All Reports

The Under Secretary for Health examines potential differences between the veterans who reported to Sexual Assault Prevention and Response Office and used VA health care and those who did not in order to improve outreach efforts to the nearly half who did not engage with VA health care.

The Under Secretary for Benefits evaluates the service-connected disability application and claims process for veterans who reported sexual assault that occurred during military service to identify and mitigate potential barriers.

The Under Secretary for Benefits examines potential differences between the veterans who reported to Sexual Assault Prevention and Response Office and used VA benefits and those who did not in order to improve outreach efforts.

Conduct a review of the convalescence claims for hip and knee replacements and resurfacing completed from February 7, 2021, through August 31, 2022, and take appropriate actions to correct convalescence periods and ensure monetary benefits are accurate.

Implement a plan to assist employees with determining the effective date, incorporating the initial month under 38 C.F.R. § 4.30, and calculating the duration of convalescence.

Develop implementation procedures to include monitoring the accuracy of claims processing when the related rating schedule has been revised.

Supplement training on the rating schedule updates to include how to apply the changes to help ensure comprehension.

Mediate the two offices’ collaboration to develop and publish updates to the personnel security policies and procedures for vetting contractor employees to include appropriate roles and responsibilities; standard contract language to communicate the requirements for vetting contractor employees, including whether a fingerprint check or background investigation is required, that can be used across the department; and a requirement that the VA organization requesting a contract provide the position designation record in the acquisition package submitted to the contracting office.

Perform and document compliance inspections of the procedures for vetting contractor employees and the issuance of VA identification credentials at medical facilities supported by Network Contracting Office 23, including the St. Cloud VA Medical Center.

Update and publish the Veterans Affairs Acquisition Regulation and Veterans Affairs Acquisition Manual to direct the department’s acquisition professionals to the correct guidance for vetting contractor employees, which should include VA’s personnel security and suitability program policy.

Update and publish or rescind Acquisition Policy Flash 16-13, “Use of VA Handbook 6500.6, Appendix A, Checklist for Information Security in VA Service Acquisitions,” to ensure VA acquisition professionals understand that VA Handbook 6500.6 is not the only personnel security policy they must comply with.

Update and publish VA Handbook 6500.6, Contract Security, in collaboration with the Office of Acquisition, Logistics, and Construction and the Office of Human Resources and Administration/Operations, Security, and Preparedness, including retitling it to better correspond to its content and removing any personnel security steps that should only be discussed in VA personnel security and suitability program policies.

Review the actions of the officials responsible for planning, awarding, and administering contract 36C26320A0021, which included vetting procedures that did not comply with federal or VA policies, and take administrative action if appropriate.

The Central Texas VA Health Care System Director reviews the care provided to the patient by Nurse Practitioner 1 and Nurse Practitioner 2 and takes action as warranted.

The Central Texas VA Health Care System Director reviews the care provided by Nurse Practitioner 1 and Nurse Practitioner 2 as licensed independent practitioners to other urology patients, and takes action as warranted.

The Central Texas VA Health Care System Director reviews the privileging and professional practice evaluation processes and performance indicators for nurse practitioners granted full practice authority in specialty care clinics to ensure compliance with current Veterans Health Administration policy and quality of care.

The Central Texas VA Health Care System Director ensures that facility leaders communicate expectations related to low-dose computed tomography scans for lung cancer screening to facility primary care providers.

Develop and implement a strategy with milestones for identifying all VA websites, confirm their inclusion in VA’s Web Registry as the current system designated by policy, and certify the accuracy of entries annually or as changes occur.

Establish a mechanism for web communication offices across VA to enforce the implementation of VA Handbook 6102 related to Section 508 compliance.

Coordinate with VA under secretaries and other assistant secretaries to ensure system owners are educated on VA Directive 6221 and its accompanying handbook requirements to request accessibility audits.

Institute a mechanism to ensure information technology system accessibility designations are accurate in the VA Systems Inventory.

Update, recertify, and republish VA Directives 6221 (accessible information and communications technology) and 6404 (systems inventory).

Update, recertify, and publish VA Directive 6515 (use of web-based collaboration technologies).

The Under Secretary for Health consider identifying a national program office to be responsible for oversight of alcohol withdrawal management across inpatient settings.

The Under Secretary for Health ensures the identified national program office responsible for oversight of alcohol withdrawal management consider requiring the development and implementation of written guidance for the management of alcohol withdrawal across all inpatient settings, to include: (a) expectations for determining alcohol withdrawal severity, level of care, and when transfer of care is indicated; (b) expected actions of nurses to communicate with prescribers based on patients’ changes in symptoms or alcohol withdrawal severity and when that communication should be followed by a prescribers face-to-face evaluation of a patient; (c) expectations for the evaluation of co-occurring conditions, expert consultation, and pharmacotherapy approaches; and (d) expectations for the collection and monitoring of outcome data for inpatient management of alcohol withdrawal at the national and healthcare system level.

The Under Secretary for Health consider the implementation of training for inpatient staff on the administration of standardized alcohol withdrawal severity scales.

Direct the Office of Financial Management to continue to develop a system for digitally capturing, analyzing, and monitoring public questionnaires to identify inauthentic or potentially fraudulent questionnaires and work with the Compensation Service to develop policies for reviewing and remediating any such public questionnaires identified.

Have the Medical Disability Examination Office update the examiner certification and signature section found in public questionnaires to include that the form is being completed under the penalty of perjury and to ask examiners to list any organizations that requested they complete the examinations on the claimant’s behalf.

Instruct the Compensation Service to provide claims processors guidance in the procedures manual on how to identify a potentially fraudulent public questionnaire, and provide the steps they should take when they suspect that a public questionnaire may be inauthentic or potentially fraudulent.

Require the Compensation Service to inform claims processors as part of the public questionnaire review process that they have a duty to review and weigh all the evidence of record, including public questionnaires, and that they have the responsibility to assign low or no probative value if they have reason to suspect that the public questionnaire is inauthentic or potentially fraudulent.

Direct the Veterans Benefits Administration to develop and provide training on authentication and fraud, including training related to public questionnaires, to provide claims processors with the knowledge to identify inauthentic or potentially fraudulent public questionnaires, and include what steps claims processors should take when they make that determination.

Develop specific policy and procedures to ensure the contractor’s investment grade audit, which includes the contractor’s energy baseline and cost savings estimates, are witnessed and validated per Federal Energy Management Program guidelines.

Publish criteria for payments for energy savings performance contracts to ensure compliance with federal law and Department of Energy Federal Energy Management Program guidance.

Develop procedures to ensure contracting officer’s representatives or other contracting officer designees have independently witnessed and validated the contractor’s energy baseline and savings estimates prior to negotiating energy savings performance contracts’ guaranteed savings amounts.

Develop oversight procedures to ensure documentation that demonstrates the contractor’s energy baseline and energy savings estimates were witnessed and validated is maintained in the official contracting records.

The executive director of VA’s Office of Construction and Facilities Management should confirm seismic evaluations are done for all critical and essential buildings in high and very high seismic zones immediately to ensure they meet life, safety, and occupancy performance standards

The executive director of the Office of Construction and Facilities Management should review the Capital Asset Inventory and work with Veterans Health Administration Office of Capital Asset Management, Veterans Integrated Service Network capital asset managers, and VA medical facility engineers to update and correct inaccurate seismic data in the Capital Asset Inventory.

The executive director of the Office of Construction and Facilities Management should submit change requests to the Capital Asset Inventory so that critical and essential designations are visible to medical center engineers and Veterans Integrated Service Network capital asset managers.

The executive director of the Office of Asset Enterprise Management should ensure facilities and Veterans Integrated Service Networks review critical and essential designations as part of their annual certifications of the Capital Asset Inventory.

Clarify guidance to ensure it includes local dialysis contract options and specifically defines when they should be used.

Establish roles and responsibilities to ensure dialysis coordinators follow required procedures when referring veterans to dialysis care in the community.

Develop and implement a plan to regularly examine and validate dialysis provider information in the Provider Profile Management System for accuracy and completeness.

Develop and implement a strategy to ensure that any new dialysis service contracts follow the John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 payment rate requirements.

The Under Secretary for Health makes certain the Veterans Health Administration complies with requirements that all acute sexual assault victim-survivors are offered prophylaxis for sexually transmitted infection when clinically indicated and monitors compliance.

The Under Secretary for Health verifies compliance with Veterans Health Administration requirements that all acute sexual assault victim-survivors are offered prophylaxis for pregnancy when clinically indicated and monitors compliance.

The Under Secretary for Health ensures all sexual assault victim-survivors are offered mental health resources, either directly through Veterans Health Administration or through the community and monitors compliance.

The Under Secretary for Health ensures compliance with Veterans Health Administration requirements for documentation of signature informed consent for forensic examinations conducted by staff at Veterans Health Administration facilities and monitors compliance.

The Under Secretary for Health coordinates with VA Office of Security and Law Enforcement to provide direction that facility policy or guidance include facility and jurisdiction-specific information necessary for frontline staff to act in accordance with jurisdiction and Veterans Health Administration requirements for VA police responding to sexual assaults.

The Under Secretary for Health ensures Veterans Health Administration’s policy specifies the required elements to include in Veterans Health Administration facilities’ policies or guidance on acute sexual assault, including jurisdiction-specific requirements, and considers an online national policy with an appendix containing each facility’s supplemental information.

The Under Secretary for Health makes certain that facility level management of acute sexual assault policy or guidance is updated to incorporate information on facility-specific resources and jurisdictional requirements as warranted, and educates staff as needed.

The Under Secretary for Health ensures that VA Police Chiefs review facility policy and guidance for police responding to sexual assaults and update to incorporate information on facility-specific resources and processes, including jurisdictional requirements, as warranted, and educates facility police officers as needed.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff document veterans’ care coordination needs within the Community Care Coordination Plan note for consults assigned a level of care coordination above basic.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff act on consults no later than two business days after receipt and document accordingly.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff schedule community care appointments in a timely manner.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff make three attempts to retrieve medical documentation from non-VA providers.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures patients in the home dialysis program receive initial and annual home visits.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff implement and sustain processes to monitor the delivery of non-VA home dialysis.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures each Veterans Integrated Service Network establishes a dialysis council.

Coordinate with the executive director of the Prosthetic and Sensory Aids Service and officials from the Veterans Health Administration’s Procurement and Logistics Office and the VA Office of Acquisition, Logistics, and Construction to develop and implement a sourcing strategy, such as national contracts or a pricing catalog across all contracts by vendor for eyeglasses prescribed by a VA provider.

Coordinate with the executive directors of the Prosthetic and Sensory Aids Service and the Veterans Health Administration’s Office of Procurement to implement a process to ensure contracting officers coordinate before awarding any Veterans Integrated Service Network–level contracts for eyeglasses to make sure these vendors offer the Veterans Health Administration the best pricing that is also consistent for the same or similar items to the extent possible.

The Under Secretary for Health evaluates whether low-dose computed tomography lung cancer screenings sent through VA community care have quality assurance practices in place that ensure timely reporting of results to VA facilities consistent with other cancer screenings that are sent through the community care program and takes corrective action to address any identified deficiencies.

The Under Secretary for Health ensures the Veterans Health Administration Office of Integrated Veteran Care reevaluates whether the minimum number of attempts prior to administratively closing consults for community care lung cancer screening with low dose computed tomography scans should continue as an ongoing process, and takes action as warranted.

The Under Secretary for Health reiterates expectations for providers to comply with the Veterans Health Administration directive regarding communication of test results to patients, including required time frames.

The Under Secretary for Health evaluates whether low-dose computed tomography lung cancer screenings sent through VA community care have quality assurance practices in place that ensure follow-up on scan results consistent with other cancer screenings that are sent through the community care program and takes corrective action to address any identified deficiencies.

The Under Secretary for Health facilitates a comprehensive review of the patient cases provided by the Office of Inspector General, assesses these patients for adverse clinical outcomes, and implements action plans as needed.

Establish a process to identify and track veterans’ files for those determined to have fire-damaged or destroyed records, such as adding a corporate flash, and update the Adjudication Procedural Manual indicating when veterans service representatives should apply such procedures.

Instruct veterans service representatives on the process for requesting service treatment and military service records for fire-related records, which includes more specific guidance on what information is required for the National Personnel Records Center to locate veterans’ records.

Ensure veterans service representatives are made aware of and follow steps as outlined in the manual for when to send required forms and conduct follow-up contact with veterans.