All Reports

District leaders and the Ft. Lauderdale, Ft. Myers, Gainesville, Lakeland, Naples, and San Juan Vet Center Directors, collaborate with the support VA medical facility clinical liaison to determine the reasons for noncompliance, take action as indicated, and monitor to ensure compliance with staff participation on the mental health executive council.

District leaders and the Lakeland Vet Center Director, determine reasons for noncompliance with High Risk Suicide Flag SharePoint site requirements and the tracking of continuity of care for at-risk clients, take action to ensure requirements are met, and monitor compliance.

District leaders and the Lakeland Vet Center Director determine reasons for noncompliance and ensure assignment of a liaison.

District leaders and the Lakeland Vet Center Director determine reasons for noncompliance and ensure assignment of an external clinical consultant.

District leaders and the Ft. Lauderdale, Ft. Myers, Gainesville, Naples, and San Juan Vet Center Directors determine reasons for noncompliance, ensure a process is implemented for completing and tracking four hours of external clinical consultation per month, and monitor compliance.

District leaders and the Ft. Lauderdale, Gainesville, and Lakeland Vet Center Directors determine reasons for noncompliance with monthly active counseling records, ensure chart audits are completed as required, and monitor compliance.

District leaders and the Ft. Lauderdale, Ft. Myers, Gainesville, Lakeland, and San Juan Vet Center Directors determine reasons for noncompliance, develop processes to ensure all staff complete mandatory trainings, and monitor compliance.

District leaders and the Gainesville and Lakeland Vet Center Directors determine reasons for noncompliance and ensure outreach plans are completed.

District leaders and the Ft Lauderdale, Ft. Myers, Naples, and San Juan Vet Center Directors determine reasons for noncompliance and ensure outreach plans include all required strategic components.

District leaders and the Ft. Myers, Naples, and San Juan Vet Center Directors determine reasons for noncompliance, ensure outreach activities are tailored to the cultural demographics of the vet center’s veteran service area, and monitor compliance.

District leaders and the Gainesville Vet Center Director determine reasons for noncompliance, ensure completion of fire and/or safety inspections, and monitor compliance.

District leaders and the Gainesville Vet Center Director determine reasons for noncompliance, ensure the risk and vulnerability assessment is completed by VA police or local law enforcement, and monitor compliance.

District leaders and the Gainesville and Naples Vet Center Director determine reasons for noncompliance, ensure automated external defibrillators are serviced annually, and monitor compliance.

District leaders and the Ft. Lauderdale and Naples Vet Center Directors determine reasons for noncompliance, ensure fire extinguishers are inspected monthly, and monitor compliance.

District leaders and the Ft. Myers Vet Center Director determine reasons for noncompliance, ensure automated external defibrillators are inspected monthly, and monitor compliance.

District leaders, and the Naples Vet Center Director, determine reasons for noncompliance and ensure evacuation plans are posted in a communal area.

District leaders and the Ft. Lauderdale, Ft. Myers, Lakeland, and Naples Vet Center Directors determine reasons for noncompliance, ensure completion of a current and comprehensive emergency and crisis plan, and monitor compliance.

District leaders and the Marietta, Bay County, and Savannah Vet Center Directors collaborate with the support VA medical facility clinical liaisons to determine the reasons for noncompliance, take action as indicated, and monitor to ensure compliance with staff participation on the mental health executive council.

District leaders and the Marietta and Charleston Vet Center Directors determine reasons for noncompliance, ensure a process is implemented for completing and tracking four hours of external clinical consultation per month, and monitor compliance.

District leaders and the Augusta, Johnson City, Marietta, Charleston, Bay County, and Savannah Vet Center Directors determine reasons for noncompliance, develop processes to ensure all staff complete mandatory trainings, and monitor compliance.

District leaders and the Charleston Vet Center Director determine reasons for noncompliance and ensure outreach plans are completed.

District leaders and the Augusta, Johnson City, Marietta, Bay County, and Savannah Vet Center Directors determine reasons for noncompliance and ensure outreach plans include all required strategic components.

District leaders and the Augusta, Johnson City, and Savanah Vet Center Directors determine reasons for noncompliance, ensure outreach activities are tailored to the cultural demographics of the vet center’s veteran service area, and monitor compliance.

District leaders and the Augusta Vet Center Director determine reasons for noncompliance, ensure the risk and vulnerability assessment is completed by VA police or local law enforcement, and monitor compliance.

District leaders and the Augusta Vet Center Director determine reasons for noncompliance, ensure fire extinguishers are serviced annually and monitor compliance.

District leaders and the Augusta, Johnson City, Charleston, and Bay County Vet Center Directors determine reasons for noncompliance, ensure fire extinguishers are inspected monthly, and monitor compliance.

The District Director and zone leaders, in conjunction with the Augusta Vet Center Director, determine reasons for noncompliance and ensure vet center obtains an automated external defibrillator.

District leaders and the Charleston Vet Center Director determine reasons for noncompliance, ensure automated external defibrillators are inspected monthly, and monitors compliance.

District leaders and the Charleston and Bay County Vet Center Directors determine reasons for noncompliance, ensure completion of a current and comprehensive emergency and crisis plan, and monitor compliance.

District leaders and the Charleston Vet Center Director determine reasons for noncompliance, and ensures ancillary staff have a desktop reference sheet to address mental health crisis situations.

The Under Secretary for Health reviews the criteria and processes used to identify and exclude healthcare providers removed from VA employment for violation of policy related to safe and appropriate care of veterans, and takes action as warranted.

The Under Secretary for Health reviews previous removals of healthcare providers from VA employment as required by VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 § 108 to determine whether the reason(s) for those removals were for violation of policy related to the safe and appropriate care of veterans, and takes action as warranted.

Holds future third-party administrators accountable for operational readiness and provider network adequacy at each facility by the time the contracts are implemented.

Develops a process to make sure the third-party administrators regularly update their Community Care Network provider lists to reflect accurate provider contact information and annotate providers who are not currently accepting VA patients.

Develops a mechanism for facilities to effectively report, track, and monitor challenges with access to specialty care services; trains all relevant staff on how to use the mechanism; make sure facilities use the mechanism routinely; and then helps facilities resolve access challenges.

Develops and communicates to facilities a standard process to request and document their needs for additional providers.

Evaluates the effectiveness of the third-party administrators’ quarterly and monthly reports for assessing network adequacy and then, if needed, modifies the language in its current contracts and makes changes to the applicable contract language for future Community Care Network contracts.

Develops its own network adequacy performance reports for each facility and communicates the results to the facilities monthly.

Conducts Advanced Medical Cost Management Solution training for community care staff at each facility on evaluating network adequacy through the tool.

Routinely evaluates the third-party administrator’s network adequacy performance reports to ensure the reports are sufficiently reliable and comply with contract requirements, and then holds third-party administrators accountable for resolving identified issues.

The Under Secretary for Health ensures Veterans Health Administration prescribers establish a diagnosis based on a complete and documented assessment prior to initiation of a stimulant to treat attention deficit hyperactivity disorder.

The Under Secretary for Health ensures Veterans Health Administration prescribers assess risks and contraindications associated with stimulant prescribing.

The Under Secretary for Health evaluates the prescription drug monitoring program query adherence goal for initial stimulant prescribing and takes action as warranted.

The Under Secretary for Health evaluates the adequacy of the referral processes related to complex mental health disorders, such as attention deficit hyperactivity disorder, and takes action as warranted.

The Under Secretary for Health considers establishing policy and clinical practice guidance related to attention deficit hyperactivity disorder diagnostic assessment and treatment with a stimulant and takes action as warranted.

Develop and implement policies and system controls to ensure all programs approved for use by vocational rehabilitation counselors for Veteran Readiness and Employment participants meet the requirements of applicable laws and regulations

Train all appropriate Veteran Readiness and Employment regional office staff on manual requirement to verify the programs are approved for use before selecting participants and to verify facility codes match from authorization through enrollment.

Ensure the DALC Recreation Group’s operations fully comply with VA Handbook 5025, Part VIII, or dissolve the group if there is insufficient employee interest in its continuation.

Update VA Handbook 7002, Logistics Management Procedures Part 3, section 7, to clarify under which circumstances, if any, VA employees are permitted to request, accept, and record any incentive items provided by vendors in connection with government purchases.

Reinforce ethics and policy requirements on the acceptance and disposition of free or donated property with all Denver Logistics Center managers and staff, including distributing to staff the Office of General Counsel’s guidance dated June 30, 2023.

Reeducate DLC managers, approving officials, and purchasing agents about VA government purchase card policy requirements that government contracted sources be fully considered and given priority when making purchases.

In consultation with the Office of General Counsel, as authorized by 31 U.S.C. § 3711, determine the full magnitude of the loss from the DALC Recreation Group’s improper sale of VA property and take appropriate action to recover the losses, including any proceeds of the auctions currently within the custody or control of the DALC Recreation Group.

Consider whether any administrative action should be taken with respect to the conduct or performance of the director of the Denver Logistics Center or any other individual involved in the improper acquisition and disposition of the incentive items, and report to the OIG any actions taken involving these individuals.

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.