OIG Reports

No. 1   to Veterans Benefits Administration (VBA)

Implement technology improvements and demonstrate progress to ensure the accuracy and completeness of information on the hypertension summary sheet.

No. 2   to Veterans Benefits Administration (VBA)

Implement a process to communicate any change in policy, procedure, or the claims processing manual associated with all automated diagnostic codes between the Office of Automated Benefits Delivery, the Office of Policy and Oversight, the Office of Field Operations, and Compensation Service to ensure guidance is clear and consistent for all claims processors.

No. 3   to Veterans Benefits Administration (VBA)

Implement an improved quality assurance process and monitor the results to ensure the accuracy of hypertension summary sheets and final decisions.

No. 4   to Veterans Benefits Administration (VBA)

Create or amend metrics to compare the timeliness of claims processing using automation tools versus the traditional process.

No. 1   to Veterans Health Administration (VHA)

The Director evaluates and determines any additional reasons for noncompliance and ensures leaders conduct institutional disclosures for applicable sentinel events.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.

No. 3   to Veterans Health Administration (VHA)

The Deputy Director evaluates and determines any additional reasons for noncompliance and ensures staff keep furnishings and equipment safe and in good repair.

No. 1   to Office of Management

Ensure that Veterans Health Administration fiscal staff are trained on VA financial policy requirements for the preparation and approval of journal vouchers (including expenditure transfers).

No. 1   to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensure providers counsel patients who have the potential to become pregnant on the risks and benefits of teratogenic medications prior to prescribing them and document this counseling in the electronic health record.

No. 1   to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)

Establish robust oversight of the personnel suitability program within responsible office(s) that includes verifying background investigations are initiated and adjudicated within prescribed timelines and that documentation is filed as required.

No. 2   to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)

Reimplement the monitoring program specifically required by VA Handbook 0710 as part of VA’s oversight efforts, or an appropriate equivalent, to identify and prevent systemic weaknesses in the personnel suitability program.

No. 3   to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)

Assess program resources and allocate staff as needed to prioritize oversight of the personnel suitability program within responsible office(s).

No. 4   to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)

Establish a plan to implement the updated staffing metrics for the Veterans Health Administration’s suitability function and consider using available hiring flexibilities.

No. 5   to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)

[Recommendation Title Missing]

No. 6   to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)

Develop and execute a plan to collect, maintain, and access sufficient and appropriate data through a single system to support the tracking of background investigations from initiation to adjudication.

No. 7   to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)

Establish a plan to ensure that future systems support the functionality needed to effectively oversee and manage the background investigation process, including addressing limitations identified in the current systems and incorporating the fields necessary to track timeliness metrics.

No. 1   to Office of Information and Technology (OIT)

The assistant secretary for information and technology and chief information officer implement a process to minimize the Information Central Analytics and Metrics Platform data reliability issues.

No. 2   to Office of Information and Technology (OIT)

The assistant secretary for information and technology and chief information officer improve vulnerability management processes to ensure system changes occur within organization timelines.

No. 3   to Office of Information and Technology (OIT)

The assistant secretary for information and technology and chief information officer develop and approve an authorization to operate for the special-purpose system.

No. 4   to Office of Information and Technology (OIT)

The assistant secretary for information and technology and chief information officer include system personnel during the security categorization process to ensure that all necessary information types are considered when determining the security categorization for special-purpose systems.

No. 5   to Office of Information and Technology (OIT)

The assistant secretary for information and technology and chief information officer implement improved mechanisms to ensure system stewards are creating plans of action and milestones for all controls that have not been implemented or assessed.

No. 6   to Office of Information and Technology (OIT)

The assistant secretary for information and technology and chief information officer ensure network segmentation controls are applied to all network segments with special-purpose systems.

No. 7   to Veterans Health Administration (VHA)

The VA medical center director install uninterruptible power supplies to eliminate single points of electrical failure supporting the facility.

No. 8   to Veterans Health Administration (VHA)

The VA medical center director ensure that hot and cold aisles in computer rooms, and electric and data cables are installed in accordance with VA standards.

No. 9   to Veterans Health Administration (VHA)

The VA medical center director validate that appropriate physical and environmental security measures are implemented and functioning as intended.

No. 10   to Veterans Health Administration (VHA)

The VA medical center director implement media sanitization methods in accordance with VA policy requirements.

No. 1   to Office of Acquisitions, Logistics, and Construction (OALC)

Issue guidance clarifying that allergens are exempt from the public law and include how the determination was reached.

No. 2   to Office of Acquisitions, Logistics, and Construction (OALC)

Formalize and communicate the process for manufacturers to request exemptions.

No. 3   to Office of Acquisitions, Logistics, and Construction (OALC)

Formalize the internal process for granting exemptions.

No. 4   to Office of Acquisitions, Logistics, and Construction (OALC)

Establish a procedure for monitoring covered drugs identified in this report as not commercially sold.

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

Develop a procedure to monitor covered drugs identified in this report as newly launched to ensure they have an established ceiling price, and make certain they are made available on the Federal Supply Schedule at the end of the 75-day period.

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

Request that noncompliant manufacturers identified by the Office of Inspector General conduct a self-audit and submit their findings for remediation.

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

Engage with the Food and Drug Administration to ensure that when manufacturers request new national drug codes, they are made aware of the public law requirements.

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

Require contracting staff at the National Acquisition Center to conduct a covered drug check for all of a manufacturer’s drugs when any pharmaceutical Federal Supply Schedule proposal or product addition modification is submitted.

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.

No. 2   to Veterans Health Administration (VHA)

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff conduct comprehensive environment of care inspections at the required frequency

No. 3   to Veterans Health Administration (VHA)

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff document VA police response times for panic alarm testing in the inpatient mental health unit.

No. 4   to Veterans Health Administration (VHA)

The Director evaluates and determines any additional reasons for noncompliance and ensures providers complete the Comprehensive Suicide Risk Evaluation within the required time frame for patients with a positive suicide risk screen.

No. 1   to Veterans Health Administration (VHA)

The Director evaluates and determines any additional reasons for noncompliance and ensures leaders conduct institutional disclosures for applicable sentinel events.

No. 2   to Veterans Health Administration (VHA)

The Director evaluates and determines any additional reasons for noncompliance and ensures staff complete suicide safety plans for patients with a positive suicide risk screen who are determined safe for discharge home from the urgent care center.