All Reports

Develop a plan to ensure manual journal vouchers are justified, documented, and approved before they are entered into the Financial Management System and that they are reviewed after posting to verify accuracy and support compliance, transparency, and audit readiness.

Require ongoing training for all staff who prepare, review, or approve manual journal vouchers, including a process to ensure that new employees complete initial training and that refresher courses are provided when policies or tools are updated.

Clarify expectations for using macro-enabled journal voucher tools by defining when the standardized macro must be used; establishing a process to communicate macro tool updates and prompt the adoption of newly released versions; and providing guidance, training, and user support to promote correct and consistent application of the tools.

Define and communicate clear oversight responsibilities for Veterans Integrated Service Network financial managers by requiring routine monitoring of documentation and compliance at facilities.

Implement procedures to monitor the data used to measure productivity to ensure the data accurately reflect the complete work of clinical resource hub physicians.

Work with appropriate officials, such as Office of Primary Care and clinical resource hub leaders, to determine whether hub physicians should be subject to existing productivity measures. If so, issue clear hubs guidance requiring adherence; if not, clearly define what should be used, and issue thorough guidance on the steps hubs must take to measure physician productivity consistently.

Clarify oversight responsibilities for monitoring productivity measures, including detailed procedures and actions that should be taken when thresholds are not met.

The Under Secretary for Health ensures that VA homeless program staff consistently document, in patients’ electronic health records, the clinical information from the Homeless Operations Management and Evaluation System.

The Under Secretary for Health makes certain that a suicide risk screening is completed with patients during intake into VA homeless programs, consistent with Veterans Health Administration policy.

The Under Secretary for Health ensures that staff complete suicide risk screening in response to danger of self-harm identified in the Homeless Operations Management and Evaluation System.

The Under Secretary for Health makes certain that homeless program staff provide and document care coordination to address patients’ mental health and substance use disorder treatment needs as identified in the Homeless Operations Management and Evaluation System.

Reassess and clarify physical inventory requirements for equipment in medical facilities to ensure they are consistent with and meet the intent of VA Directive 7002.

Ensure that facility directors require custodial officers to regularly review nonexpendable inventory to determine whether the equipment is required and take appropriate action.

Ensure medical facility directors review inventory list compliance data to identify noncompliant services and implement a process to resolve noncompliance.

Ensure the Veterans Health Administration’s Procurement and Logistics Office, in coordination with VA’s Office of Acquisition and Logistics, regularly monitors inventory compliance data to identify and communicate with noncompliant facilities to proactively address delinquent inventories.

Require medical facilities to use a standardized report of survey dashboard to centrally report all lost, stolen, or damaged items.

Require medical facility directors to review inventory compliance and establish a process to ensure noncompliant equipment—to include equipment identified in this audit—is reported as lost, stolen, or damaged within required time frames.

Reiterate through formal communication that facilities and regional Veterans Integrated Service Networks are required to fully implement and use the Strategic Equipment Planning Guide and Enterprise Equipment Request process for equipment planning and approval and develop a system to monitor compliance and verifying facilities are using the process as required.

Ensure relevant staff complete training on the Strategic Equipment Planning Guide and Enterprise Equipment Request process that explains user roles and responsibilities.

Ensure facilities define and assign Strategic Equipment Planning Guide and Enterprise Equipment Request user roles and responsibilities as applicable.

Reiterate through the formal communication advised in recommendation 1 that the Strategic Equipment Planning Guide and Enterprise Equipment Request process are required for all equipment planning and approval—and clearly define whether there are any exceptions.

Specify when and which equipment purchases require review and approval by additional subject matter experts.

Ensure a disability compensation examiner who has completed PACT Act training provides an independent assessment and medical opinion for the 29 VHA and five VBA nonpresumptive PACT Act opinions identified by the Office of Inspector General that were provided before completing PACT Act training, and readjudicate the claims as needed.

The principal executive director of the Office of Acquisition, Logistics, and Construction considers whether any additional training or other measures are necessary with respect to reporting the wrongdoing of a supervisor and the acceptance of free meals and drinks by VA employees during the February 2023 site visit.

The principal executive director of the Office of Acquisition, Logistics, and Construction determines whether any additional guidance, training, or oversight is needed with respect to ensuring VA employees do not improperly solicit sponsorships for VA events that do not primarily benefit veterans.

VA’s designated agency ethics official determines whether any additional steps need to be taken in connection with Ms. Dawson’s 2023 public financial disclosure based on the findings of this report.

Confirm that medical facility directors develop local guidance on using automated dispensing cabinets in accordance with VHA Directive 1108.21 (and any revisions to this directive) and that facilities comply with that local guidance.

Require Pharmacy Benefits Management Services to revise VHA Directive 1108.21 to include routine monitoring for the use of generic information as a requirement in facility-level guidance for automated dispensing cabinets.

Ensure, in coordination with the controlled substance coordinator, or appropriate designee, and Veterans Integrated Service Networks, that reports detailing cabinet transactions for controlled substances removed using generic information are reviewed as part of required controlled substance inspections.

The Under Secretary for Health ensures the establishment of Veterans Integrated Service Network-level multidisciplinary cancer committees.

The Under Secretary for Health ensures Veterans Integrated Service Network staff submit an inventory of available oncology services and facility points of contact to the National Oncology Program Office annually.

The Under Secretary for Health ensures complexity level 1 and 2 facilities pursue membership in the National Cancer Institute’s National Clinical Trial Network or the National Cancer Institute Community Oncology Research Program.

The Under Secretary for Health ensures the establishment of facility-level multidisciplinary cancer committees, or partnering with another facility or Veterans Integrated Service Network to provide the required committee functions.

The Under Secretary for Health reviews the operations of oncology-related program offices to ensure the required oversight of Veterans Integrated Service Network and facility oncology program implementation.

Evaluate whether VA should establish an enterprise-wide governance structure for Caseflow development, consistent with VA’s initial comprehensive plan to Congress.

Develop a well-defined roadmap for the future development and implementation of Caseflow.

Enforce contract requirements through improved oversight, ensuring violations are identified and remediated.

Evaluate which staff should have access to and should update the Consult Toolbox when records are requested or received and update the “Consult Business Rules and Uses of the Consult Package Standard Operating Procedure” to reflect necessary changes.

Include controls within the Consult Toolbox to prevent errors and improve data quality, including controls on administrative closure of low-risk consults and documenting the records-retrieval method.

Update consult closure policies and procedures to clarify requirements for administrative closure and determine whether metrics for the percentage of records received should be a requirement and included in policy.

Determine whether Veterans Health Administration facilities’ community care offices should continue to be required to use the administrative closure report for oversight of administratively closed consults, and if not, determine what reports should be required.

Evaluate the workload of community care staff to determine the most efficient way to structure and execute their duties.

Determine if there are mechanisms to identify standardization opportunities and increase efficiency for improving records return processes.

Ensure community care staff follow procedures to reduce duplicate records received.

Evaluate ways to increase use of provider electronic records portals to reduce reliance on electronic fax when retrieving medical records.

Consider increased implementation of technologies to improve records processing once received to reduce the manual renaming of electronic files and uploading of records into the electronic health record.

Ensure records from the Joint Longitudinal Viewer are uploaded into the electronic health record.

Develop and implement a method to identify and report separate quality statistics for the Military Sexual Trauma Operations Center.

Update the existing two-signature review process for claims processors and designated reviewers to include an increased focus on military sexual trauma denials.

Develop and implement a process to assess designated reviewers’ competency in processing denied military sexual trauma claims and monitor effectiveness.

Update the relevant sections on transportation expenses in the Veterans Benefits Administration’s Adjudication Procedures Manual to align with each other.

Ensure automation is consistent with the policy for processing the transportation benefit.