Date Issued
|
Report Number
14-00257-67
All Reports
Date Issued
|
Report Number
14-00258-66
Date Issued
|
Report Number
12-04536-308
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Information and Technology (OIT)
Closure Date: 7/29/2014
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, ensure all of the time needed to develop and deploy each remaining Pharmacy Reengineering increment, to include the initial operating capability phase, is reported and monitored on the Project Management Accountability System Dashboard.
No. 2
to Information and Technology (OIT)
Closure Date: 12/18/2014
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, develop guidance and a reliable methodology for capturing and reporting planned and actual project costs at the increment level on the Project Management Accountability System Dashboard for the remaining increments of Pharmacy Reengineering software development.
No. 3
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, establish guidance on replanning software development projects that have been paused in sufficient detail to demonstrate that increments of the projects are well thought out and achievable.
No. 4
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, establish controls to ensure information technology projects have sufficient leadership and staff assigned throughout the project life cycle.
No. 5
to Information and Technology (OIT)
Closure Date: 12/18/2014
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, establish plans on how future Pharmacy Reengineering development will be funded until a decision is made regarding transferring this effort to the Integrated Electronic Health Record project.
Date Issued
|
Report Number
13-01316-22
Date Issued
|
Report Number
13-00090-346
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/14/2014
Ensure that CBOC clinicians document foot care education provided to diabetic patients in the electronic health record.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/11/2014
Ensure that CBOC clinicians perform risk assessments and document risk levels for diabetic patients in the electronic health record.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/11/2014
Ensure that CBOC clinicians document referrals for preventative foot care, including foot wear, as clinically indicated, for patients with diabetes in the electronic health record.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
Ensure that CBOC managers establish a process to consistently link breast imaging and mammography results to the appropriate radiology mammogram or breast study order for all fee basis and contract patients.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
Ensure that CBOC managers establish a process to notify patients of normal mammogram results within the allotted timeframe and that notification is documented in the electronic health record.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
Ensure that service chiefs¿ documentation in VetPro reflects documents reviewed and the rationale for privileging or re-privileging CBOC providers.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
Ensure that facility Directors grant privileges consistent with the services provided at the CBOCs.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 9/11/2014
Ensure that adequate resources and controls are in place to address deficiencies in the invoice validation process and to reduce the risk of overpayments.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
Ensure that the oversight of the contract acquisition process is compliant with VA Directives, including a thorough pre-award review and interim contract authority prior to contract approval.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
Ensure that all new CBOCs undergo the required contract approval processes prior to initiating operations.
Date Issued
|
Report Number
12-00366-339
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to National Cemetery Administration (NCA)
Closure Date: 6/26/2014
We recommend the Under Secretary for Memorial Affairs ensure the Contracting Service establish procedures to ensure contracts are properly awarded according to the Federal Acquisition Regulations.
No. 2
to National Cemetery Administration (NCA)
Closure Date: 6/26/2014
We recommend the Under Secretary for Memorial Affairs ensure acquisition plans, market research, and evaluations of past performance are properly documented in the contract files.
No. 3
to National Cemetery Administration (NCA)
Closure Date: 6/26/2014
We recommend the Under Secretary for Memorial Affairs ensure Contracting Service establish procedures to ensure competitive procurement methods are used to the maximum extent possible.
No. 4
to National Cemetery Administration (NCA)
Closure Date: 6/26/2014
We recommend the Under Secretary for Memorial Affairs coordinate with the Office of Acquisition, Logistics, and Management to resolve Electronic Contract Management System issues to ensure system capabilities are fully used.
No. 5
to National Cemetery Administration (NCA)
Closure Date: 8/5/2014
We Recommend the Under Secretary for Memorial Affairs ensure Contracting Service fully implements the Integrated Oversight Process and ensure required contract reviews are conducted before awarding contracts.
Date Issued
|
Report Number
12-02708-301
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 9/18/2013
We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction implement controls to ensure the Virtual Office of Acquisition project and all future information technology development fall within the control and oversight of the Project Management Accountability System.
No. 2
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 9/8/2013
We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction ensure the Technology Acquisition Center submits a business case to the Office of Information and Technology justifying how the costs associated with duplicative system requirements and future system maintenance will be managed moving forward.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 13,000,000.00
Date Issued
|
Report Number
12-04524-321
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 11/18/2013
We recommend the Under Secretary for Benefits reinforce to schools participating in the Veterans Retraining Assistance Program they must monitor VA students' attendance and grades for satisfactory academic progress.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 11/18/2013
We recommend the Under Secretary for Benefits reinforce to schools participating in the Veterans Retraining Assistance Program they are required to report VA students' changes in enrollment to VBA within 30 days.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 11/18/2013
We recommend the Under Secretary for Benefits revise the certifying official handbook to state a veteran's signed statement should not be used as the only means of verifying attendance.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 11/18/2013
We recommend the Under Secretary for Benefits reinforce to schools participating in the Veterans Retraining Assistance Program they need to accurately report credit hours and class terms in the VA ONline Certification of Enrollment system.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 2/25/2014
We recommend the Under Secretary for Benefits include language on the Interactive Voice Response scripts to warn veterans of the potential penalty for certifying false enrollment information.
No. 6
to Veterans Benefits Administration (VBA)
Closure Date: 1/23/2014
We recommend the Under Secretary for Benefits implement a plan to monitor veterans currently enrolled at the schools that had their approval withdrawn or suspended to ensure they meet Veterans Retraining Assistance Program full-time attendance requirements and are making positive progress towards program completion.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 12,000,000.00
Date Issued
|
Report Number
12-01702-303
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/15/2014
We recommended that the Under Secretary for Health ensures that VHA performs a detailed analysis of workload and resource use to determine whether there is continued need for the numbers of sites at the current levels and whether changes in the requirements for dedicated polytrauma resources are needed.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/6/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that Level IV sites performing comprehensive TBI evaluations have approved alternate plans.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/3/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians consistently complete TBI evaluations within 30 days of positive screens and that compliance is monitored.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/15/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that the case management process meets requirements and that compliance is monitored.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/15/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that staff caring for polytrauma patients have the documented competencies required for caring for polytrauma patients and that compliance is monitored.
Date Issued
|
Report Number
12-00040-268
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Team Leaders receive, review, and approve psychosocial assessments and counseling plans prior to authorizing contracted counseling services.
No. 2
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Team Leaders conduct and document client assessments after 1 year of eligibility for contracted client services.
No. 3
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Team Leaders conduct annual onsite quality reviews for contractors who participate in the Contract for Fee Program.
No. 4
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Readjustment Counseling Service uses a standard template that includes terms and conditions that are consistent with those in the Readjustment Counseling Service policy.
No. 5
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Readjustment Counseling Service maintains and monitors counseling service contracts in accordance with Readjustment Counseling Service and Veterans Health Administration policy.
No. 6
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Team Leaders authorize contracted counseling services in accordance with Readjustment Counseling Service and Veterans Health Administration policy.
Date Issued
|
Report Number
13-01987-263
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that the Under Secretary for Health implement procedures to ensure that future VHA internal assessments resulting from adverse events include clear guidance to facilities on minimal required steps and supporting documentation.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/15/2014
We recommended that the Under Secretary for Health require facilities to develop processes for assessing the risks and benefits of adopting new medical products or devices that may require significant changes in nursing procedures.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/15/2014
We recommended that the Under Secretary for Health ensure that facility nursing education departments are sufficiently staffed to provide comprehensive and ongoing nursing education, especially when adopting new medical products or devices that may significantly change nursing procedures.
Date Issued
|
Report Number
13-01189-267
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/27/2014
We recommended that the Under Secretary for Health address the reported compliance issues when revising the current Prevention of Legionella Disease directive.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/26/2014
We recommended that the Under Secretary for Health provide a plan that simplifies implementation of the directive, and that provides guidance, education, and monitoring of the implementation of the revised Prevention of Legionella Disease directive when issued.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/23/2013
We recommended that the Under Secretary for Health consider re-evaluation of the current stratification plan that identifies risk of Legionnaires’ disease based on transplant status.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/27/2014
We recommended that the Under Secretary for Health institute a national-level water safety committee that will provide expert and technical assistance for collaborative decision-making at the local level in the control and prevention of waterborne disease.
Date Issued
|
Report Number
13-01846-235
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Office of Management (OM)
Closure Date: 4/2/2014
We recommend the Executive in Charge for the Office of Management and Chief Financial Officer coordinate with the Acting Assistant Secretary of the Office of Human Resources and Administration to implement existing telework expansion plans for reducing greenhouse gas emissions and to encourage VA employees to use alternative forms of commuting.
No. 2
to Office of Management (OM)
Closure Date: 1/17/2014
We recommend the Executive in Charge for the Office of Management and Chief Financial Officer identify additional strategies for meeting requirements to reduce greenhouse gas emissions.
No. 3
to Office of Management (OM)
Closure Date: 1/17/2014
We recommend the Executive in Charge for the Office of Management and Chief Financial Officer identify additional strategies for meeting requirements to reduce fleet petroleum consumption.
Date Issued
|
Report Number
13-00644-231
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 2/3/2015
We recommend the Acting Assistant Secretary for Human Resources and Administration improve the development and management of ADVANCE-funded acquisitions by strengthening the Strategic Management Group's process to fully assess program offices' procurement requests against VA's existing internal capacities.
No. 2
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 1/14/2014
We recommend the Acting Assistant Secretary for Human Resources and Administration take immediate action to assess veteran demand for call center services and modify the terms of its interagency agreement with the Office of Personnel Management to reflect anappropriate level of call center operations and related costs, including staffing resources.
No. 3
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 1/14/2014
We recommend the Acting Assistant Secretary for Human Resources and Administration modify the Veteran Employment Services Office's interagency agreement with the Office of Personnel Management to require routine data reports on call centers' performance that include call volume, length of calls, blocked calls, wait times, and the overall accuracy of information provided to callers.
No. 4
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 1/14/2014
We recommend the Acting Assistant Secretary for Human Resources and Administration develop a process to independently assess the performance of the Veteran Employment Services Office's employment call centers by establishing metrics such as call volume, call wait times, hang-ups, and accuracy of information.
No. 5
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 3/31/2015
We recommend the Acting Assistant Secretary for Human Resources and Administration develop policy that prohibits the approval of modifications to interagency agreement terms that combine the costs and terms of distinct deliverables into one deliverable.
No. 6
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 1/14/2014
We recommend the Acting Assistant Secretary for Human Resources and Administration develop requirements to test and assess functions to be contracted to determine if these functions are inherently governmental as part of the acquisition planning process for all future contracts awarded to support the Veteran Employment Services Office's operations and initiatives.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 17,500,000.00
Date Issued
|
Report Number
13-01741-215
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/10/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians communicate positive CRC screening test, diagnostic test, and biopsy results to patients within 14 days and document notification in the EHR.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/25/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians document follow-up plans or document that no follow-up is warranted within 14 days of positive CRC screening results.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/14/2015
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians discuss diagnostic testing options with patients and that desired testing is performed within 60 days of the positive CRC screening results.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 11/25/2013
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians complete general or surgical evaluations within 30 days of positive CRC pathology.
Date Issued
|
Report Number
13-01743-192
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians consistently document all required elements of comprehensive pre-sedation assessments and that facilities monitor compliance.
No. 2
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that when there is a provider change, clinicians consistently document that the patient was informed of and agreed to the change and that facilities monitor compliance.
No. 3
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians consistently discharge MS patients appropriately and safely and that facilities monitor compliance.
Date Issued
|
Report Number
13-01744-187
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/19/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that all facilities fully implement the staffing methodology and complete all required steps.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 6/19/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that facilities improve processes to use the available data to manage and provide safe, cost-effective staffing.
Date Issued
|
Report Number
13-01742-188
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/7/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility leaders, ensures that facilities take action to improve post-discharge follow-up for MH patients, particularly those who were identified as high risk for suicide.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/7/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility leaders, ensures that clinicians consistently follow the required processes for patients who fail to report for scheduled MH appointments and document actions taken.
Date Issued
|
Report Number
12-01480-183
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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.
Date Issued
|
Report Number
12-04524-171
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
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.