OIG Seal
Department of Veterans Affairs, Office of Inspector General
Michael J. Missal, Inspector General

OIG Reports

| 19-06147-50 | Summary | Report

Recommendations (10)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

Direct the Medical Supplies Program Office to implement procedures requiring chief logistics officers at Veterans Integrated Service Networks to monitor facility processes for verification and certification of distribution fee invoices to ensure invoice accuracy prior to payment by the Financial Services Center.

No. 2   to Veterans Health Administration (VHA)

Require Veterans Integrated Service Network directors to ensure their chief logistics officers develop distribution fee monitoring and review procedures for facility logistics audits and compliance reviews to ensure invoices are adequately reviewed, verified, and certified.

No. 3   to Veterans Health Administration (VHA)

Require Veterans Integrated Service Network directors to ensure facility chief logistics officers and contracting officer’s representatives review and update the election forms according to contract requirements and provide copies to the Medical/Surgical Prime Vendors for acknowledgment.

No. 4   to Veterans Health Administration (VHA)

Require Veterans Integrated Service Network directors to ensure facility contracting officer’s representatives verify that distribution fee rates match with those on the election forms and pricing schedule by comparing transaction data from the vendors to VHA-maintained transaction data, and reconcile payments as appropriate.

No. 5   to Office of Acquisitions, Logistics, and Construction (OALC)

Require the Strategic Acquisition Center to develop and add modifications to the Medical/ Surgical Prime Vendor-Next Generation contract requiring prime vendors to provide reports to VA medical facilities with detailed medical and surgical transaction data, fee amounts, and fee percentage rates applied to each transaction on distribution fee invoices.

No. 6   to Office of Acquisitions, Logistics, and Construction (OALC)

Require the Strategic Acquisition Center contracting officer to work with the Medical Supplies Program Office to ensure that Medical/Surgical Prime Vendor contracting officer’s representatives are assigned to each VA medical facility.

No. 7   to Office of Acquisitions, Logistics, and Construction (OALC)

Require the Strategic Acquisition Center to appropriately modify the Medical/Surgical Prime Vendor contract to define annual facility purchase as well as adding a provision for paying the annual facility purchase amount based on the estimated total spend until year-end reconciliation.

No. 8   to Office of Acquisitions, Logistics, and Construction (OALC)

Require the Strategic Acquisition Center to also appropriately modify the Medical/ Surgical Prime Vendor contract to require the prime vendors—rather than the facility—to reconcile to annual facility purchases at the end of the year.

No. 9   to Veterans Health Administration (VHA)

Require the Medical Supplies Program Office to establish policy that clearly defines the source VA medical facilities should use to estimate their annual facility purchase amounts and determine the year-end amounts.

No. 10   to Veterans Health Administration (VHA)

Require VA medical facilities to review their on-site representative fees paid during fiscal year 2018 and future years to ensure they were paid based on the actual annual facility purchase amounts, consistent with the Medical/Surgical Prime Vendor-Next Generation contract, and reconcile payment discrepancies as appropriate.

Total Monetary Impact of All Recommendations

Open: $ 3,700,000.00
Closed: $ 0.00

| 20-00102-73 | Summary | Report

Recommendations (2)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Benefits Administration (VBA)

The director of the Chicago VA regional benefits office ensure the errors identified by the review team are corrected.

No. 2   to Veterans Benefits Administration (VBA)

The director of the Chicago VA regional benefits office monitor the effectiveness of the actions taken to improve the accuracy of administrative error corrections, and determine what additional measures, if any, are needed to make certain that claims processors understand how to apply national and local procedures for correcting administrative errors.

Total Monetary Impact of All Recommendations

Open: $ 67,000.00
Closed: $ 0.00

| 20-01387-89 | Summary | Report

Recommendations (2)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Under Secretary for Health requires facility directors ensure that staff who reprocess colonoscopes at community-based outpatient clinics complete initial training within the required 90 days prior to independently reprocessing equipment and maintain documentation.

No. 2   to Veterans Health Administration (VHA)

The Under Secretary for Health requires facility directors confirm that sterile processing services staff who reprocess colonoscopes at community-based outpatient clinics receive ongoing continuing education through monthly in-services and maintain documentation.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 20-00130-86 | Summary | Report

Recommendations (7)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Network Director evaluates and determines any additional reasons for noncompliance and ensures the development of a written policy that establishes and maintains a comprehensive environment of care program at the Veterans Integrated Service Network level.

No. 2   to Veterans Health Administration (VHA)

The Network Director evaluates and determines any additional reasons for noncompliance and ensures an annual review of the Emergency and Continuity of Operations Plans; Hazards Vulnerability Analysis; and collective Veterans Integrated Service Network-wide strengths, weaknesses, priorities, and requirements for improvement are submitted to executive leaders for review and approval.

No. 3   to Veterans Health Administration (VHA)

The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the lead Women Veterans Program Manager provides quarterly program updates to executive leaders.

No. 4   to Veterans Health Administration (VHA)

The Network Director evaluates and determines any additional reasons for noncompliance and makes certain the lead Women Veterans Program Manager completes annual site visits at each facility.

No. 5   to Veterans Health Administration (VHA)

The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the lead Women Veterans Program Manager completes assessments to identify staff education gaps related to women’s health and develops or adapts educational programs, materials, and/or resources where gaps are identified.

No. 6   to Veterans Health Administration (VHA)

The Network Director evaluates and determines any additional reasons for noncompliance and ensures that Veterans Integrated Service Network-led facility reusable medical equipment inspection results are posted within the required time frame.

No. 7   to Veterans Health Administration (VHA)

The Network Director evaluates and determines additional reasons for noncompliance and ensures that facility corrective action plans are developed within the required time frame.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 20-00421-63 | Summary | Report

Recommendations (6)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Benefits Administration (VBA)

The OIG recommended that the under secretary for benefits create written guidelines for tracking, identifying, notifying, registering, and exempting individuals required to take skills certification tests.

No. 2   to Veterans Benefits Administration (VBA)

The OIG recommended that the under secretary for benefits establish a tracking mechanism to ensure all eligible individuals required to take tests are identified and notified of testing dates at least 30 days prior to test administration.

No. 3   to Veterans Benefits Administration (VBA)

The OIG recommended that the under secretary for benefits provide an update to the plan submitted to Congress explaining why all employees and supervisors who have claims-processing functions listed in the original plan are not subject to skills certification testing.

No. 4   to Veterans Benefits Administration (VBA)

The OIG recommended that the under secretary for benefits implement a plan to ensure staff who failed their most recent skills certification test and remain in the same position are provided training from individual training plans to remediate the deficiencies in their skills and competencies.

No. 5   to Veterans Benefits Administration (VBA)

The OIG recommended that the under secretary for benefits establish an oversight plan to ensure training set out in approved training plans is provided to individuals who fail skills certification tests.

No. 6   to Veterans Benefits Administration (VBA)

The OIG recommended that the under secretary for benefits notify Congress of plans to take personnel actions against individuals who fail consecutive skills certification tests after remediation for the same positions in compliance with the Honoring America’s Veterans and Caring for Camp Lejeune Families Act of 2012.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-06902-23 | Summary | Report

Recommendations (6)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The OIG recommended the under secretary for health ensures the Payment Operations and Management directorate reevaluates all sample claims identified in this audit as not processed in accordance with Office of Community Care guidance, and takes appropriate corrective action as needed.

No. 2   to Veterans Health Administration (VHA)

The OIG recommended the under secretary for health ensures there is a contract requirement that the contractor’s employees must follow Office of Community Care guidance for processing non-VA care claims.

No. 3   to Veterans Health Administration (VHA)

The OIG recommended the under secretary for health ensures the contractor’s standard operating procedures for claims processing are accurate and a mechanism is put in place to keep the contractor’s procedures updated to reflect current Office of Community Care claims processing procedures.

No. 4   to Veterans Health Administration (VHA)

The OIG recommended the under secretary for health ensures the Office of Community Care develops and implements clear controls for reviewing and updating, if necessary, the quality assurance surveillance plan requirements at least annually

No. 5   to Veterans Health Administration (VHA)

The OIG recommended the under secretary for health ensures the Payment Operations and Management personnel make full use of the established communication tracking tool.

No. 6   to Veterans Health Administration (VHA)

The OIG recommended the under secretary for health ensures the Payment Operations and Management leaders provide timely training and additional guidance to their staff and the contractor’s employees on applying and using standardized denial and rejection reasons, and employees follow procedures to process claims with no authorizations to ensure consistent and accurate claims processing.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-07053-51 | Summary | Report

Recommendations (11)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

Provide clarifying guidance and controls to clinic staff on making determinations to send purchase requests and consult notifications to the appropriate purchasing agents.

No. 2   to Veterans Health Administration (VHA)

Provide clarifying guidance to purchasing agents on how to effectively evaluate biologic implant purchase requests for the correct funding source.

No. 3   to Veterans Health Administration (VHA)

Provide clarifying guidance to prosthetic agents to ensure they receive clinic staff consult notifications on all prosthetic purchases of biologic implants.

No. 4   to Veterans Health Administration (VHA)

Create a biologic implant cost code for general-purpose funds to improve funding accountability and potentially assist in ensuring all biologic implant use is tracked.

No. 5   to Veterans Health Administration (VHA)

Direct the Procurement and Logistics Office to clarify guidance on the use of an approved inventory management system specific to biologic implants and the related VHA network, office, and facility staff responsibilities.

No. 6   to Veterans Health Administration (VHA)

Monitor facility compliance with the use of an approved inventory management system for completeness and accuracy.

No. 7   to Veterans Health Administration (VHA)

Direct the Procurement and Logistics Office to ensure logistics staff perform inventory reviews of biologic implants, as required.

No. 8   to Veterans Health Administration (VHA)

Monitor medical facility compliance with required reviews of on-site inventory.

No. 9   to Veterans Health Administration (VHA)

Establish a structure for oversight responsibility that can provide guidance for tracking implanted biologics.

No. 10   to Veterans Health Administration (VHA)

Create policies and procedures for facilities to follow as they implement effective controls for tracking biologic implants.

No. 11   to Veterans Health Administration (VHA)

Establish standardized systems and requirements for facility staff to appropriately record necessary biologic implant attributes for accurate and accessible tracking of recipients to advance patient safety.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 20-00563-68 | Summary | Report

Recommendations (7)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Washington DC VA Medical Center Director evaluates documentation processes for entering the Breast Imaging-Reporting and Data System as primary diagnostic codes in the electronic health record and takes actions as necessary.

No. 2   to Veterans Health Administration (VHA)

The Washington DC VA Medical Center Director evaluates the processes for notification of mammography exam results by ordering providers and takes actions as necessary.

No. 3   to Veterans Health Administration (VHA)

The Washington DC VA Medical Center Director fully implements action plans for all issues listed in the September 2019 National Radiology Program Office site visit and monitors to completion.

No. 4   to Veterans Health Administration (VHA)

The National Radiology Program Office ensures mammography programs have a comprehensive standard operating procedure manual and confirms compliance.

No. 5   to Veterans Health Administration (VHA)

The Washington DC VA Medical Center Director develops and implements a comprehensive standard operating procedure manual covering critical technical, clerical, and administrative functions for the facility’s Mammography Program.

No. 6   to Veterans Health Administration (VHA)

The Washington DC VA Medical Center Director evaluates the oversight and training processes for the facility’s Mammography Program medical support assistant and takes actions as necessary.

No. 7   to Veterans Health Administration (VHA)

The Washington DC VA Medical Center Director evaluates mammography technology staff training processes and takes actions to ensure mammography technology staff receive training through a formalized program.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 20-02959-62 | Summary | Report

Recommendations (2)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

Provide specific guidance for personnel in facilities and Veterans Integrated Service Network offices to report expired personal protective equipment supplies into the Response Monitoring Tool and refine the tool to allow the entry of expired supply levels on hand.

No. 2   to Veterans Health Administration (VHA)

Communicate effective verification measures for facilities and Veterans Integrated Service Networks to improve the reliability and consistency of reported personal protective equipment on-hand quantity and usage information.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 20-00295-61 | Summary | Report

Recommendations (4)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Benefits Administration (VBA); Veterans Health Administration (VHA)

The OIG recommended that the under secretary for benefits and the under secretary for health formalize interagency sharing processes between the Veterans Benefits Administration’s Denver regional office and the Veterans Health Administration’s Office of Community Care on how data and information will be shared between both offices to prevent payments from continuing to deceased spina bifida beneficiaries.

No. 2   to Veterans Benefits Administration (VBA); Veterans Health Administration (VHA)

The OIG recommended that the under secretary for benefits and the under secretary for health take the following actions establish clear written guidance on sharing beneficiary data between the Veterans Benefits Administration’s Denver regional office and the Veterans Health Administration’s Office of Community Care to ensure all entitled beneficiaries are enrolled in health care.

No. 3   to Veterans Benefits Administration (VBA)

The OIG recommended that the under secretary for benefits institute standardized procedures to help the Veterans Benefits Administration’s national call center agents provide accurate and comprehensive information about spina bifida benefits.

No. 4   to Veterans Health Administration (VHA)

The OIG recommended that the under secretary for health direct the Veterans Health Administration’s Office of Community Care to develop a process to ensure those beneficiaries who are not using the services for which they are eligible, or need assistance with locating those services, receive them.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

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