Open Recommendations

The Syracuse VA Medical Center Director evaluates the communication of established contingency plans and ensures alignment with high reliability organization principles.

The Syracuse VA Medical Center Director ensures the monitoring and evaluation of patient transfers according to Veterans Health Administration Directive 1094(1) and takes action as warranted.

The Syracuse VA Medical Center Director ensures annual procedural complexity designation infrastructure reviews are completed accurately and ensures administrative actions are performed as required.

The New York/New Jersey VA Healthcare Network Director evaluates fiscal year 2026 procedural complexity designation infrastructure reviews for all Veterans Integrated Service New York/New Jersey VA Health Care Network facilities and takes action to ensure reviews are accurate and deficiencies are addressed as required.

The Under Secretary for Health ensures a timeliness expectation for infrastructure waiver submissions pursuant to Veterans Health Administration Directive 1220(1).

The New York/New Jersey VA Healthcare Network Director evaluates the circumstances that led to Network and Syracuse VA Medical Center leaders not following clinical restructuring requirements according to VHA Directive 1043.

The Syracuse VA Medical Center Director evaluates the implementation of high reliability organization principles when communicating changes to clinical operations that include stakeholders, service and section leaders, and staff input.

The Syracuse VA Medical Center Director evaluates facility contract processes and takes action to ensure leaders maintain adequate oversight of contracting milestones.

The Syracuse VA Medical Center Director evaluates the communication of established contingency plans and ensures alignment with high reliability organization principles.

The Syracuse VA Medical Center Director ensures the monitoring and evaluation of patient transfers according to Veterans Health Administration Directive 1094(1) and takes action as warranted.

The Syracuse VA Medical Center Director ensures annual procedural complexity designation infrastructure reviews are completed accurately and ensures administrative actions are performed as required.

The New York/New Jersey VA Healthcare Network Director evaluates fiscal year 2026 procedural complexity designation infrastructure reviews for all Veterans Integrated Service New York/New Jersey VA Health Care Network facilities and takes action to ensure reviews are accurate and deficiencies are addressed as required.

The Under Secretary for Health ensures a timeliness expectation for infrastructure waiver submissions pursuant to Veterans Health Administration Directive 1220(1).

Develop a plan and timeline to issue regulations for States to implement SNAP Electronic Benefits Transfer security measures that detect and prevent card cloning and skimming fraud so that the projected fraudulent and replaced benefits, totaling $555 million, could be put to better use.

USDA OIG has determined that this recommendation contains sensitive information and will not be publicly released due to privacy concerns.

USDA OIG has determined that this recommendation contains sensitive information and will not be publicly released due to privacy concerns.

The Under Secretary for Health clarifies the requirements for suicide risk and intervention training for audiologists and delineates responsibility for ensuring training is completed as required.

The Under Secretary for Health evaluates the definition of healthcare provider for the purposes of suicide risk and intervention training.

The Under Secretary for Health evaluates the accuracy of suicide risk and intervention training assignment, consistent with Veterans Health Administration policy, for all healthcare providers.

The Under Secretary for Health ensures audiology staff complete suicide risk identification screening as required.

The Under Secretary for Health evaluates oversight of and barriers to mental health integration in audiology services and takes action as appropriate.

The Under Secretary for Health clarifies the requirements for suicide risk and intervention training for audiologists and delineates responsibility for ensuring training is completed as required.

The Under Secretary for Health evaluates the definition of healthcare provider for the purposes of suicide risk and intervention training.

The Under Secretary for Health evaluates the accuracy of suicide risk and intervention training assignment, consistent with Veterans Health Administration policy, for all healthcare providers.

The Under Secretary for Health ensures audiology staff complete suicide risk identification screening as required.

The Under Secretary for Health evaluates oversight of and barriers to mental health integration in audiology services and takes action as appropriate.

Enforce procedures for Veterans Health Administration human resources officials to monitor employee service obligations and initiate a debt notice when an employee breaches that agreement, if warranted.

Identify and review active incentives of Veterans Health Administration employees who transferred within or left VA and take action, if appropriate.

Establish enhanced internal controls to ensure compliance with the law on recruitment, relocation, and retention incentives and take appropriate action when an employee with an active service obligation transfers within the Veterans Health Administration.

Complete the evaluation of the incentives awarded to the employees identified in this report who may not have fulfilled their service obligations, determine whether a debt was incurred, and take any appropriate action.

Enforce procedures for Veterans Health Administration human resources officials to monitor employee service obligations and initiate a debt notice when an employee breaches that agreement, if warranted.

Identify and review active incentives of Veterans Health Administration employees who transferred within or left VA and take action, if appropriate.

Establish enhanced internal controls to ensure compliance with the law on recruitment, relocation, and retention incentives and take appropriate action when an employee with an active service obligation transfers within the Veterans Health Administration.

Complete the evaluation of the incentives awarded to the employees identified in this report who may not have fulfilled their service obligations, determine whether a debt was incurred, and take any appropriate action.

Establish procedures to monitor compliance with FLRA’s Alternative Work Schedules policy.

Provide training to all employees (which includes supervisors) on all available alternative work schedules. This training should be provided to all new employees during employee orientation and to all employees whenever significant changes to the policy occur.

Modify the FLRA Policy No. 3640.2 Work Schedule Selection Form to the correct flexible schedule options that employees may choose.

We recommend the Vice President, Power Supply and Fuels, determine if impacts from program implementation and adoption challenges have been incorporated in future goals.

Implement a process to thoroughly review the journal entry and supporting documentation used to record and calculate imputed cost, respectively, to ensure that the cost is accurately recorded in the general ledger.

Take appropriate action to award retirement benefits to the 35 claimants identified in our audit.

To prevent future errors, establish controls to ensure employees request and document evidence of lag earnings when claimants allege such earnings.

To prevent future errors, establish controls to ensure employees review prior retirement claims for claimants who may be entitled to additional benefits based on prior claims.

The Marion VA Health Care System Director ensures primary care nursing staff’s adherence to facility fall prevention policy and monitors compliance.

The Marion VA Health Care System Director evaluates the facility fall prevention policy to consider expectations for mental health staff’s role in responding to patient reports of falls at home.

The Marion VA Health Care System Director ensures compliance with the primary care program facility policy concerning specialty consultation staff’s communication with a patient’s primary care provider regarding patient concerns.

The Marion VA Health Care System Director ensures compliance with the facility patient problem list standard operating procedure.

The Marion VA Health Care System Director strengthens processes to ensure compliance with Veterans Health Administration timeliness standards for obtaining and scanning community care records.

The Marion VA Health Care System Director reviews facility care coordination practices between primary care providers and community care providers, identifies barriers to sharing patient treatment information to inform clinical decision-making, and takes action as warranted.

The Marion VA Health Care System Director ensures community care staff adhere to requirements regarding completion of community care-care coordination plan notes and monitors compliance.

The Marion VA Health Care System Director conducts a review of the facility primary care scheduling processes to ensure compliance with Veterans Health Administration and facility policy on care coordination within Patient Aligned Care Teams.