All Reports

Update VA’s Adjudication Procedures Manual on when personnel should request medical disability examinations and opinions.

Reduce examination and medical opinion overdevelopment by establishing a plan to continue the development of examination request tools and evaluate the effectiveness of these efforts for any future enhancements.

Correct the two errors involving prematurely denied Dependency and Indemnity Compensation claims.

Conduct a file review of the reopened Dependency and Indemnity Compensation claims granted under the PACT Act from January 1 through August 31, 2023, and take appropriate actions to ensure monetary benefits and notification letters are accurate.

Consider whether modifications could be made to the reevaluation request process consistent with the PACT Act and related regulations and, should this result in a policy change, consult with the VA Office of General Counsel.

The Under Secretary for Health ensures Veterans Health Administration leaders assess reasons for noncompliance with training requirements and takes action as warranted.

The Under Secretary for Health evaluates whether toxic exposure screening is negatively affecting primary care workload and takes action to mitigate as needed.

Implement and periodically monitor the effectiveness of a plan to provide oversight for unsent packages in the Package Manager application.

Implement a plan to address existing unsent packages in the Package Manager application.

Improve vulnerability management processes to ensure all vulnerabilities are identified and that plans of action and milestones are created for vulnerabilities that cannot be mitigated by VA deadlines.

Implement a more effective system life-cycle process to ensure network devices are running authorized software and operating systems that are configured to approved baselines and free of vulnerabilities.

Ensure all file systems holding veteran information are encrypted in accordance with NIST and VA policy requirements.

Maintain an accurate inventory of personnel with key access to the facility.

Enable improved audit logging capability to monitor administrator access to sensitive information hosted on the Workload Reporting and Productivity Assessing file server.

Execute the compliance plan for the Veterans Benefits Administration’s personnel suitability program.

Ensure the Veteran Benefits Administration’s personnel suitability program oversight verifies background investigations are initiated and adjudicated within prescribed timelines and that documentation is filed as required.

Establish a plan to ensure robust oversight of the National Cemetery Administration’s personnel suitability program that includes verifying background investigations are initiated and adjudicated within prescribed timelines and that documentation is filed as required.

Evaluate resource requirements for the personnel suitability program to ensure that all personnel suitability requirements are being met.

Establish and implement guidance for quality assurance measures over the data used to develop and justify the ambulatory care budget estimate.

Ensure the deputy under secretary for health provides oversight and holds the Office of Finance accountable for developing, documenting, and implementing standard operating procedures to include defining roles and responsibilities and requirements for oversight and quality assurance for development of the ambulatory care budget estimate.

Implement the Veterans Health Administration Data Governance Council, to include developing policies and processes for data management across the Veterans Health Administration.

Ensure the Veterans Health Administration Data Governance Council identifies authoritative data sources and nominates data stewards for approval by the VA Data Governance Council.

Assess electronic health record major performance incident data needs and contractually commit to real-time data sharing that will provide greater awareness of system operations.

Develop a formal procedure for verifying performance metrics and associated credits to ensure the department receives the remedies it is due under the contract.

Update the process for prioritizing major performance incidents to ensure that notification and resolution occur in a consistent manner.

Develop effective notification and resolution metrics that consistently capture results for all major performance incidents, regardless of the owner, and enforce them.

Identify the information needed in post-resolution reports, such as corrective and preventative actions, and require the contractor to consistently collect, verify, and report that information as a contract deliverable.

Develop a plan to ensure all clinicians are familiar with the national downtime procedures.

Identify the appropriate backup system and develop a training strategy to ensure clinicians can use the system during downtime.

Assess facilities’ patient safety reports identified during this audit to determine if additional actions need to be taken and, if so, provide an action plan.

Develop a mechanism to better identify major performance incidents and negative patient outcomes and provide a plan to prioritize and address their causes.

Reevaluate the risk determination for the Veterans Health Administration Geographic Information System and determine if the system should be set to a security categorization level of “moderate” based on the personally identifiable information and other sensitive data maintained in the system.

Ensure the Data Breach Response Service director instructs staff associated with the incident response process that each security and privacy incident that occurs must be captured on a separate Privacy Security Events Tracking System ticket, confirms document investigation details are accurate, and reassesses whether the security incidents were a breach.

Request that the contractor perform a self-audit of local VA claims.

Verify that the contractor has completed the process of refunding local VA claims.

Establish policies and procedures for Grant and Per Diem liaisons to obtain reliable discharge information from grantees when veterans exit from the Grant and Per Diem Program.

Implement controls, including enhanced medical facility and grantee guidance and training, to ensure grantee files and VA medical record documentation of veteran housing outcomes are consistent with Homeless Operations, Management, and Evaluation System data definitions and support the data in the Homeless Operations, Management, and Evaluation System.

Implement controls, such as quality reviews, to ensure Homeless Operations, Management, and Evaluation System outcome data are supported by and consistent with veteran medical records and grantee files.

Confirm VA has resumed submitting biweekly reports and, therefore, has submitted reports from June 2023 to present as required by the VA Transparency & Trust Act of 2021.

Confirm that the American Rescue Plan Act of 2021 section 8002 quarterly reports are submitted to Congress within the time frame established on the Consolidated Appropriations Acts of 2022 and 2023, which is no later than 30 days after the end of each fiscal quarter.

Coordinate with administration and staff office chief financial officers to ensure that the finance office staff responsible for the management of open obligations know and understand VA financial policy requirements for the review of open obligations included in quarterly obligation reports.

Ensure that annual reports to Congress include the steps VA is taking to improve the onboard timeline for facilities for which the duration of the onboarding process exceeds the metrics laid out in the Veterans Health Administration’s time-to-hire model, or successor model, as required by section 3008(b) of the Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020.

Track facilities’ supply chain personnel vacancies as part of the quality control reviews and take appropriate action.

Develop guidelines that define when facility supply chain management problems require additional interventions and then routinely identify them for network director action.

Ensure facility and network directors work with the Procurement and Logistics Office on a plan to identify resources and milestones to resolve identified supply chain management problems for identified facilities.

Direct the program office to develop a process to provide resources when needed to help networks and facilities resolve persistent supply chain management deficiencies, including those identified in this report.

Continue Procurement and Logistics Office efforts to automate tracking that will accurately capture and monitor all quality control review results, corrective action plans, and implementation of those plans.

Update the Procurement and Logistics Office audits of the quality control program to apply risk‑based sampling, evaluate action plan sufficiency and implementation, and use the results to continuously improve quality control review guidance and requirements.

Improve vulnerability management processes to ensure plans of action and milestones are created for vulnerabilities that cannot be mitigated within OIT timelines.

Implement a more effective system life-cycle process to ensure network devices are running operating systems that are configured to approved baselines and free of vulnerabilities.

Implement a process to verify that when employees are terminated, all their accounts are disabled.

Ensure network segmentation controls are applied to all network segments with special-purpose systems.

Implement a process to retain database logs for a period consistent with VA’s record retention policy.