All Reports

Assess whether an enhancement to the Quality Management System could mitigate the risk of claims processors closing special-focused review errors without correction and develop a process to ensure corrective actions are taken on all errors.

Establish clear oversight roles and responsibilities of the program office and of regional network telehealth and medical facility leads to monitor medical facility social worker and telehealth staff compliance with the “Digital Divide Standard Operating Procedure” for conducting assessments, ordering, and scheduling.

Develop and implement a mechanism to alert the requesting clinic that a patient has a loaned device and can now be scheduled for a VA Video Connect appointment.

Update the digital divide consult training to include procedure updates and ensure social workers and facility telehealth and Remote Order Entry System coordinators who process digital divide consults and video device orders complete the training and take refresher training as needed.

Implement procedures to require responsible staff to check for duplicate devices before submitting a device order consult.

Establish an alert in the Remote Order Entry System to notify the responsible staff member that a patient already has an issued device before ordering another, and initiate retrieval activities for duplicate devices.

Delegate in the “Digital Divide Standard Operating Procedure” facility staff to monitor the tablet dashboard for VA Video Connect appointment activity and device use, and clearly define regional network telehealth leads’ oversight responsibilities to ensure facilities initiate retrieval activities when warranted.

Establish an automated mechanism using the tablet dashboard to routinely identify the devices that meet retrieval priorities and also initiate retrieval of those that already meet retrieval requirements.

Address restrictions in the refurbishment process, implement accessible and trackable reporting of devices waiting to be refurbished, and implement a structured purchasing model to guide new device purchases and maintain an appropriate inventory level.

Provide appropriate oversight and ensure coordination between designated program offices to implement a comprehensive identity, credential, and access management policy.

Update and publish a VA directive and handbook associated with identity and access management that includes current National Institute of Standards and Technology requirements.

Update and publish VA directives and handbooks associated with the Homeland Security Presidential Directive 12 Program and VA’s personnel security and suitability program as required by VA’s enterprise directives management procedures.

Implement a formal procedure to ensure all improperly created debts identified by the review team are corrected, and certify the results to the OIG.

Ensure the program office and VA’s Office of Information and Technology work together to revise the questionnaire to make it clearer and easier for veterans to more quickly complete the questionnaire and schedule exams.

The Deputy Secretary reviews the process that led to Oracle Cerner’s failure to inform VA of the unknown queue and takes action as indicated.

The Deputy Secretary evaluates the unknown queue technology and mitigation process and takes action as indicated.

Issue a clarifying communication to the office’s personnel that all staff have a right to speak directly and openly with Office of Inspector General staff without fear of retaliation, and that, irrespective of any processes established to facilitate the flow of information, Electronic Health Record Modernization Integration Office personnel are encouraged to communicate directly with OIG staff when needed to proactively clarify requests and avoid confusion.

Provide clear guidance that the office’s personnel must provide timely, complete, and accurate responses to requests for all data or information without alteration, unless other formats are requested, with full disclosure of the methodology, any data limitations, or other relevant context. This includes prompt OIG access to entire datasets consistent with the Inspector General Act of 1978, as amended.

Determine whether any administrative action should be taken with respect to the conduct or performance of the executive director of Change Management.

Determine whether any administrative action should be taken with respect to the conduct or performance of Change Management’s director for training strategy.

The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.