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

OIG Reports

| 21-02903-214 | Summary | Report

Recommendations (6)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Under Secretary for Health reviews vulnerabilities related to life-sustaining treatment processes and do not resuscitate orders within Veterans Health Administration facilities

No. 2   to Veterans Health Administration (VHA)

The Michael E. DeBakey VA Medical Center Director evaluates staff’s reliance on the electronic health record as the definitive source for verification of life-sustaining treatment orders and patients’ code statuses and takes action as indicated

No. 3   to Veterans Health Administration (VHA)

The Michael E. DeBakey VA Medical Center Director ensures that corrective actions from internal and quality management reviews are fully developed, implemented, and monitored for effectiveness.

No. 4   to Veterans Health Administration (VHA)

The Michael E. DeBakey VA Medical Center Director ensures that the electronic health record displays life-sustaining treatment orders where staff can easily locate the information.

No. 5   to Veterans Health Administration (VHA)

The Michael E. DeBakey VA Medical Center Director ensures that modifications to patients’ life-sustaining treatment orders, including do not resuscitate orders, are confirmed with the patient and surgical team and documented in the electronic health record prior to surgical procedures requiring anesthesia.

No. 6   to Veterans Health Administration (VHA)

The Michael E. DeBakey VA Medical Center Director determines that facility staff review patients’ code statuses for any changes upon patients’ return to units after surgical procedures.

| 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

| 21-03339-208 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Capital Health Care Network Director reviews and evaluates the March 2021 Administrative Investigation Board action plan to identify open actions and ensures completion.

No. 2   to Veterans Health Administration (VHA)

The Beckley VA Medical Center Director ensures a review of Veterans Health Administration and Beckley VA Medical Center policies related to professional practice evaluations, including supervisory roles, review periods, and service-specific data collection, and takes action as appropriate.

No. 3   to Veterans Health Administration (VHA)

The Beckley VA Medical Center Director reviews and evaluates Veterans Health Administration and Beckley VA Medical Center policies related to disclosures and quality management actions such as look-back reviews and patient safety reporting to ensure such actions are timely, objective, and documentation is sufficient to address the issue under review.

No. 4   to Veterans Health Administration (VHA)

The Beckley VA Medical Center Director ensures staff education of Veterans Health Administration and Beckley VA Medical Center policies related to employee misconduct and monitors compliance.

No. 5   to Veterans Health Administration (VHA)

The Beckley VA Medical Center Director evaluates processes for reporting providers to the state licensing boards, including initial and comprehensive reviews, and monitors compliance.

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