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

OIG Reports

| 21-00797-248 | Summary | Report

Recommendations (7)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures that Intimate Partner Violence Assistance Program protocols are developed at all medical centers consistent with the national requirement.

No. 2   to Veterans Health Administration (VHA)

The Under Secretary for Health evaluates the sufficiency of current guidance and operational status regarding Intimate Partner Violence Assistance Program coordinators’ dedicated time and population needs, and takes action as warranted.

No. 3   to Veterans Health Administration (VHA)

The Under Secretary for Health determines the appropriate guidance for dedicated administrative staff support in consideration of the Intimate Partner Violence Assistance Program coordinators’ responsibilities, and takes action as warranted.

No. 4   to Veterans Health Administration (VHA)

The Under Secretary for Health considers the establishment of standardized Intimate Partner Violence staff training content and format as well as the evaluation of training efficacy, and takes action as warranted.

No. 5   to Veterans Health Administration (VHA)

The Under Secretary for Health develops intimate partner violence screening requirements based on the current guidance and patient population needs, and takes action as warranted.

No. 6   to Veterans Health Administration (VHA)

The Under Secretary for Health expedites standardized program evaluation processes with oversight and reporting responsibilities to ensure identification of implementation and program deficiencies and monitoring of corrective action and performance improvement plans.

No. 7   to Veterans Health Administration (VHA)

The Under Secretary for Health evaluates the current guidance and operational status related to the roles and oversight functions of the Veterans Integrated Service Network Intimate Partner Violence Assistance Program champions and lead coordinators and clarifies expectations and requirements.

| 21-02641-229 | Summary | Report

Recommendations (3)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

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

Assess compliance weaknesses identified by VA Office of Procurement Policy, Systems and Oversight internal reviews, and implement corrective actions determined appropriate.

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

Require contracting officers responsible for Buy American Act compliance deficiencies identified by contract file reviewers and VA Office of Procurement Policy, Systems and Oversight internal reviews to attend refresher Buy American Act–specific training.

No. 3   to Veterans Health Administration (VHA)

Evaluate the contract file review procedures to make certain they require the use of the Definitions of Comment Categories, and presolicitation and preaward checklists, and document that use, to strengthen compliance.

| 21-02145-243 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

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

Ensure the director of the Office of Operations, Security, and Preparedness creates a written policy establishing minimum standards for ballistic armor for Executive Protection Division personnel based on agents’ input, industry best practices and research, and relevant threat levels, which is routinely reassessed for adequacy.

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

Make certain that the director of the Office of Security and Law Enforcement develops onboarding procedures for new Executive Protection Division personnel who are or may be assigned to protective details or motorcades of the VA Secretary or Deputy Secretary, including procedures for measuring personnel and procuring new ballistic vests or assessing and approving the use of an employee’s own vest to ensure it meets minimum safety standards.

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

Require the director of the Office of Security and Law Enforcement to establish procedures to track the maintenance and expiration of ballistic vests assigned to Executive Protection Division personnel and to ensure their replacement as needed.

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

Instruct the director of the Office of Security and Law Enforcement to create procedures for monitoring compliance with the standard operating procedure requirement to wear ballistic armor, such as periodic inspections, and establish consequences for noncompliance.

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

The OIG recommends that the director of the Office of Security and Law Enforcement conducts a review of the condition of all firearms currently assigned to EPD special agents and determines whether any are in need of replacement.

| 21-03203-239 | Summary | Report

Recommendations (7)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Southeast Network Director facilitates a comprehensive review of Patient A’s episode of care, from the time and date of the patient’s hospitalization through the date and time of the patient’s death, to identify practitioner and process improvements that may reduce the potential for future incidents, and takes appropriate actions.

No. 2   to Veterans Health Administration (VHA)

The Columbia VA Health Care System Director ensures providers carefully consider facility resources when evaluating medically-complex patients for admission and when determining whether admitted patients’ medical complexities exceed the facility’s capabilities to meet patients’ needs.

No. 3   to Veterans Health Administration (VHA)

The Columbia VA Health Care System Director ensures that the peer review committee record the committee members formal discussions specific to the peer review in meeting minutes, and monitors ongoing compliance.

No. 4   to Veterans Health Administration (VHA)

The Columbia VA Health Care System Director evaluates quality management practices that impede the timeliness of institutional disclosures, ensures current practices are in alignment with Veterans Health Administration policy, and takes action as warranted.

No. 5   to Veterans Health Administration (VHA)

The Columbia VA Health Care System Director ensures that root cause analyses are completed within the required 45-day time frame to promptly identify and address system vulnerabilities.

No. 6   to Veterans Health Administration (VHA)

The Columbia VA Health Care System Director facilitates a comprehensive administrative review of the vascular surgeon’s disregard of surgical and invasive procedure protocols and Stop the Line principles, consults with the Office of Regional Counsel and human resource specialists, and takes administrative actions, as appropriate.

No. 7   to Veterans Health Administration (VHA)

The Columbia VA Health Care System Director evaluates facility staff’s informed consent and time-out practices, to include the review of pertinent medical images, and ensures practices are consistent with correct surgery and invasive procedure requirements, takes action as appropriate, and monitors compliance.

| 22-00973-215 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

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

Implement a more effective process to maintain consistent inventory information for all network segments.

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

Implement a vulnerability management program that ensures system changes occur within organization timelines.

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

Implement effective system life-cycle processes to ensure network devices meet standards mandated by the VA Office of Information and Technology Configuration Control Board.

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

Develop and implement a process to retain database logs for a period consistent with VA’s record retention policy.

No. 5   to Veterans Health Administration (VHA)

Validate that appropriate physical and environmental security measures are implemented and functioning as intended.

| 21-03906-226 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

Coordinate with the Prosthetic and Sensory Aids Service executive director to (1) develop and issue guidance clearly articulating eligibility requirements for the lifetime benefit amounts to address non-service-connected disabilities and (2) communicate this guidance in an effective manner, such as including specific language in handbooks, providing examples of scenarios to reinforce the requirements, and requiring annual training to make sure all prosthetic staff responsible for the program understand these eligibility requirements.

No. 2   to Veterans Health Administration (VHA)

Coordinate with the Prosthetic and Sensory Aids Service executive director to make sure Veterans Integrated Service Network prosthetic representatives look at veteran eligibility for non-service-connected disability benefits in their annual reviews of medical facilities’ prosthetics programs.

No. 3   to Veterans Health Administration (VHA)

Coordinate with the Prosthetic and Sensory Aids Service executive director to correct and update inaccurate information on the publicly accessible Home Improvements and Structural Alterations Program website.

No. 4   to Veterans Health Administration (VHA)

Coordinate with the assistant under secretary for health for operations and the Prosthetic and Sensory Aids Service executive director to make sure medical facilities or Veterans Integrated Service Networks implement procedures for verifying that veterans’ Home Improvement and Structural Alterations packages include documentation of approval and justification for all improvements and alterations paid for with program benefits.

No. 5   to Veterans Health Administration (VHA)

Coordinate with the assistant under secretary for health for operations and the Prosthetic and Sensory Aids Service executive director to ensure medical facilities and Veterans Integrated Service Network directors implement procedures to capture when key documentation is received and monitor these dates to ensure facilities adhere to timelines for the Home Improvements and Structural Alterations Program and take corrective action when they are not meeting standards outlined in 38 C.F.R. §§ 17.3100 through 17.3130 and VHA Directive 1173.14.

Total Monetary Impact of All Recommendations

Open: $ 13,798,444.00
Closed: $ 0.00

| 22-00971-217 | Summary | Report

Recommendations (8)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

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

Implement a more effective process to maintain consistent inventory information for all network segments.

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

Improve the vulnerability and flaw remediation program to accurately identify vulnerabilities and enforce flaw remediation.

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

Implement effective configuration control processes that ensure network devices maintain vendor support.

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

Perform security control assessments of the video surveillance system and obtain an authorization to operate in accordance with set policy.

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

Ensure installation of distributed network infrastructure equipment that meets VA installation standards, to include proper equipment mounting and clearance.

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

Ensure routine maintenance is conducted on uninterruptible power supplies.

No. 7   to Office of Information and Technology (OIT)

Implement database authentication processes that comply with VA security requirements.

No. 8   to Office of Information and Technology (OIT)

Implement a physical access control system for the data center and core switch room that is supportable and can meet VA logging requirements.

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