All Reports

In collaboration with the director of Veterans Integrated Service Network 16, verify engineering staff are complying with Veterans Health Administration policies and guidance associated with architectural and engineering design review and inspection procedures.

Verify that all engineering staff understand and are trained on VA design and physical security requirements related to minor and nonrecurring maintenance construction projects.

Verify that engineering staff who develop independent government cost estimates are sufficiently trained on developing a statement of work and how these documents affect the cost estimates.

Ensure engineering staff are documenting their review and acceptance of architectural and engineering designs as required by the Federal Acquisition Regulation before the solicitation of construction contracts.

Develop and implement procedures to maintain stock within the required thresholds as outlined in Veterans Health Administration Directive 1761.

Ensure all relevant supply chain staff receive appropriate and recurring training and require supervisors to perform ongoing monitoring—including periodic inventory reviews and root‑cause analyses—to strengthen controls over VA supplies.

Develop and implement, in collaboration with the Veterans Integrated Service Network, local procedures that require custodial officers to notify supply chain staff when equipment is relocated, and establish protocols to validate and update equipment location and ensure equipment items are properly tagged.

Ensure expendable supplies labeled expired are, in fact, expired and appropriate documentation is completed before turning the supplies in.

Address the physical security issues discussed in this report and provide recurring training on proper physical security controls and procedures to individuals with authorized access to the primary inventory point and warehouses.

Evaluate contractor performance under the contracts awarded for inventory management systems in the Augusta VA Health Care System and take appropriate action to ensure performance in accordance with the contract and to recover funds.

Ensure supply chain management staff effectively address deficiencies identified during Veterans Integrated Service Network quality control reviews.

Confer with the VA Office of General Counsel to determine whether VA should assert a claim to recover the $11.2 million paid for services not received

Evaluate and take any needed actions to make sure policies and procedures require appropriate officials to accurately ascertain information security requirements for contracts that involve sensitive information prior to award.

Create and mandate standardized due process letters for clear and unmistakable errors and severance of service connection, drafted in compliance with 38 C.F.R. § 3.103.

Update procedures to require an enhanced level of review for all final decisions associated with proposed adverse actions resulting from clear and unmistakable errors so that decisions are compliant with 38 C.F.R. § 3.105 and the M21-1 Adjudication Procedures Manual.

Develop an automated report that periodically identifies proposed adverse actions without a final decision and applicable pending end product, and ensure identified cases are reviewed and resolved as appropriate, to maintain compliance with the M21-1 Adjudication Procedures Manual and the M21-4 Manual.

Correct all errors identified by this review as appropriate, so claim processing actions are compliant with 38 C.F.R. § 3.103 and 3.105, the M21-1 Adjudication Procedures Manual, and the M21-4 Manual.

Update the Adjudication Procedures Manual to require documentation of each specific action taken when staff certify mail as unidentifiable.

Provide all employees who process unidentified mail appropriate access to all systems and resources necessary to identify a claimant.

Implement a plan to ensure all Veterans Benefits Administration contact and correspondence with claimants is documented and stored as required by the Adjudication Procedures Manual. As part of this plan, ensure documentation is easily accessible to appropriate staff.

Provide claims assistants who process unidentified mail with consistent quality reviews specific to their handling of unidentified mail.

Consider implementing a training module on processing unidentified mail, including guidance on appropriate work credit for claims assistants, and incorporating it into the national training curriculum. This training could be beneficial for all personnel involved in mail processing, including supervisors and records management officers.

Consider the need for adjustments to current or for future contractual requirements that would improve mental health appointment timeliness by third-party administrators.

Identify and disseminate best practices used by healthcare systems to contact veterans, evaluate barriers to broader adoption of those practices, and implement a plan that supports consistent use of those best practices to improve scheduling timeliness.

Ensure that systems used to identify available community providers capture the full range of preferences that matter to veterans, so scheduling can better align with their individual needs and expectations for care.

Evaluate whether the third-party administrator’s network adequacy standards for mental health providers meet demand for both in person and telehealth, and if needed, modify the language to explicitly require sufficient availability of both in‑person and telehealth mental health providers to meet veteran demand.

Conduct a review to determine the best approach for increasing external use of available systems by community providers to streamline communication between the Veterans Health Administration and community providers and develop, implement, and monitor an action plan based on the review’s findings.

Assess the need for standardized guidance or contractual requirements that prohibit community mental health providers from requesting additional forms containing information already provided in the Veterans Health Administration referral documentation and implement measures to ensure compliance.

Consult with the VA Office of General Counsel to establish a clear and consistent interpretation of 38 C.F.R. § 4.59, to include clarification of whether pain alone without painful motion is sufficient to warrant a compensable evaluation.

Based on the clarified interpretation of 38 C.F.R. § 4.59, consider revising the Adjudication Procedures Manual to improve consistency of terms, and notify claims processors of the revision.

Assess whether guidance is clear to claims processors regarding the requirement to review all evidence, including both objective and subjective evidence, as well as the proper weight that should be given to each piece of evidence.

Determine what actions are necessary to the evaluation builder tool to mitigate confusion and ensure decision consistency for all musculoskeletal joint conditions.

Review and update applicable sections of the VA Fiduciary Program Manual to clarify how to properly evaluate an allegation, including detailing what constitutes a misuse allegation that must be documented and reviewed, and when an investigation is needed, in coordination with the VA Office of General Counsel if necessary.

Clarify in the VA Fiduciary Program Manual how potential misuses of beneficiary funds, such as red flag indicators, must be addressed and documented, and reinforce with training or resources as needed.

Clearly communicate the evidentiary standard staff should use in the allegation phase to help ensure application of different standards is accurate and easily understood and results in consistent compliance with how investigations are initiated, and consider consulting with the VA Office of General Counsel if necessary.

Develop a plan to implement or enhance the national quality review program to ensure compliance with procedural guidance for processing all phases of misuse allegations.

Create a process for facilities to regularly update and verify specialty care clinics’ phone numbers listed in internal facility directories and on websites.

Annually evaluate and verify that automated interactive phone systems route veterans directly to the correct specialty care clinic and assess whether the phone systems support first-call resolution.

Reconfigure specialty care clinics’ phone lines to be able to collect required call performance data and assess whether centralized queues enhance the efficiency of phone management.

Provide guidance to specialty care clinics on how they should manage and respond to voicemails, including for routine reviews of voicemail data.

Provide guidance that assigns both the responsibility for and the frequency of routine monitoring of call performance data and analyses of complaint data trends from the patient advocate system to identify and address veterans’ phone access issues for specialty care clinics.

Standardize and enforce a documented monthly process for reviewing and validating open obligations—including undelivered orders and accruals—with defined staff roles, responsibilities, and communication protocols, in alignment with VA financial policy.

In conjunction with the Office of Acquisition, Logistics, and Construction, establish and document procedures that define roles and communication requirements with requesting and contracting offices to ensure timely end-date modifications and deobligation of funds that are no longer needed.

In coordination with the VA Office of Financial Policy, develop VBA‑specific procedures aligned with appendix F of VA Financial Policy, “Obligations,” and confirm those procedures are consistently implemented to support reconciliation, documentation, and closure of open obligations in the Integrated Financial and Acquisition Management System.

Update the local inventory procedure to include a process for securing information technology equipment when temporary space is needed and for tracking and distributing this equipment, in accordance with federal and VA requirements.

Assess the age of all unused information technology inventory to determine what should be used and what should be disposed of based on federal and VA requirements, and take action to address the results.

Develop and communicate guidance that explains what detail should be included in a valid justification for every Veterans Benefits Management System for Rating override.

Develop and implement a plan to reestablish an overrides quality review process that provides individualized feedback for claims processors.

Develop and implement a plan to monitor the effectiveness of override reviews and continue to address areas and trends that are found to need improvement.

Identify the business need for the override review tab and, if there is one, develop and implement requirements for updating and using it.

Develop and implement a plan that addresses the limitations of the aggregate dashboard.

Strengthen and monitor the automation process to ensure that automated Dependency and Indemnity Compensation rating decisions and notifications fully comply with all legal requirements and procedural guidance.

Ensure the Pension and Fiduciary Service revises the quality review checklist for automated death benefits decisions so that those decisions undergo the same scrutiny as traditionally processed claims.

Consult with VA’s Office of General Counsel to determine whether the modernization plan submitted to Congress—regarding service-connected death benefit grants—complies with section 701(b) of the PACT Act and take appropriate corrective action if needed.

Take corrective action on the remaining three of seven instances that led to about $612,000 in improper payments.

Update requirements provided to the VA Hines Information Technology Center to ensure all foreign beneficiaries, including those with an address in the Philippines, are included in the annual end product generation.

Update the Veterans Benefits Administration’s Adjudication Procedures Manual to clarify and strengthen the actions claims processors should take to verify foreign beneficiaries are alive.

Ensure jurisdiction guidance for routine reviews for residents in the Philippines is clearly communicated to all regional offices.

Provide guidance to assist claims processors in verifying information in the Veterans Benefits Administration’s systems compared to the results from the Social Security Administration inquiry results.

Update the Adjudication Procedures Manual to require claims processors to upload the Social Security Administration inquiry results to beneficiaries’ records.

Enforce procedures for Veterans Health Administration human resources officials to monitor employee service obligations and initiate a debt notice when an employee breaches that agreement, if warranted.

Identify and review active incentives of Veterans Health Administration employees who transferred within or left VA and take action, if appropriate.

Establish enhanced internal controls to ensure compliance with the law on recruitment, relocation, and retention incentives and take appropriate action when an employee with an active service obligation transfers within the Veterans Health Administration.

Complete the evaluation of the incentives awarded to the employees identified in this report who may not have fulfilled their service obligations, determine whether a debt was incurred, and take any appropriate action.

Require the chief operating officer to direct the Veterans Integrated Service Network directors to fully integrate the core services in accordance with policy to improve operational efficiencies and access for veterans.

Establish a process requiring medical facility directors to coordinate with the Office of Integrated Veteran Care and the clinical contact centers before setting up or maintaining a local phone queue for services the clinical contact center provides.

Require the Office of Integrated Veteran Care to direct the clinical contact center leaders to determine if schedulers are arbitrarily ending calls in the telephone system to remain in after-call work status longer than needed to reduce the number of calls routed to them.

Require the Office of Integrated Veteran Care to review and address inconsistencies in guidance on schedulers’ availability.

Direct clinical contact center leaders to routinely evaluate and, if needed, address schedulers’ handle time and availability time to improve performance and reduce inefficiencies.

Direct the Office of Integrated Veteran Care to include schedulers’ handle time and availability time as part of VA Health Connect’s annual performance plans to make sure clinical contact centers monitor and address these areas.

Make sure the Office of Integrated Veteran Care and chief operating officer evaluate VA Health Connect staffing for scheduling and, if necessary, reallocate staff so all clinical contact centers provide core services and meet required performance standards for scheduling.

Direct the Office of Integrated Veteran Care to formalize and clarify internal waiver guidance and include examples of the specific evidence that would be required for a clinical contact center not to provide 24-hour services—such as exploring the use of other strategies like routing calls to another service or partnering with other centers to provide coverage.

Ensure the assistant under secretary for health for the Office of Integrated Veteran Care and chief operating officer periodically review the clinical contact center waiver submissions and the planned actions to comply with VA Health Connect requirements.