Recommendation: The Under Secretary for Health should establish steps for communicating to VA's actuarial consultant information on data quality, including any limitations, used in the actuarial modeling that informs VA's community care budget estimates. (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 establish further steps for assessing and communicating to stakeholders the degree of overall uncertainty associated with actuarial projections for community care that inform the community care budget estimates. (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: Congress should consider requiring VA to establish an overall wait-time performance measure for veterans to receive care under the VCCP that will permit VA to measure and monitor the timeliness of VCCP appointments and compare timeliness to that of VA medical facilities. (Matter for Consideration 1)

Agency: Congress
Status: Open

Comments: When we determine what steps the Congress has taken, we will provide updated information.

Recommendation: The Under Secretary of Health should align its monitoring metrics with the time frames established in the VCCP scheduling process. (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 of Health should conduct a review of community provider enrollment and use of the HSRM to include identifying and taking steps to remove any challenges to community provider enrollment and use; and, if determined appropriate, establish a requirement for community providers to use the HSRM; and (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 Under Secretary of Health should direct VAMC leadership to assess their community care staffing and resource needs, and develop a plan to address any identified risks to their ability to schedule appointments in a timely manner, including strategies to adjust staff levels and address recruitment and retention challenges as needed. (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 Under Secretary for Health should, in collaboration with relevant VBA and NCA officials, improve its process to accurately identify all on-campus veteran deaths by suicide by ensuring that it uses updated information and corroborates information with VA facility officials. (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 expand the policy requirement for a root cause analysis to include all cases of on-campus veteran death by suicide, regardless of whether the veterans involved were enrolled in VHA health care services at the time of their death. (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 Under Secretary for Health should direct the Office of Mental Health and Suicide Prevention to expand its analyses of on-campus veteran deaths by suicide to include all relevant information VA collects for these incidents, such as data from root causes analyses and information collected through the Behavioral Health Autopsy Program. (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 Under Secretary for Health should fully define in VHA policy the oversight roles and responsibilities related to ensuring facilities' adherence to disbursement agreement policies, including roles related to ReDPro and the role of VISNs. (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 more clearly define in VHA policy the purposes of the periodic independent audits and the ReDPro checklist reviews—including differentiating their purposes from one another and ensuring that they do not unnecessarily overlap. (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 Under Secretary for Health should ensure that OAA and CBI modify the ReDPro checklist and associated guidance, to include ensuring that checklist items are clearly stated, relevant to the updated purpose of the ReDPro checklist, and not unnecessarily duplicative of items to be addressed by the periodic independent audits. The guidance should also include detailed instruction on what the compliance officers should review, and how they should determine the appropriate response for each checklist item. (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 Under Secretary for Health should ensure that OAA and CBI develop and provide additional ReDPro training for compliance officers, consistent with the updated checklist and guidance. This training should include general information on GME programs and disbursement agreement oversight, as well as detailed information about how ReDPro reviews should be conducted. (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: The Under Secretary for Health should ensure that OAA implements a standardized independent audit tool that is consistent with the updated purpose of the periodic independent audits, and does not unnecessarily overlap with the ReDPro checklist. This could include modifying its existing recommended checklist, or developing a new tool. (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 Under Secretary for Health should ensure that OAA develops guidance for periodic independent audits to assist the audit teams and facility management in understanding how audits are to be conducted. (Recommendation 6)

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 ensure that OAA develops substantive training for independent audit team members, consistent with the updated audit purpose, guidance, and tools. This training should include general information on GME programs and disbursement agreement oversight, as well as detailed information about how the independent audits should be conducted. (Recommendation 7)

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: For implementation of the EHR system at future VA medical facilities, we recommend that the Secretary of VA direct the EHRM Executive Director to clarify terminology and include adequate detail in descriptions of local workshop sessions to facilitate the participation of all relevant stakeholders including medical facility clinicians and staff. (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 Assistant Deputy Under Secretary for Health for Administrative Operations should develop and document a process for estimating total activation costs for major medical facility projects. This process should reflect the 12 steps for developing a reliable cost estimate outlined in the GAO Cost Guide. (Recommendation 1)

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

Comments: As of July 2020, VHA is developing a policy to document its process for estimating total life cycle activation costs for major medical facility projects. VHA expects to complete this effort by December 2020.

Recommendation: The Assistant Deputy Under Secretary for Health for Administrative Operations should develop and document a process for comparing actual activation costs for major medical facility projects to estimates. This process should identify the personnel responsible for comparing the estimated costs to the actual expenses and document their responsibilities. (Recommendation 2)

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

Comments: As of July 2020, VHA is developing a policy that will include guidance on comparison of actual activation costs to project estimates and that will document the parties responsibility for comparing these costs. VHA expects to complete this effort by December 2020.

Recommendation: The Assistant Deputy Under Secretary for Health for Administrative Operations should define and document what items and services officials can purchase with activation funds. (Recommendation 3)

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

Comments: As of July 2020, VHA is developing a policy that will define and document what items and services officials can purchase with activation funds. VHA expects to complete this effort by December 2020.

Recommendation: The Assistant Deputy Under Secretary for Health for Administrative Operations should define and document when facilities should cease to spend activation funds. (Recommendation 4)

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

Comments: As of July 2020, VHA is developing a policy that will define and document when facilities should cease to spend activation funds. VHA expects to complete this effort by December 2020.

Recommendation: ASPR should develop a response personnel strategy to ensure, at a minimum, a lead ASPR liaison officer is consistently at the local emergency operations center(s) during an emergency support functions (ESF) #8 response and another liaison, if not more, is at strategic location(s) in the area. (Recommendation 1)

Agency: Department of Health and Human Services: Office of the Assistant Secretary for Preparedness and Response
Status: Open

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

Recommendation: As ASPR finalizes its federal patient movement framework, the agency should exercise the framework with its National Disaster Medical System (NDMS) partners to ensure that patients evacuated through NDMS will be consistently tracked from the start of their evacuation. (Recommendation 2)

Agency: Department of Health and Human Services: Office of the Assistant Secretary for Preparedness and Response
Status: Open

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

Recommendation: ASPR should put controls in place to ensure data on all NDMS evacuated patients are complete and accurate. (Recommendation 3)

Agency: Department of Health and Human Services: Office of the Assistant Secretary for Preparedness and Response
Status: Open

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

Recommendation: ASPR Region II should revise its Incident Response Plans for the territories to include strategies for providing chronic and primary care in isolated communities. These strategies could include the incorporation of Federally Qualified Health Centers and other local health clinics as part of a response. (Recommendation 4)

Agency: Department of Health and Human Services: Office of the Assistant Secretary for Preparedness and Response
Status: Open

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

Recommendation: ASPR should work with support agencies to develop and finalize memorandums of agreement that include information on the capabilities and limitations of these agencies to meet ESF#8 core capabilities. (Recommendation 5)

Agency: Department of Health and Human Services: Office of the Assistant Secretary for Preparedness and Response
Status: Open

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

Recommendation: ASPR should develop a strategy demonstrating how it ESF#8 core capabilities can be provided through HHS and ESF#8 support agencies if DOD's capacity to respond is limited. (Recommendation 6)

Agency: Department of Health and Human Services: Office of the Assistant Secretary for Preparedness and Response
Status: Open

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

Recommendation: ASPR should take steps to ensure the perspectives of key external parties are incorporated in the development of HHS's after-action reviews, following future ESF#8 activations. (Recommendation 7)

Agency: Department of Health and Human Services: Office of the Assistant Secretary for Preparedness and Response
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 ensure that facility officials who are responsible for credentialing, reviewing credentials, and hiring receive periodic mandatory training. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: As of March 2020, VA officials told us that they expect to have this recommendation implemented during calendar year 2020.

Recommendation: The Under Secretary for Health should develop policies and guidance regarding DEA registrations, including the circumstances in which Drug Enforcement Administration (DEA) waivers may be required, the process for requesting them, and a mechanism to ensure that facilities follow these policies. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: As of March 2020, this recommendation remains open. VA sent a letter to DEA asking for clarification about DEA employment waivers and received a response from DEA dated November 26, 2019. VA officials told us that they are considering the input from DEA and consulting with relevant stakeholders to determine next steps. To fully implement this recommendation, VA needs to provide evidence of actions taken to ensure that DEA requirements regarding DEA registrations and employment waivers are met. Such actions include developing policies regarding when a DEA employment waiver may be necessary and guidance about how to request such a waiver.

Recommendation: The Under Secretary for Health should identify and review providers whose DEA registrations were revoked or surrendered for cause and determine whether an employment waiver may be needed from DEA. (Recommendation 3)

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: As of March 2020, VA has reported important steps toward implementing this recommendation. Specifically, VA officials told us that they reviewed licensed independent practitioners to see if any that are currently employed at VA have a revoked or surrendered DEA registration. They identified at least one provider with a revoked or surrendered DEA registration. To fully implement this recommendation, VA needs to provide evidence that appropriate action was taken for this provider, such as obtaining a DEA waiver if necessary.

Recommendation: Once VA's new software for managing authorizations has been fully implemented, the Undersecretary for Health should monitor data on secondary authorization requests approval decision time frames to ensure VA medical facilities are in adherence with VA policy, assess the reasons for nonadherence with the policy, and take corrective actions as necessary. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA agreed with our recommendation and stated that it has already taken steps to improve compliance with secondary authorization request approval timeframes.by identifying challenges, agreeing on improvement actions, and providing training. According to VA, its new Health Share Referral Manager system, which VA expects will be fully implemented across all medical facilities by December 2019, will automate secondary authorization request reporting and tracking. According to VA, it will utilize this new system to ensure compliance with secondary authorization request approval time frames.

Recommendation: The Undersecretary for Health should collect data and monitor compliance with the Choice Program contractual requirements pertaining to customer service for community providers, and take corrective actions as necessary. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA agreed with our recommendation and stated that it currently does not have the ability to monitor and assess the performance of customer service operations under the Choice Program contracts. VA has included additional requirements for customer service in the Veterans Community Care Network request for proposals and plans to monitor compliance with these requirements under the Veterans Community Care Program. VA expects to implement this recommendation by December 2019.

Recommendation: The Under Secretary for Health should work with the Department of Veterans Affairs (VA's) Office of Construction and Facilities Management to ensure that VHA incorporates the 12 steps in the GAO Cost Estimating and Assessment Guide in VHA's updated construction projects' cost-estimating guidance. (Recommendation 1)

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

Comments: The Office of Capital Asset Management Engineering and Support (OCAMES) is working with the Office of Construction and Facility Management (OCFM) to make necessary updates to CFM's Cost Estimating and Assessment Guide. GAO has reviewed VA's revisions and found that while they incorporated information on two of the 12 steps in GAO's Cost Estimating and Assessment Guide, the guidance currently meets or substantially meets only 4 of the 12 steps. GAO met with OCFM and OCAMES staff in April 2020 to further discuss our guidance and how to apply it. The VA staff will consider how to further apply our guidance.

Recommendation: The Under Secretary for Health should obtain information on cost increases, schedule delays, and reasons for contract modifications in its updated Capital Asset Database through requiring medical center staff to provide the information or another appropriate method. (Recommendation 5)

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

Comments: OCAMES is finalizing updates and fixing issues related to improvements to the Capital Asset Database; these updates include additional information related to change orders. Due to unexpected challenges with data connections and issues; however, these improvements have not yet been completed. The change in completion date is caused by data connection issues and progress on the overall system was stalled. GAO will continue to monitor VA's progress in implementing this recommendation.

Recommendation: The Under Secretary for Health should develop a comprehensive plan that includes elements such as milestones and roles and responsibilities for updating VHA's Capital Asset Database. (Recommendation 6)

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

Comments: OCAMES is still finalizing updates and fixing issues related to improvements to the Capital Asset Database. Until the updates have been finalized, roles and responsibilities cannot be created. Upon completion of updates, roles and responsibilities will be developed.

Recommendation: The Under Secretary for Health should establish an achievable wait-time goal for the consolidated community care program that VA plans to implement that will permit VHA to monitor whether veterans are receiving VA community care within time frames that are comparable to the amount of time they would otherwise wait to receive care at VHA medical facilities. (Recommendation 1)

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

Comments: The Veterans Health Administration (VHA) agreed with our recommendation and stated in March 2020 that it is taking steps to establish a wait-time goal for the new consolidated community care program-the Veterans Community Care Program. Actions include updating VHA's current directives and the implementation of the HealthShare Referral Manager, a software system that will provide VHA the capability to monitor wait times.

Recommendation: The Under Secretary for Health should design an appointment scheduling process for the consolidated community care program that VA plans to implement that sets forth time frames within which (1) veterans' referrals must be processed, (2) veterans' appointments must be scheduled, and (3) veterans' appointments must occur, which are consistent with the wait-time goal VHA has established for the program. (Recommendation 2)

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

Comments: The Veterans Health Administration (VHA) agreed with our recommendation and stated in March 2020 that it is taking steps to design an appointment scheduling process for the new consolidated community care program-the Veterans Community Care Program. This includes actions to develop a wait-time goal, and the development and review of VHA's new community care directive.

Recommendation: The Under Secretary for Health should establish a mechanism that will allow VHA to systematically monitor the average number of days it takes for VAMCs to prepare referrals, for VAMCs or TPAs to schedule veterans' appointments, and for veterans' appointments to occur, under the consolidated community care program that VA plans to implement. (Recommendation 3)

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

Comments: The Veterans Health Administration (VHA) agreed with our recommendation and stated in March 2020 that it is taking steps to establish a mechanism to monitor appointment timeliness for the new consolidated community care program-the Veterans Community Care Program. This includes the implementation of the HealthShare Referral Manager, a software system that will allow VHA to measure timeliness of appointment scheduling actions, development of a wait-time goal, review of current VHA directives, and the development of reports that can be used by VA medical centers to monitor appointment scheduling timeliness.

Recommendation: The Under Secretary for Health should implement a mechanism to prevent veterans' clinically indicated dates from being modified by individuals other than VHA clinicians when veterans are referred to the consolidated community care program that VA plans to implement. (Recommendation 4)

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

Comments: The Veterans Health Administration (VHA) agreed with our recommendation and stated that it is taking steps to implement a mechanism to prevent veterans' clinically indicated dates (CID) from being modified by VHA staff other than VHA providers for the new consolidated community care program-the Veterans Community Care Program. Specifically, VHA developed the HealthShare Referral Manager (HSRM), a software system for VA medical center (VAMC) staff to use to manage VCCP referrals, including creating authorizations and scheduling veteran appointments with community providers. VHA deployed the HSRM at all VAMCs as of June 24, 2019, and according to VHA officials, the system was fully implemented as of December 31, 2019. In March 2020, VHA provided documentation that shows (1) the VHA clinician populates the CID field when they create the referral in VA's electronic medical record system, (2) when the referral is forwarded to HSRM for referral management and appointment scheduling by VAMC staff, the CID field in HSRM is auto-populated based on the CID in VA's electronic medical record system, and (3) the auto-populated CID field in HSRM cannot be edited. However, under VA's current scheduling process, some VHA staff can still edit the referral after the VHA provider enters the CID and before it is sent to the HSRM for scheduling. VHA will need to take action to ensure this part of the process has protections to ensure veterans' CIDs aren't modified after being entered by the VHA provider.

Recommendation: The Under Secretary for Health should implement a mechanism to separate clinically urgent referrals and authorizations from those for which the VAMC or the TPA has decided to expedite appointment scheduling for administrative reasons. (Recommendation 5)

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

Comments: The Veterans Health Administration (VHA) did not concur with this recommendation, and states a mechanism is no longer needed as VA medical center staff are responsible for appointment scheduling under the new consolidated community care program, the Veterans Community Care Program (VCCP), not staff from third-party administrators. However, we believe this recommendation is still relevant, and in July 2020 we asked VHA for evidence to show that VA medical center staff, when scheduling VCCP appointments, are not changing routine referrals to an urgent status to expedite appointment scheduling in cases of delays.

Recommendation: The Under Secretary for Health should (1) establish oversight mechanisms to ensure that VHA is collecting reliable data on the reasons that VAMC or TPA staff are unsuccessful in scheduling veterans' appointments through the consolidated community care program VA plans to implement, and (2) demonstrate that it has corrected any identified deficiencies. (Recommendation 6)

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

Comments: The Veterans Health Administration (VHA) agreed with our recommendation and stated in March 2020 that it is taking steps to establish an oversight mechanism to ensure VHA is collecting reliable data in cases where staff are unsuccessful in scheduling veterans' appointments for the new consolidated community care program-the Veterans Community Care Program. This includes actions to implement the HealthShare Referral Manager, a software system that will allow VHA to produce reports on reasons for unsuccessful scheduling attempts, development of a community care directive, and an analysis of the reasons behind unsuccessful scheduling.

Recommendation: The Secretary of Veterans Affairs should ensure that the contracts for the consolidated community care program VA plans to implement include performance metrics that will allow VHA to monitor average driving times between veterans' homes and the practice locations of community providers that participate in the TPAs' networks. (Recommendation 7)

Agency: Department of Veterans Affairs
Status: Open

Comments: The Veterans Health Administration agreed with this recommendation, and as of March 2020, reported that it included performance metrics related to drive times in its contracts for the new third-party administrators in Regions 1-4 of the new Community Care Network under the Veterans Community Care Program. The contracts for Regions 5 and 6 have not been awarded yet.

Recommendation: The Under Secretary for Health should issue a comprehensive policy directive and operations manual for the consolidated community care program VA plans to implement and ensure that these documents are reviewed and updated in a timely manner after any significant changes to the program occur. (Recommendation 10)

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

Comments: The Veterans Health Administration agreed in principle with this recommendation, and stated that it has taken action to develop a new community care directive, which was under technical review as of March 2020.

Recommendation: To improve care for women veterans, the Secretary of Veterans Affairs should direct the Under Secretary for Health to strengthen the environment of care inspections process and VHA's oversight of this process by expanding the list of requirements that facility staff inspect for compliance to align with VHA's women's health handbook, ensuring that all patient care areas of the medical facility are inspected as required, clarifying the roles and responsibilities of VA medical facility staff responsible for identifying and addressing compliance, and establishing a process to verify that noncompliance information reported by facilities to VHA Central Office is accurate and complete.

Agency: Department of Veterans Affairs
Status: Open

Comments: As of October 2018, VA has taken some actions to address this recommendation, but additional actions are needed to fully implement it. We will update the status of this recommendation when we receive additional information from VA.

Recommendation: To improve care for women veterans, the Secretary of Veterans Affairs should direct the Under Secretary for Health to monitor women veterans' access to key sex-specific care services--mammography, maternity care, and gynecology--under current and future community care contracts. For those key services, monitoring should include an examination of appointment scheduling and completion times, driving times to appointments, and reasons appointments could not be scheduled with community providers.

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: As of June 2017, VHA still lacks data and performance measures for the availability under Choice of sex-specific care, such as mammograms, maternity care, or gynecology. In contrast, for another VA care in the community program, PC3 (a program that the Choice third party administrators also administer) VHA collects data and has performance measures to evaluate women veterans' access to mammography and maternity care. To fully implement this recommendation, VHA needs to extend the collection of data to include care delivered through the Choice Program and other community care programs and establish related performance measures. VA is in the process of letting contracts for its new community care program and is expected to have contracts in place for all regions of the country in fiscal year 2019