Recommendation: The Secretary of VA should improve the completeness and accuracy of use of force data in Report Executive by addressing (1) incomplete categorization of the type of force used, (2) inaccurate data on the highest level of force used, and (3) the potential for duplicate data entries. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Secretary of VA should implement plans to include analytical features in Report Executive that will position the agency to analyze use of force data at VA medical centers nationwide, including by officer; type of force used; and facility, among other variables. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Secretary of VA should ensure that medical centers submit records of all locally initiated use of force investigations and any resulting disciplinary action to VA headquarters office(s) with responsibility for police oversight. (Recommendation 3)

Agency: Department of Veterans Affairs
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Secretary of VA should implement plans for obtaining a quality database to collect all locally initiated use of force investigations at medical centers. (Recommendation 4)

Agency: Department of Veterans Affairs
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: Once positioned to do so, the Secretary of VA should analyze all use of force investigations and any resulting disciplinary action by facility; officer; and outcome, among other variables. (Recommendation 5)

Agency: Department of Veterans Affairs
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with the Surgeons General of the military departments and the Director of the DHA, consistently collect complete and accurate information about the quality of available civilian health care in proximity to its MTFs (such as ratings from the Centers for Medicare and Medicaid Services and perceptions from MTF officials who regularly coordinate with civilian providers, among other means) and assess that information to inform recommendations for future MTF restructuring decisions. (Recommendation 1)

Agency: Department of Defense
Status: Open

Comments: DOD partially concurred with this recommendation. In its response, the department described its planned implementation steps, such as publishing measures it may use for assessing available civilian health care. We will continue to monitor the status of the measures and any other actions the department takes to address the recommendation.

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with the Surgeons General of the military departments and the Director of the DHA, consistently collect complete and accurate information about the extent to which current health care providers within the TRICARE networks meet access-to-care standards, and assess that information to inform recommendations on future MTF restructuring decisions. (Recommendation 2)

Agency: Department of Defense
Status: Open

Comments: DOD partially concurred with this recommendation. The department noted actions underway and planned to implement it, including a centralized appointment booking system and monitoring access to care as MTFs restructure. We will continue to monitor the status of this effort and any other actions the department takes to address the recommendation.

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with the Surgeons General of the military departments and the Director of the DHA, consistently collect complete and accurate information about the extent to which non-network civilian health care providers that could be incorporated into the TRICARE network meet access-to-care standards in terms of drive time, and assess that information to inform recommendations on future MTF restructuring decisions. (Recommendation 3)

Agency: Department of Defense
Status: Open

Comments: DOD partially concurred with this recommendation, and described planned steps to implement it for future MTF restructuring decisions. We will continue to monitor actions the department takes to address the recommendation.

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with the Surgeons General of the military departments and the Director of the DHA, conducts a sensitivity analysis of the relative cost-effectiveness of MTF-provided care compared to civilian-provided care under varying assumptions, and document that information for decision makers to inform recommendations on future MTF restructuring decisions. Varying conditions could include different types of health care services, reducing the cost of military personnel salaries, and increasing estimated MTF wRVUs and civilian reimbursement rates. (Recommendation 4)

Agency: Department of Defense
Status: Open

Comments: DOD partially concurred with this recommendation. We will continue to monitor actions the department takes to address the recommendation.

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with the Surgeons General of the military departments and the Director of the DHA, establishes clear roles and responsibilities for executing and monitoring transitions for MTFs identified for restructuring. (Recommendation 5)

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation and described actions underway and planned to implement it. We will continue to monitor actions the department takes to address the recommendation.

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with the Surgeons General of the military departments and the Director of the DHA, defines measurable objectives for MTF restructuring transitions, establishes thresholds and goals for each objective, and applies them to evaluate progress and challenges. For example, measurable objectives, thresholds, and goals, should include an evaluation of medical providers' clinical readiness, civilian health care provider adequacy, and the cost-effectiveness of MTF and purchased care. (Recommendation 6)

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation and described actions underway and planned to implement it. We will continue to monitor actions the department takes to address the recommendation.

Recommendation: The Under Secretary for Health should take steps to improve communication to VAMC staff (including HIV lead clinicians) about the availability of data on the time frames in which test results are communicated to veterans. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Under Secretary for Health should disseminate data to HIV lead clinicians on the extent to which veterans who test positive for HIV are linked to care within recommended time frames. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Secretary of Veterans Affairs should ensure that the Associate Executive Director of VA's NAC puts controls in place to better ensure the completeness of vendor FSS sales reporting. (Recommendation 1)

Agency: Department of Veterans Affairs: Office of the Secretary
Status: Open

Comments: VA concurred with this recommendation and is taking steps to implement it. In August 2020, VA reported that it has taken steps to better ensure the completeness of vendor FSS sales reporting, including by conducting more active monitoring of the sales data submitted by vendors. These steps are ongoing, but NAC has reported a decrease in the number of FSS contractors not reporting sales.

Recommendation: The Secretary of Veterans Affairs should ensure that the Associate Executive Director of VA's NAC assesses data on the participation of and items and services offered by veteran-owned small businesses in NAC's FSS program, in order to determine whether their program is meeting the needs of VHA contracting officers who use it given the Veterans First requirements they must meet. (Recommendation 2)

Agency: Department of Veterans Affairs: Office of the Secretary
Status: Open

Comments: VA concurred with this recommendation and is taking steps to implement it. In August 2020, VA reported that NAC has conducted additional outreach to veteran-owned small businesses regarding FSS participation, and plans to conduct analysis of these businesses' participation in FSS by the end of fiscal year 2020.

Recommendation: The Secretary of Veterans Affairs should ensure that the Associate Executive Director of VA's NAC directs the FSS Director to develop a mechanism to consistently obtain and analyze VHA user feedback on the FSS program. (Recommendation 3)

Agency: Department of Veterans Affairs: Office of the Secretary
Status: Open

Comments: VA concurred with this recommendation and has taken several actions to more consistently obtain VHA user feedback on the FSS program, including holding meetings with each VHA regional contracting office and participating in VHA integrated project teams and other recurring meetings. We have requested documentation of these activities, but VA has yet to provide it.

Recommendation: The Secretary of Veterans Affairs should ensure that the Associate Executive Director of VA's NAC provides FSS contracting staff with comprehensive FSS guidance. (Recommendation 4)

Agency: Department of Veterans Affairs: Office of the Secretary
Status: Open

Comments: VA concurred with this recommendation and NAC reported in August 2020 that it has taken steps to make existing guidance on the FSS program more accessible to FSS contracting staff. We have requested more documentation from VA to confirm that the guidance is comprehensive.

Recommendation: The Secretary of Veterans Affairs should ensure that the Associate Executive Director of VA's NAC develops an FSS-specific training program to include essential skills and processes to meet ongoing training needs for new and existing contracting staff. (Recommendation 5)

Agency: Department of Veterans Affairs: Office of the Secretary
Status: Open

Comments: VA concurred with this recommendation and NAC reported in August 2020 that it has implemented additional introductory training for new FSS contracting staff, as well as quarterly training events for all FSS contracting staff. We have requested additional documentation from VA on the content of the quarterly training.

Recommendation: The Administrator of GSA should work with the Secretary of VA to develop a memorandum of understanding outlining the roles and responsibilities of GSA and NAC for collaborating under GSA's delegation of authority to VA for the healthcare-related Federal Supply Schedules, including the processes through which the two organizations will coordinate and share useful tools and practices. (Recommendation 6)

Agency: General Services Administration: Office of the Administrator
Status: Open

Comments: GSA concurred with this recommendation. In August 2020, GSA stated that it has met with VA and agreed to develop an interagency memorandum of understanding by December 2020.

Recommendation: The Secretary of Veterans Affairs should work with the Administrator of GSA to develop a memorandum of understanding outlining the roles and responsibilities of GSA and NAC in collaborating under GSA's delegation of authority to VA for the healthcare-related Federal Supply Schedules, including the processes through which the two organizations will coordinate and share useful tools and practices. (Recommendation 7)

Agency: Department of Veterans Affairs: Office of the Secretary
Status: Open

Comments: VA concurred with this recommendation. In August 2020, GSA stated that it has met with VA and agreed to develop an interagency memorandum of understanding by December 2020.

Recommendation: The Administrator of GSA should take steps to document its delegation of authority for the healthcare-related Federal Supply Schedules to VA. (Recommendation 8)

Agency: General Services Administration: Office of the Administrator
Status: Open

Comments: GSA concurred with this recommendation. In August 2020, GSA stated that it is working to develop updated delegation of authority and will provide further details by December 2020.

Recommendation: The Secretary of Veterans Affairs should ensure that the Associate Executive Director of VA's NAC assesses the appropriateness of NAC's current timeliness goals for FSS contract awards and takes steps to comprehensively identify and address barriers to achieving them. (Recommendation 9)

Agency: Department of Veterans Affairs: Office of the Secretary
Status: Open

Comments: VA concurred with this recommendation. In August 2020, VA reported that NAC has confirmed that existing timeliness goals are appropriate, and that NAC officials meet on a quarterly basis to discuss barriers to meeting these goals. We have requested more detail from NAC on the barriers they have identified and steps they are taking to address them so that we can assess whether they are comprehensive.

Recommendation: The Secretary of Veterans Affairs should ensure that the Associate Executive Director of VA's National Acquisition Center takes measures to ensure greater efficiency in the offer-intake process, such as providing additional guidance for vendors or by adopting a system that includes checks for completeness of required vendor documentation. (Recommendation 10)

Agency: Department of Veterans Affairs: Office of the Secretary
Status: Open

Comments: VA concurred with this recommendation. In August 2020, VA reported that NAC has developed a checklist for assessing the completeness of submitted offers, and that new offers are currently processed in an average of two days. NAC is considering adoption of an automated offer intake system. We have requested additional details from NAC on the recent average offer processing time.

Recommendation: The Secretary of Veterans Affairs should take steps to assess duplication between VA's FSS and MSPV programs, to determine if this duplication is necessary or if efficiencies can be gained. (Recommendation 11)

Agency: Department of Veterans Affairs: Office of the Secretary
Status: Open
Priority recommendation

Comments: VA concurred with this recommendation. In August 2020, VA stated that it is analyzing duplication of contracting across the department as part of its Category Management efforts, and expects to complete an internal report on this issue in early 2021.

Recommendation: The Under Secretary for Health should ensure that any action plan for achieving health equity includes key elements for successful implementation by consistently applying criteria identified in GAO's past work on effectively managing performance, including developing performance measures to assess progress and creating clear lines of accountability by designating specific offices or officials with responsibility for coordinating efforts to implement actions and committing resources necessary for achieving its goals and objectives. (Recommendation 1)

Agency: Department of Veterans Affairs: Office of the Under Secretary for Health
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: To ensure the availability of information on health care outcomes by race and ethnicity throughout the VA health care system, the Secretary of Veterans Affairs should conduct an assessment to determine the completeness and accuracy of race and ethnicity data captured in VA's electronic health record, and implement corrective actions as necessary to resolve any identified deficiencies. (Recommendation 2)

Agency: Department of Veterans Affairs: Office of the Secretary
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Secretary of Veterans Affairs should develop a department-wide succession plan for leadership and mission-critical occupations that incorporates key leading practices for succession planning. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: As of April 2020, VA reported that it is developing a department-wide succession plan for leadership positions and mission-critical occupations. VA estimated it would complete this plan by September 30, 2020. When VA provides us a copy of the completed plan, we will provide updated information.

Recommendation: The Under Secretary for Health should incorporate key leading practices into VHA's succession planning processes, including monitoring and evaluating VHA's succession planning. (Recommendation 2)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: As of April 2020, VHA reported that it is developing guidance and metrics, developing a process to assess field-based succession planning actions, and incorporating evaluations and updates of implementation strategies into its succession plan. VHA also indicated that it is developing a new VHA Executive Succession Plan. VHA plans to complete these actions by December 2021. When we receive VHA's updated plans and guidance, we will provide updated information.

Recommendation: The Under Secretary for Benefits should develop a succession planning process for all leadership positions and incorporate key leading practices into VBA's succession planning for leadership positions and mission-critical occupations. These practices include aligning the plans with strategic goals, identifying strategies to close workforce gaps, and monitoring and evaluating VBA's succession planning. (Recommendation 3)

Agency: Department of Veterans Affairs: Veterans Benefits Administration
Status: Open

Comments: As of April 2020, VBA reported that it is developing succession plans that align with VBA's strategic goals and identify succession planning strategies. VBA also indicated that it plans to review, assess, and update the plans annually. According to VBA, its plans will cover mission-critical occupations as well as leadership positions within those mission-critical occupations. However, VBA stated that VA's Corporate Senior Executive Management Office (CSEMO) is responsible for planning related to VBA's senior executives and that VBA will coordinate with CSEMO on succession planning for senior executives. To implement our recommendation, VBA will need to demonstrate that VBA, or CSEMO in coordination with VBA, has developed succession planning processes that cover all leadership positions (including senior executives) and mission-critical occupations. VBA expects to complete its succession plans by September 30, 2020. When we receive VBA's completed plans, we will provide updated information.

Recommendation: The Secretary of Veterans Affairs should update VA's 2003 directive on workforce and succession planning to incorporate relevant legal requirements, including Office of Personnel Management strategic human capital management regulation requirements. (Recommendation 4)

Agency: Department of Veterans Affairs
Status: Open

Comments: As of April 2020, VA reported that its updated directive is going through the Department's internal review and concurrence process. VA estimated it would complete the directive by July 31, 2020. When VA provides us a copy of the directive, we will provide updated information.

Recommendation: The Under Secretary for Health should develop a process to assess the overall performance of VISNs in managing and overseeing medical centers. (Recommendation 1)

Agency: Department of Veterans Affairs: Office of the Under Secretary for Health
Status: Open

Comments: VHA concurred with our recommendation. In December 2019, VHA reported efforts to modernize its governance structure with a newly created VHA Governance Board. In February 2020, VHA reported additional efforts to charter governance councils to support the VHA Governance Board and work continues to develop these councils and responsibilities, with a target completion date of September 2020. For closure, VHA will need to provide documentation that shows the process developed to assess the overall performance of VISNs in managing medical centers. Providing documentation explaining how these governance structures plan to assess overall VISN performance, including any metrics or tools that would be used as a part of this process, would be useful in determining if this recommendation can be considered for closure.

Recommendation: The Under Secretary for Health should establish a comprehensive policy that clearly defines VISN roles and responsibilities for managing and overseeing medical centers. (Recommendation 2)

Agency: Department of Veterans Affairs: Office of the Under Secretary for Health
Status: Open
Priority recommendation

Comments: VHA concurred in principle with our recommendation. In December 2019, VHA told us they were working to streamline reporting structures at all levels, focusing on governance and workflow, including defining consistent levels of authority. In February 2020, VHA told us they were realigning Central Office in addition to making changes to the governance structure to support clarity of roles and responsibilities. VHA plans to crosswalk existing policies to the new structure and organizations, with a target completion date of September 2020. Following completion of VHA's efforts to streamline Central Office and ensure reporting structures are in place, VHA will need to provide policy documentation that clearly outlines VISN roles and responsibilities, including how these governance structures plan to define the VISN's roles and responsibilities. While governance and reporting structures are a first step, it is important for roles and responsibilities to be clearly outlined in a policy vehicle, as VHA requires the use of policy to assign responsibilities for executing a course of action to individuals or groups.

Recommendation: The Under Secretary for Health should establish a process to routinely oversee VISN staffing, to include ensuring VISNs are consistent with VHA's standardized VISN staffing levels and positions, and documenting the rationale for approving staffing that does not adhere to VHA's standardized approach. (Recommendation 3)

Agency: Department of Veterans Affairs: Office of the Under Secretary for Health
Status: Open

Comments: VHA concurred with our recommendation. In December 2019, VHA reported its office for Manpower Management began reviewing changes to VISN organizational structure and positions. In February 2020, VHA provided GAO with the guidance for VISN staffing and a draft Manpower Management directive, with target completion date of May 2020 for approval. For closure, VHA should provide the approved VA Directive 5010 documentation outlining the process developed to routinely oversee VISN staffing, including efforts by the DUSHOM in partnership with Workforce Management and Consulting and Manpower and Management, such as policy directives, organizational charts, amongst others.

Recommendation: To improve VA's ability to plan for and align its facilities with estimated changes to veterans' needs and expectations, we recommend that the Secretary of Veterans Affairs ensure the appropriate offices and administrations develop and implement a process to assess veterans' changing expectations and disseminate this information to VAMCs. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with this recommendation, but noted that it had already developed and implemented effective systems for obtaining Veterans' input in facility planning. However, we found that the information VA collects through these efforts may be limited based on our review of VA's surveys, including VSignals and the Survey of Enrollees, as well as our discussions with several Veterans Service Organizations. For example, we found that VA's efforts were limited because they either focused on overall veteran expectations without a means of assessing how they differed by demographics, or they focused on veteran satisfaction with their past experiences. Moreover, satisfaction with past experiences, as operationalized by VA for the surveys we reviewed, measured how someone is with what they received--while "expectations," as defined by VA, would measure or gain insight into what it is that someone would want, and which may or may not be what they are receiving. Thus, while satisfaction, as operationalized by VA, can be an indicator of an expectation, as defined by VA, the two are not synonymous. Although VA considers this recommendation closed, we are working with them to identify ways that expectations, as VA has defined the term, can be measured.

Recommendation: To improve VA's ability to plan for and align its facilities with estimated changes to veterans' needs and expectations, we recommend that the Secretary of Veterans Affairs ensure the appropriate offices and administrations instruct VAMCs on how to meet VA's strategic goal of incorporating veterans' changing needs and expectations into facility planning, such as by identifying certain resources or tools and directing VAMCs to use them. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: VA agreed with the recommendation and indicated that it would instruct users on what data to use in planning and updates, which would help ensure veterans' input is incorporated where appropriate. As of its fiscal year 2021 budget justification, VA still had not provided this guidance to the VAMCs, but noted that it would provide it in scheduled facility planning calls that were expected to start in the second quarter of fiscal year 2020.

Recommendation: To improve VA's ability to plan for and align its facilities with estimated changes to veterans' needs and expectations, we recommend that the Secretary of Veterans Affairs ensure the appropriate offices and administrations provide additional instruction to VAMCs on how to incorporate the concept of foundational health services into facility planning. (Recommendation 3)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with this recommendation and noted that it would clarify prior guidance on the foundational health services for VAMCs, which it expected to complete in June 2019. In November 2019, VA told us that it had reviewed this prior guidance from August 2017 that had defined foundational services, and has rescinded it. However, we are working with VA to determine if this decision to rescind the prior guidance was distributed to VAMCs.

Recommendation: To improve VA's ability to plan for and align its facilities with estimated changes to veterans' needs and expectations, we recommend that the Secretary of Veterans Affairs ensure the appropriate offices and administrations systematically gather feedback from facility planners and address (as necessary) their concerns with the reliability of the SCIP process, including providing additional information on how SCIP's space estimates are derived. (Recommendation 4)

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: VA agreed with this recommendation and indicated that it would update its training instructions to facility planners by adding an explanation of how SCIP space estimates are derived. In addition, VA noted that it would survey facility planners about their concerns with the SCIP space estimates, and use these results to either address the concerns or make improvements to SCIP. As of November 2019, VA had not completed the training or the survey, but noted that they are in the process of updating training materials for the FY22 SCIP planning process--which was targeted to start 2019. We will work with VA to obtain relevant documentation of these efforts.

Recommendation: The Under Secretary of Health should ensure all RME inspections are being conducted and reported as required and that the inspection results VHA has are complete. (Recommendation 1)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: VA agreed with this recommendation and indicated it would establish an oversight process for reviewing and monitoring findings from inspections. VA has described some of the oversight actions it has put in place and noted that actions would be completed in 2020. We will update the status of this recommendation when additional information is received.

Recommendation: The Under Secretary of Health should examine the Sterile Processing Services workforce needs and take action based on this assessment, as appropriate. (Recommendation 3)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: VA agreed with this recommendation and indicated it would review workforce needs and take necessary actions. VA has described some of the actions taken and noted that actions would be completed in 2019. We will update the status of this recommendation when additional information is received.

Recommendation: The Administrator of HRSA should require covered entities to register contract pharmacies for each site of the entity for which a contract exists. (Recommendation 1)

Agency: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration
Status: Open

Comments: HHS does not concur with this recommendation and, as of July 2020, did not plan to take any actions to implement the recommendation. As noted in our report, without complete information on contract pharmacy arrangements--including information on with sites of a covered entity have contracts with a contract pharmacy--HRSA cannot ensure that it is optimally targeting the limited number of audits done each year. Additionally, manufacturers lack important information to help ensure that 340B discounted drugs are only provided to pharmacies with a valid 340B contract with the covered entity site for which the drug is being dispensed.

Recommendation: The Administrator of HRSA should issue guidance to covered entities on the prevention of duplicate discounts under Medicaid managed care, working with CMS as HRSA deems necessary to coordinate with guidance provided to state Medicaid programs.(Recommendation 2)

Agency: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration
Status: Open
Priority recommendation

Comments: HHS concurred with this recommendation. In July 2020, HHS indicated that it believes that guidance does not provide HRSA appropriate enforcement capability and that this recommendation can only be accomplished after policy is issued. HRSA has requested regulatory authority for all aspects of the 340B Program in the FY 2021 President's Budget.

Recommendation: The Administrator of HRSA should incorporate an assessment of covered entities' compliance with the prohibition on duplicate discounts, as it relates to Medicaid managed care claims, into its audit process after guidance has been issued and ensure that identified violations are rectified by the entities. (Recommendation 3)

Agency: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration
Status: Open
Priority recommendation

Comments: HHS concurred with this recommendation. In July 2020, HHS indicated that it believes that guidance does not provide HRSA appropriate enforcement capability and that this recommendation can only be accomplished after policy is issued. HRSA has requested regulatory authority for all aspects of the 340B Program in the FY 2021 President's Budget.

Recommendation: The Administrator of HRSA should issue guidance on the length of time covered entities must look back following an audit to identify the full scope of noncompliance identified during the audit.(Recommendation 4)

Agency: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration
Status: Open

Comments: HHS concurred with this recommendation. In July 2020, HHS indicated that it believes that guidance does not provide HRSA appropriate enforcement capability and that this recommendation can only be accomplished after policy is issued. HRSA has requested regulatory authority for all aspects of the 340B Program in the FY 2021 President's Budget.

Recommendation: The Administrator of HRSA should require all covered entities to specify their methodology for identifying the full scope of noncompliance identified during the audit as part of their corrective action plans, and incorporate reviews of the methodology into their audit process to ensure that entities are adequately assessing the full scope of noncompliance. (Recommendation 5)

Agency: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration
Status: Open

Comments: HHS does not concur with this recommendation and, as of July 2020, did not plan to take any actions to implement the recommendation. HHS noted that requiring all covered entities subject to an audit to specify their methodology for identifying the full scope of noncompliance identified during the audit would create a significant burden for covered entities. However, as noted in our report, HRSA already requires covered entities with audit findings to determine the full scope of noncompliance and requires entities subject to a targeted audit to provide their methodology for such assessments to HRSA. Thus, it is unclear how requiring covered entities subject to risk-based, as opposed to targeted, audits to provide HRSA with a written description of methodologies that they are already required to formulate and implement would create a significant additional burden. Without this information, HRSA does not have reasonable assurance that the majority of covered entities have adequately identified all instances of noncompliance.

Recommendation: The Administrator of HRSA should require all covered entities to provide evidence that their corrective action plans have been successfully implemented prior to closing audits, including documentation of the results of the entities' assessments of the full scope of noncompliance identified during each audit.(Recommendation 6)

Agency: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration
Status: Open

Comments: HHS does not concur with this recommendation and, as of July 2020, did not plan to take any actions to implement the recommendation. HHS stated that requiring all covered entities with audit findings to provide evidence that their corrective action plans have been successfully implemented would create an undue burden for covered entities. However, HRSA already requires such evidence from covered entities subject to targeted audits, and it is unclear how providing evidence of implementation of corrective actions that entities developed and are required to implement would create significant additional burden for these entities. Additionally, without such evidence HRSA does not have a reasonable assurance that the majority of covered entities audited have corrected the issues identified in the audit, and are not continuing practices that could lead to noncompliance.

Recommendation: The Administrator of HRSA should provide more specific guidance to covered entities regarding contract pharmacy oversight, including the scope and frequency of such oversight. (Recommendation 7)

Agency: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration
Status: Open

Comments: HHS concurred with this recommendation. In July 2020, HHS indicated that it believes that guidance does not provide HRSA appropriate enforcement capability and that this recommendation can only be accomplished after policy is issued. HRSA has requested regulatory authority for all aspects of the 340B Program in the FY 2021 President's Budget.

Recommendation: The Secretary of VA should, in collaboration with ISC, review and revise VA's risk management policies for VHA facilities to ensure VA incorporates ISC standards, as appropriate. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: Shortly after the issuance of the report, VA notified GAO that it was in the process of working with the lnteragency Security Committee (ISC) to update its vulnerability assessment program, with a target completion date of January 2019. Despite multiple attempts, as of June 2020, VA has not provided any information on its progress in updating its program.

Recommendation: The Secretary of VA should develop an oversight strategy that allows VA to assess the effectiveness of risk management programs at VHA facilities system-wide. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

Comments: Shortly after the issuance of the report, VA notified GAO that it had identified OS&LE as the internal entity responsible for conducting a complete review of VA's current risk management policies and processes for VA facilities and that it was reviewing an ISC-certified risk assessment tool for possible implementation consideration. Despite multiple attempts, as of June 2020, VA had not provided an update on its efforts to implement this recommendation.

Recommendation: To clarify IT requirements within the Executive Agreement, to enable VA and DOD to make an informed recommendation about whether the FHCC should continue after the end of the demonstration, and to provide useful information for other integrations that may be considered in the future, the Secretaries of Veterans Affairs and Defense should develop plans with clear definitions and specific deliverables, including time frames for two IT capabilities-documentation of patient care to support medical and dental operational readiness and outpatient appointment enhancements-and formalize these plans, for example, by incorporating them into the Executive Agreement.

Agency: Department of Veterans Affairs
Status: Open

Comments: We will update the status of this recommendation when we receive additional information. As of September 2019, VA and DOD officials have not provided information or documentation to address this recommendation.

Recommendation: To clarify IT requirements within the Executive Agreement, to enable VA and DOD to make an informed recommendation about whether the FHCC should continue after the end of the demonstration, and to provide useful information for other integrations that may be considered in the future, the Secretaries of Veterans Affairs and Defense should develop plans with clear definitions and specific deliverables, including time frames for two IT capabilities-documentation of patient care to support medical and dental operational readiness and outpatient appointment enhancements-and formalize these plans, for example, by incorporating them into the Executive Agreement.

Agency: Department of Defense
Status: Open

Comments: We will update the status of this recommendation when we receive additional information. As of September 2019, VA and DOD officials have not provided information or documentation to address this recommendation.

Recommendation: To systematically gauge the extent to which deficiencies identified by individual AIBs may be occurring throughout VHA; and to maximize opportunities for sharing information across VHA to improve its overall operations, the Secretary of Veterans Affairs should direct the Under Secretary for Health to establish a process to collect and analyze aggregate data from AIB investigations, including the number of investigations conducted, the types of matters investigated, whether the matters were substantiated, and systemic deficiencies identified.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with this recommendation and noted that it would explore any new processes for collecting and analyzing aggregate data from AIB investigations. In September 2015, VA reported that VHA had established a workgroup to review this recommendation and also had created a database to collect and analyze aggregate data from AIB investigations into senior executive service (SES) employees. Based on the results of an informal survey as well as its analysis of AIB data for SES employees, VA stated that central office oversight of the AIB process is not needed and that several systems already in place capture data on system-wide risks (e.g., sexual assault reporting, Issue Briefs, and National Center for Patient Safety Patient Safety Information System Program). In December 2016, VA reported that it convened another workgroup in September 2016 to re-examine this recommendation. That workgroup ultimately determined that oversight of AIBs at the national level continues to not be warranted. In April 2018, VA reported that it does not intend to take any further action in response to this recommendation, and it reaffirmed this position in March 2020.

Recommendation: To systematically gauge the extent to which deficiencies identified by individual AIBs may be occurring throughout VHA; and to maximize opportunities for sharing information across VHA to improve its overall operations, the Secretary of Veterans Affairs should direct the Under Secretary for Health to establish a process for sharing information about systemic changes, including policies and procedures implemented in response to the results of AIB investigations, which may have broader applicability throughout VHA.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with this recommendation and noted that it would explore any new processes for collecting and analyzing aggregate data from AIB investigations. In September 2015, VA reported that it had established a working group to review this recommendation. In addition, VA also had created a database to collect and analyze aggregate data from AIB investigations into senior executive service (SES) employees to identify trends and address deficiencies. Based on an informal survey of its working group and its analysis of AIB data for SES employees, VA stated that VISNs currently provide adequate oversight of the AIB process and notify VA central office when appropriate and that a comprehensive review of its AIB data for SES employees identified no system-wide issues. Ultimately, VA stated that it could not justify the resources needed to implement this recommendation. In April 2018, VA reported that it does not intend to take any further action in response to this recommendation, and it reaffirmed this position in March 2020.