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

OIG Reports

| 21-00497-46 | Summary | Report

Recommendations (3)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

Develop guidelines requiring supervisors to use VHA systems to monitor documentation of efforts to contact patients to schedule an appointment and to take corrective action as appropriate.

No. 2   to Veterans Health Administration (VHA)

Establish a tool to monitor whether clinicians are properly indicating the appropriateness of alternative forms of care and whether staff offered them to patients when clinically appropriate.

No. 3   to Veterans Health Administration (VHA)

Reassess the frequency of and approach to its training for scheduling community care consults to VHA facilities as revisions are made to the various tools.

| 20-03351-08 | Summary | Report

Recommendations (1)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The OIG recommended that the acting under secretary for health perform additional analyses to ensure materially accurate specialty care workload data are used to implement the Asset and Infrastructure Review Commission recommendations.

| 19-07812-29 | Summary | Report

Recommendations (6)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The OIG recommended that the under secretary for health implement comprehensive guidance for staff who schedule home oxygen consults that includes processes for working with patients who do not or are unable to attend scheduled reevaluations, and for determining how and when to discontinue home oxygen services when appropriate.

No. 2   to Veterans Health Administration (VHA)

The OIG recommended that the under secretary for health update guidance to include any exceptions to the scheduling time frame based on the type of home oxygen services patients are prescribed.

No. 3   to Veterans Health Administration (VHA)

The OIG recommended that the under secretary for health update policy to assign oversight responsibility for ensuring the number of home or telehealth visits outlined in guidance is conducted.

No. 4   to Veterans Health Administration (VHA)

The OIG recommended that the under secretary for health require the network contracting offices to provide oversight so that (1) contracting officers ensure vendor performance evaluations and quality assurance reports are completed and documented in the electronic contract management system, and (2) contracting officers comply with requirements when designating contracting officer’s representatives.

No. 5   to Veterans Health Administration (VHA)

The OIG recommended that the under secretary for health clearly communicate processes or tools that staff should use to achieve the contract monitoring requirements outlined in the Federal Acquisition Regulation.

No. 6   to Veterans Health Administration (VHA)

The OIG recommended that the under secretary for health ensure facilities in Veterans Integrated Service Network 7 review orders that were paid for home oxygen services without an awarded contract and submit a request for ratification to the head of the contracting activity for any unauthorized commitments.

| 20-01099-249 | Summary | Report

Recommendations (6)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

Ensure the Office of Community Care implements automated payment system controls to reject non VA claims that exceed the number of authorized visits or cutoff dates or includes treatment codes that deviate from established standards for care.

No. 2   to Veterans Health Administration (VHA)

Ensure the Office of Community Care conducts ongoing payment system audits to identify and minimize improper payments of unauthorized claims.

No. 3   to Veterans Health Administration (VHA)

Direct the Health Information Management program office in coordination with the Office of Community Care and facility chiefs of staff to ensure facilities are conducting post payment audits of billed acupuncture and chiropractic services to verify non VA providers are properly supporting their claims and to develop processes for corrective actions based on audit results.

No. 4   to Veterans Health Administration (VHA)

Ensure the Office of Community Care and the Health Information Management program office, in coordination with the offices of Acupuncture and Chiropractic services, make any current and future continuing education material related to documenting acupuncture and chiropractic services available to non VA providers.

No. 5   to Veterans Health Administration (VHA)

Direct facility chiefs of staff to require those authorized to approve non VA care to document review of prior care before approving additional services.

No. 6   to Veterans Health Administration (VHA)

Instruct facility chiefs of staff to require VA providers to document their clinical justification for additional care requested by a veteran.

Total Monetary Impact of All Recommendations

Open: $ 341,700,000.00
Closed: $ 0.00

| 20-04237-09 | Summary | Report

Recommendations (12)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Office of Management

Continue the system modernization efforts that provide VA with the capability to generate the required DATA Act reporting files containing the necessary elements to meet compliance with the DATA Act. Ensure the modernization will provide the following: a. Accurate reporting of object class, program activity codes, program activity names, and all other elements required by the DATA Act. b. Award identification to allow VA to be able to develop a File C and reconcile the File C to both summary level data (Files A and B) and award level data (File D). c. Reconciliations with subsidiary systems. d. A mechanism to ensure transactions are reported that currently may be excluded due to the use of 1358s. e. Standardized data fields to allow management to record an award ID across financial and supporting systems. f. Subsidiary systems that are consistent with USSGL or adequately mapped to USSGL to ensure transactions contain the necessary data elements/field required to meet DATA Act reporting. g. Differentiation between direct and reimbursable amounts.

No. 2   to Office of Management

Implement a grants management solution across all of VA’s grant programs and develop processes to ensure integration with the new reporting system.

No. 3   to Office of Management

3. Improve researching of all root causes of differences between the VBA source systems and the monthly GTAS balances as part of their File B reconciliations. Also, differences should be accumulated and assessed at an aggregate level. The total differences either allocated to programs, reclassified out of other programs, or attributed to MinX JVs should be researched and reported as part of the SAO sub-certification process.

No. 4   to Office of Management

Continue mapping efforts and ensure programs without entitlement codes are recorded with the correct program activity codes and names rather than defaulting to Compensation.

No. 5   to Office of Management

Work with component level SAO’s to ensure timely receipt of signed certifications.

No. 6   to Office of Management

Include more information in the SAO certifications, the Data Quality Plan document and the data submission about the costing and aggregation methodologies VA uses to report VHA data to increase transparency.

No. 7   to Office of Management

Implement internal controls and update policies and procedures to improve the accuracy of and completeness of the information submitted for DATA Act reporting. The internal controls should ensure the following: a. Excluded payments not reported due to zip code issues are researched, cleared, and reported in VBA’s life insurance FABS submission. b. The default code “90” for Congressional District is not used when the county or zip code are unknown; instead, perform research to obtain the required data. c. Guidance from OMB and Treasury is requested on the proper reporting of the face amount of insurance policies in VBA’s FABS submissions. d. Management’s policies and procedures (e.g., Standard Operating Procedures) and narratives are updated on a timely basis in coordination with the VA PMO for the most current DATA Act submission procedures and reporting requirements.

No. 8   to Office of Management

Ensure that reconciliations are complete, reconciling items are identified and researched, and any resolutions are clearly documented.

No. 9   to Office of Management

Investigate potential controls or processes that could identify 1358s that should be reported until the system modernization can implement a solution.

No. 10   to Office of Management

Implement internal controls and update policies and procedures to improve the accuracy of and completeness of the information submitted for FABS reporting. The update should include and adhere to all FABS and DAIMS reporting requirements.

No. 11   to Office of Management

Improve reviewing and validating eCMS actions to underlying contract documentation to assess the completeness and accuracy of data stored in eCMS. Identified exceptions should continue to be documented, and appropriate corrective actions (e.g., adequate training and guidance) should be completed to ensure and improve completeness and accuracy of data stored in eCMS.

No. 12   to Office of Management

Coordinate and report system errors to Treasury on an as needed basis to ensure all required or derivable data elements are reported for FABS submission.

| 19-06004-225 | Summary | Report

Recommendations (7)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The director of the VA Sierra Pacific Network (VISN 21) should ensure out-of-cycle projects conform to NRM policy urgent-need criteria before approving projects.

No. 2   to Veterans Health Administration (VHA)

The director of VISN 21 should study the feasibility of using non-engineering staff to oversee NRM contracts, contracting out for project requirements to free up VISN engineering resources, and sharing engineering resources between VISN 21 facilities.

No. 3   to Veterans Health Administration (VHA)

The under secretary for health should implement an engineering staffing model for medical facilities that supports the achievement of VA strategic goals.

No. 4   to Veterans Health Administration (VHA)

The under secretary for health should perform annual reviews of the engineering staffing model to determine if adjustments are needed to achieve VA strategic goals.

No. 5   to Veterans Health Administration (VHA)

The under secretary for health should ensure medical facilities design long-range action plans that are feasible based on expected NRM budget levels.

No. 6   to Office of Asset Enterprise Management

The executive director of the Office of Asset Enterprise Management, in coordination with the under secretary for health, should enforce NRM policy’s urgent-need criteria on out-of-cycle NRM project approvals.

No. 7   to Veterans Health Administration (VHA)

The under secretary for health in coordination with the executive director of the Office of Asset Enterprise Management should create a standardized set of performance measures and reporting standards for offices involved in developing, approving, and executing long-range action plans to ensure NRM projects that align with strategic goals are executed.

| 20-03407-253 | Summary | Report

Recommendations (2)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Office of Acquisitions, Logistics, and Construction (OALC); Veterans Health Administration (VHA)

Implement a plan that brings the five new noncompliant land use agreements into compliance with the West Los Angeles Leasing Act of 2016, the draft master plan, and other federal laws, allowing reasonable time to correct deficiencies noted in this report.

No. 2   to Veterans Health Administration (VHA)

Ensure VA’s capital asset inventory accurately reflects all land use agreements lasting six months or longer on the West Los Angeles campus.

| 20-01802-234 | Summary | Report

Recommendations (4)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

Coordinate with appropriate officials, including the VA Office of General Counsel, and determine if 38 U.S.C. § 1703(i) and other reimbursement practices cited in this report apply to the reimbursement rates medical facilities should pay for prosthetic and orthotic items provided by vendors. If they do apply, develop and issue guidance requiring medical facilities to adhere to them; if they do not apply, develop and issue guidance on steps medical facilities need to take to ensure they purchase prosthetic and orthotic items at reasonable prices.

No. 2   to Veterans Health Administration (VHA)

Develop and implement effective procedures to monitor prosthetic spending to make sure medical facilities reimburse vendors at reasonable prices for all prosthetic and orthotic items in accordance with updated pricing policies and processes.

No. 3   to Veterans Health Administration (VHA)

Coordinate with appropriate officials such as the Prosthetic and Sensory Aids Service executive director and the executive director, Rehabilitation and Prosthetics Service, to establish a formal oversight structure that defines the roles and responsibilities of those charged with providing oversight of the prosthetics program, rescind handbooks that reflect an outdated oversight structure, and communicate updated oversight expectations to the Veterans Integrated Service Networks to promote consistent program oversight.

No. 4   to Veterans Health Administration (VHA)

Resolve National Prosthetics Patient Database limitations and establish requirements to routinely monitor medical facilities’ input of data to improve accuracy.

Total Monetary Impact of All Recommendations

Open: $ 20,000,000.00
Closed: $ 0.00

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