Open Recommendations

Review and pay claimants the underpayments we identified, as applicable.

Add controls to ensure employees properly notify claimants when disability claims are denied and manual notifications are required.

Add controls to ensure employees complete all mandatory claim development prior to denying disability claims.

The principal executive director of the Office of Acquisition, Logistics, and Construction considers whether any additional training or other measures are necessary with respect to reporting the wrongdoing of a supervisor and the acceptance of free meals and drinks by VA employees during the February 2023 site visit.

The principal executive director of the Office of Acquisition, Logistics, and Construction determines whether any additional guidance, training, or oversight is needed with respect to ensuring VA employees do not improperly solicit sponsorships for VA events that do not primarily benefit veterans.

VA’s designated agency ethics official determines whether any additional steps need to be taken in connection with Ms. Dawson’s 2023 public financial disclosure based on the findings of this report.

Facility leaders identify barriers to providers completing toxic exposure screenings and implement actions to ensure providers complete screenings within 30 days of initiation.

Resume conducting firsthand investigations, in accordance with Title 44 section 1909, paragraph 2.

Update SOD 312 to include rubrics and definitions, along with a simple checklist, as a minimal firsthand investigation that executives can use during commemorative event trips.

Request JCP approval for measures that are considered necessary for the economical and practical implementation of the FDLP, such as including commemorative events, training, or consultations as firsthand investigations.

Develop and use a system of recordkeeping to track notifications to the JCP and JCP approval of SuDoc activities for the economical and practical implementation of the FDLP.

Clarify and document the Division of Management’s formal delegation of authority to the law enforcement unit for Board physical security decisions.

Establish and document physical security standards for the agency that include a risk-based decisionmaking framework to
a. raise and resolve physical security considerations and concerns.
b. document physical security decisions, including describing the rationale for any deviations from physical security standards.

Assign responsibility for managing third-party access cards for Board-leased spaces.

Ensure that the responsible group develops and implements a process to
a. collect and deactivate third-party access cards from offboarded Board personnel.
b. periodically reconcile third-party access card rights against human resources' list of active Board employees and contractors.

Establish a policy that defines the Technical Security Bureau’s responsibilities and the standard operating procedures needed to fulfill those responsibilities.

Develop and document
a. measurable performance objectives for the Technical Security Bureau’s responsibilities.
b. a monitoring process to assess the Technical Security Bureau’s progress toward achieving those objectives.

Confirm that medical facility directors develop local guidance on using automated dispensing cabinets in accordance with VHA Directive 1108.21 (and any revisions to this directive) and that facilities comply with that local guidance.

Require Pharmacy Benefits Management Services to revise VHA Directive 1108.21 to include routine monitoring for the use of generic information as a requirement in facility-level guidance for automated dispensing cabinets.

Ensure, in coordination with the controlled substance coordinator, or appropriate designee, and Veterans Integrated Service Networks, that reports detailing cabinet transactions for controlled substances removed using generic information are reviewed as part of required controlled substance inspections.

The Overton Brooks VA Medical Center Director conducts a comprehensive review of the patient’s hospitalization and takes action as indicated, including quality management improvement processes such as a peer review.

The Overton Brooks VA Medical Center Director ensures medical staff recognize the importance of obtaining hospitalized patients’ non-VA medical records and assesses the current processes for obtaining non-VA medical records, identifies any barriers to completion, and takes action as warranted.

The Overton Brooks VA Medical Center Director assesses the application of the one-to-one observation policy and practices at the facility, and takes action as warranted.

The Overton Brooks VA Medical Center Director reviews interim behavioral patient record flag processes to ensure implementation of safety strategies for staff and patients, and takes action as warranted.

The Overton Brooks VA Medical Center Director evaluates whether documentation of patient and patient-related behavioral events are reflected accurately in the electronic health record to facilitate continuity of care and communication among medical staff and takes action as necessary.