2013
We recommended that the Assistant Secretary for Information Technology establish a strategic human capital plan development process that includes Office of Information Technology's senior management, managers, and employees along with appropriate stakeholders from across VA and its administrations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/2/2014
We recommended that the Assistant Secretary for Information Technology develop and implement a strategic human capital plan that includes roles and responsibilities; human capital goals, objectives, and strategies; performance measures; and milestones as outlined in the Human Capital Assessment and Accountability Framework.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/2/2014
We recommended that the Assistant Secretary for Information Technology ensure the Office of Information Technology's strategic human capital plan is aligned with VA's missions, goals, and objectives; and integrated into the Information Technology and VA Strategic Plans.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/12/2013
We recommended that the Assistant Secretary for Information Technology ensure the Office of Information Technology has an adequate number of leadership and staff positions assigned to administer its strategic human capital program.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/2/2014
We recommended that the Assistant Secretary for Information Technology develop a leadership succession plan, including key actions and associated milestones for its implementation.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/2/2014
We recommended that the Assistant Secretary for Information Technology ensure that all information technology leadership and employee competency assessments and gap analyses are completed.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/2/2014
We recommended that the Assistant Secretary for Information Technology develop leadership and workforce development and hiring strategies for closing identified competency gaps.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 11/4/2013
We recommended that the Assistant Secretary for Information Technology maintain a current listing of contracts used by each OIT organizational element and the functions performed to identify areas where OIT uses contractors to address competency gaps.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/2/2014
We recommended that the Assistant Secretary for Information Technology institute metrics and a process to measure the effectiveness of its strategies for evaluating and improving human capital management.
Audit of VA’s Systems Interconnections with Research and University Affiliates
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11-01823-294

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/15/2014
We recommend the Assistant Secretary for Information and Technology establish or update all Memoranda of Understanding and Interconnection Security Agreements needed to accurately reflect operational environments and require that research partners implement information security controls commensurate with VA's information security standards.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 9/17/2014
We recommend the Assistant Secretary for Information and Technology support the Under Secretary for Health by providing the information technology infrastructure needed to implement a centralized data governance and storage model to securely manage research information over the data life cycle.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 10/3/2014
We recommend the Assistant Secretary for Information and Technology direct Information Security Officers to partner with the Veterans Health Administration's Institutional Review Boards, research personnel, and research partners to routinely conduct joint oversight and monitoring of research labs to ensure security of sensitive veterans' data, compliance of data collections with research protocols, and fulfillment of the Department's information security requirements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/15/2015
We recommend the Under Secretary for Health develop and implement a centralized data governance and storage model that ensures accurate inventory of all research data collected, data collection compliance with research protocols, and secure management of research information over the data life cycle.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2013
We recommend the Under Secretary for Health require the Office of Research and Development to partner with Information Security Officers to routinely conduct joint oversight and monitoring of research labs to ensure security of sensitive veterans' data, compliance of data collections with research protocols, and fulfillment of the Department's information security requirements.
Review of VA's Alleged Incomplete Installation of Encryption Software Licenses
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12-01903-04

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 10/11/2012
We recommended the Assistant Secretary for Information Technology complete the software encryption project assessment to determine whether to continue or terminate the project.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/5/2014
We recommended the Assistant Secretary for Information Technology, if it is determined to continue the project, develop a plan that includes sufficient human resources and monitoring to install and activate all of the purchased encryption software licenses.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 5,100,000.00
Review of Alleged Delays in VA Contractor Background Investigations
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12-00165-277

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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: 10/18/2013
We recommend that the Assistant Secretary for Operations, Security, and Preparedness implement improved policies, procedures, and practices to reduce the backlog of contractor background investigations and educate appropriate personnel on VA's personnel security requirements and contractor on-boarding processes.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 1/30/2019
We recommend that the Assistant Secretary for Operations, Security, and Preparedness, in conjunction with the Assistant Secretary for Information Technology, implement a central case management system to automate the background investigation process and effectively monitor VA contractor status and associated contract costs during the background investigation process.
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