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

OIG Reports

| 21-03061-209 | Summary | Report

Recommendations (2)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Benefits Administration (VBA)

Centralize all Camp Lejeune-related claims processing at the Louisville VA Regional Office, or implement a plan and report progress mitigating the error rate disparity between the Louisville Regional Office and other regional offices.

No. 2   to Veterans Benefits Administration (VBA)

Conduct and report to the Office of Inspector General the results of targeted quality reviews of Camp Lejeune-related claims from all regional offices processing these claims until the accuracy rate meets or exceeds the Veterans Benefits Administration’s overall national accuracy goal for disability compensation claims.

Total Monetary Impact of All Recommendations

Open: $ 13,800,000.00
Closed: $ 0.00

| 21-01361-192 | Summary | Report

Recommendations (6)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Benefits Administration (VBA)

Update the special-focused review standard operating procedure to require analysis of why errors occurred.

No. 2   to Veterans Benefits Administration (VBA)

Establish controls to ensure special-focused review reports communicate both benefit entitlement and procedural errors.

No. 3   to Veterans Benefits Administration (VBA)

Establish controls to ensure special-focused review reports communicate all errors identified at both the national and regional office levels.

No. 4   to Veterans Benefits Administration (VBA)

Implement a process to measure the effectiveness of actions taken in response to each special-focused review and determine whether a follow-up review is needed.

No. 5   to Veterans Benefits Administration (VBA)

Reassess special-focused review errors marked as “corrected” to determine whether corrective actions were taken.

No. 6   to Veterans Benefits Administration (VBA)

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.

| 21-02668-182 | Summary | Report

Recommendations (10)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

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.

No. 2   to Veterans Health Administration (VHA)

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.

No. 3   to Veterans Health Administration (VHA)

Clarify timeliness goals for the digital divide consult, and video device order placement.

No. 4   to Veterans Health Administration (VHA)

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.

No. 5   to Veterans Health Administration (VHA)

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

No. 6   to Veterans Health Administration (VHA)

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.

No. 7   to Veterans Health Administration (VHA)

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.

No. 8   to Veterans Health Administration (VHA)

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.

No. 9   to Veterans Health Administration (VHA)

Augment tracking mechanisms for packages sent to patients to ensure VA receipt of the retrieval kit so that devices are accurately recorded in inventory and available for refurbishment and reissue.

No. 10   to Veterans Health Administration (VHA)

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.

Total Monetary Impact of All Recommendations

Open: $ 14,478,000.00
Closed: $ 0.00

| 21-02401-190 | Summary | Report

Recommendations (3)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Benefits Administration (VBA)

Improve monitoring procedures and demonstrate progress toward ensuring all felony referrals are processed.

No. 2   to Veterans Benefits Administration (VBA)

2. Update fugitive felon letters and ensure they are consistently sent with all required information.

No. 3   to Veterans Benefits Administration (VBA)

Review unprocessed felony referrals identified in this report, take corrective action as needed, and report the efforts taken to the OIG.

| 22-00210-191 | Summary | Report

Recommendations (4)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Office of the Secretary

Designate roles and responsibilities for all program offices involved in VA’s identity, credential, and access management program.

No. 2   to Office of the Secretary

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

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

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

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

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.

| 21-01351-151 | Summary | Report

Recommendations (4)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Benefits Administration (VBA)

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

No. 2   to Veterans Benefits Administration (VBA)

Enact a formal procedure to review all VBA compensation awards not already reviewed by the OIG that were completed since January 1, 2020, with debts due to reduced disability levels, take corrective action as appropriate, and report the results to the OIG.

No. 3   to Veterans Benefits Administration (VBA)

Develop and demonstrate progress toward implementing a plan to update the electronic system to make employees aware of each period in which an award creates a debt.

No. 4   to Veterans Benefits Administration (VBA)

Develop a mechanism to review the effectiveness of the recommendations periodically and a process for determining what additional measures, if any, are needed.

Supplemental InformationToggle Content

Related Report

Successive VA Errors Created a $210,000 Debt for a Veteran with a “Service-Connected Mental Illness”

| 22-00066-184 | Summary | Report

Recommendations (7)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The OIG made the following recommendation to the director of the VA Black Hills Health Care System: Ensure finance office staff conduct reviews on all inactive open obligations as required by VA Financial Policy, vol. 2, chap. 5, “Obligations Policy.”

No. 2   to Veterans Health Administration (VHA)

Establish procedures to ensure cardholders comply with processing requirements as stated in VA’s Financial Policy, vol. XVI, chap. 1B, “Government Purchase Card for Micro-Purchases.”

No. 3   to Veterans Health Administration (VHA)

Establish controls to confirm approving officials and purchase cardholders review their purchases and make sure contracting is used when it is in the best interest of the government.

No. 4   to Veterans Health Administration (VHA)

Develop measures to confirm that completed VA Form 0242 submissions are accurate and updated for all cardholders.

No. 5   to Veterans Health Administration (VHA)

Ensure the supply chain management staff implement a plan to monitor and correct unit conversion factor errors consistently and promptly to improve data reliability in the Generic Inventory Package.

No. 6   to Veterans Health Administration (VHA)

Develop and implement a plan to achieve an inventory turnover rate closer to the Veterans Health Administration-recommended level.

No. 7   to Veterans Health Administration (VHA)

Establish measures to improve compliance with the VHA directive to avoid end-of-year pharmaceutical purchases.

Total Monetary Impact of All Recommendations

Open: $ 174,468.00
Closed: $ 0.00

| 21-02704-135 | Summary | Report

Recommendations (7)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Benefits Administration (VBA)

Take any needed corrective actions on the four errors involving the improperly granted conditions based on burn pit exposure.

No. 2   to Veterans Benefits Administration (VBA)

Review all denials of compensation claims identified as burn pit claims completed from May 1, 2020, to May 1, 2021, for conditions claimed by eligible veterans to be due to burn pit exposure; correct any errors identified; and provide certification of completion of the review to the Office of Inspector General.

No. 3   to Veterans Benefits Administration (VBA)

Review all denials of compensation claims not identified as burn pit claims completed from May 1, 2020, to May 1, 2021, for conditions of bronchial asthma, chronic bronchitis, allergic rhinitis, sleep apnea, and chronic obstructive pulmonary disease submitted by veterans who served where and when burn pits were used even if not specifically cited in the claim; correct any errors identified; and provide certification of completion of the review to the Office of Inspector General.

No. 4   to Veterans Benefits Administration (VBA)

Update the Adjudications Procedures Manual to provide separate and specific guidance for when claims should be considered based on burn pit exposure and proper development for these claims.

No. 5   to Veterans Benefits Administration (VBA)

Modify the examination request web-based application to add specialty language into medical opinion requests for burn pit exposure claims, to include the contents from the fact sheet for burn pit claims.

No. 6   to Veterans Benefits Administration (VBA)

Implement a plan to develop controls that review the accuracy of rating decisions going forward to minimize improper denials for burn pit claims, correct any errors identified, and address error trends.

No. 7   to Veterans Benefits Administration (VBA)

Update training materials and ensure they are consistent with the adjudication procedures manual guidance for developing burn pit exposure claims.

Total Monetary Impact of All Recommendations

Open: $ 78,300.00
Closed: $ 0.00

| 21-02732-153 | Summary | Report

Recommendations (7)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

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.

No. 2   to Veterans Health Administration (VHA)

Improve controls to ensure the registry website maintains accurate contact information for environmental health coordinators.

No. 3   to Veterans Health Administration (VHA)

Assess the feasibility of veteran-centric guidance that assigns medical facility follow-up responsibilities and identifies processes for determining whether unscheduled veterans with an interest in an exam still want to be scheduled, and then track responses and completions.

No. 4   to Veterans Health Administration (VHA)

Implement a mechanism to ensure medical facilities meet the 90-day timeliness standard for the completion of requested exams, including performance metrics.

No. 5   to Veterans Health Administration (VHA)

Ensure Veterans Integrated Service Network and facility environmental health personnel routinely review their performance data and address any challenges with scheduling registry exams with directors.

No. 6   to Veterans Health Administration (VHA)

Ensure the program office reviews registry exam data and continues to work with VA’s Office of Information and Technology to ensure all facilities and veterans are included and properly coded.

No. 7   to Veterans Health Administration (VHA)

Establish procedures for medical facilities to transfer assigned veterans to receive an exam at a closer facility or as otherwise appropriate.

| 21-01081-155 | Summary | Report

Recommendations (8)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

Establish controls to ensure contracting officers’ representatives upload required documentation of acceptability of supplies and services to the electronic contracting officer representative file prior to payment.

No. 2   to Veterans Health Administration (VHA)

Establish a requirement and a process for branch chiefs to consistently monitor contract administration documentation.

No. 3   to Veterans Health Administration (VHA)

Assess existing contracts that require an electronic contracting officer representative file and take corrective actions to ensure compliance.

No. 4   to Veterans Health Administration (VHA)

Establish controls to ensure contracting officers create an electronic contracting officer representative file for all contracts requiring a contracting officer’s representative.

No. 5   to Veterans Health Administration (VHA)

Assess existing contracts to ensure contracting officers have completed contracting officer’s representative delegation memorandums, if required.

No. 6   to Veterans Health Administration (VHA)

Establish controls to ensure contracting officers and contracting officer’s representatives have a completed contracting officer’s representative delegation memorandum in the electronic contracting officer representative file, if required.

No. 7   to Veterans Health Administration (VHA)

Establish a quality assurance process to ensure compliance with contract administration requirements for establishing an electronic contracting officer representative file, completing contracting officer’s representative delegation memorandums, and maintaining acceptance documentation.

No. 8   to Veterans Health Administration (VHA)

Assess whether additional training is needed to clarify officials’ roles and responsibilities for documenting acceptance of supplies and services.

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