Open Recommendations

Ensure the program clarifies and defines requirements for pain management teams in the new Veterans Health Administration Directive 1151, Pain Management and Opioid Safety.

Establish means to periodically validate the status information of facilities’ pain management teams.

Require the program and the chief operating officer to assess and ensure corrective actions are taken to address each medical facility’s lack of progress in achieving compliance with the requirement to have a pain management team as mandated by the Jason Simcakoski Memorial and Promise Act.

We recommend that the OGP Associate Administrator strengthen the PMRD’s policies and procedures to: more clearly define the PMR scoring system and its relevance to the PMR report findings and recommendations; clearly identify the findings and recommendations in the PMR report, including whether corrective action is required to address each finding; and ensure all required corrective actions are included in a CAP and implemented.

We recommend that the OGP Associate Administrator perform training and oversight to ensure proper administration and closeout of CAPs.

District leaders and the Evanston, La Crosse, and Milwaukee Vet Center Directors collaborate with the support VA medical facility to determine reasons for noncompliance with staff participation on the mental health executive council, take action as indicated, and monitor compliance.

District leaders and the Evanston, Gary Area, La Crosse, and Milwaukee Vet Center Directors determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented, and monitor compliance.

District leaders and the Gary Area Vet Center Director determine reasons for noncompliance with Vet Center Director review of 10 percent of active client records monthly for each counselor’s caseload, ensure completion, and monitor compliance.

District leaders and the Gary Area, La Crosse, and Milwaukee Vet Center Directors determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.

District leaders and the Evanston, Gary Area, and Milwaukee Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.

District leaders and the La Crosse Vet Center Director determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.

District leaders determine reasons why the closing of the Milwaukee Vet Center resulted in multiple communication failures, and ensure all clients are notified of the new location, the Vet Center Call Center has accurate information, and websites include correct location and phone number information.

The Readjustment Counseling Service Chief Officer considers developing written guidance for vet center closure and temporary relocation processes including oversight responsibilities.

Reconcile the differences between grantees’ internal accounting records and FFRs to determine the propriety of the component payments or require grantees to perform this reconciliation. Additionally, AmeriCorps should test and include the unmatched reporting errors as unknown payment errors in the projection of the improper payment estimate.

Determine whether awardees associated with FFRs submitted for Seniors awards were submitted by eligible organizations during the FFR data pull process. If it is determined that any AmeriCorps Seniors grantees were ineligible to receive the grant, AmeriCorps should include the entire FFR as an improper payment.

Implement additional quality control steps, proposed in response to NFR 2, to its improper payment data pulling and sampling process to ensure that all payments included are appropriate for the programs determined to be susceptible to improper payments. 

Publish improper payment and unknown payment estimates for NST in the accompanying materials provided with the FY 2025 annual financial statements in accordance with OMB guidance. 

Update its NST test plan to require the tester to verify that sampled education awards were only used to cover allowable COA expenses for members who earned the award (unless appropriately transferred).

Improve its quality control procedures to ensure AmeriCorps selects its NST sample and extrapolates its NST improper payment estimates consistent with its NST SEMP. Specifically, its quality control procedures should ensure AmeriCorps:
a. Excludes only records in the payment population that do not represent applicable disbursements, as justified in its SEMP.
b. Extrapolates its improper payment estimate only on the payments included within the sampling frame, unless otherwise justified and approved by OMB.
c. Documents the methodology used to extract the NST payment population used for sampling and the procedures used to verify the payment population is complete and accurate.

The OIG recommends the Under Secretary for Health evaluates facility leaders for appropriate supervisory behavior and professional communication and takes actions as needed.

The OIG recommends the Under Secretary for Health determines whether the Veterans Integrated Service Network Director and other Veterans Integrated Service Network leaders were aware of, but did not address, facility leaders’ unprofessional behavior and communication, and takes actions as needed.

The OIG recommends the Under Secretary for Health ensures the Veterans Integrated Service Network and facility directors oversee the inventory management system, resolve medical supply deficiencies, and monitor actions for sustained improvement.

The OIG recommends facility leaders develop action plans to ensure providers communicate test results to patients timely.

The OIG recommends the Under Secretary for Health directs the national VHA Quality and Patient Safety Program staff to review the facility’s quality management program and determine whether actions by facility and Veterans Integrated Service Network leaders effectively addressed system issues affecting patient safety, including nursing leaders’ lack of access to safety reports, and missed opportunities for institutional disclosures, and takes action as needed.

The Under Secretary for Health evaluates facility leaders for appropriate supervisory behavior and professional communication and takes actions as needed.