Recommendation: The Undersecretary for Health should consistently collect sexual orientation data in VHA's health record system, which could include adding a field for providers to input veterans' sexual orientation. (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 Undersecretary for Health should analyze veterans' sexual orientation data in order to assess health care outcomes for lesbian, gay, and bisexual veterans. (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 Undersecretary for Health should consistently collect veterans' self-identified gender identity data within and across record systems. (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 Undersecretary for Health should analyze veterans' self-identified gender identity data in order to assess health care outcomes for transgender veterans. (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 Secretary of Veterans Affairs should ensure the Executive Director of the Veterans Health Administration's Office of Procurement and Logistics, as part of the Veterans Health Administration's ongoing efforts to establish and maintain supplier agreements for the Medical-Surgical Prime Vendor 2.0 formulary, examines opportunities to reduce the number of items delivered via drop shipment to minimize less-preferred methods to purchase supplies. (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 Veterans Affairs should ensure the Executive Director of the Veterans Health Administration's Office of Procurement and Logistics, as part of the Veterans Health Administration's ongoing efforts to establish and maintain supplier agreements for the Medical-Surgical Prime Vendor 2.0 formulary, examines opportunities to establish delivery time frame requirements for drop-shipped items. (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 the Executive Director of the Veterans Health Administration's Office of Procurement and Logistics automates aspects of the manual Medical-Surgical Prime Vendor formulary management process where feasible, such as electronic transmittal of real-time updates to medical centers and prime vendors, to minimize ordering errors and delivery delays. (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 Veterans Affairs should ensure the Executive Director of the Veterans Health Administration's Office of Procurement and Logistics and the Strategic Acquisition Center develop processes to routinely use transaction-level data to validate prime vendor performance on key program metrics, such as order completion rate, and identify how this information will be used to oversee the prime vendors. (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 Secretary of Veterans Affairs should ensure the Executive Director of the Veterans Health Administration's Office of Procurement and Logistics develops a process for calculating accurate historical coverage and utilization data for the Medical-Surgical Prime Vendor program, such as archiving monthly formulary snapshots, to increase visibility into medical center needs and issues over time. (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 Veterans Affairs should ensure the Executive Director of the Veterans Health Administration's Office of Procurement and Logistics develops a plan for assessing the results of the Defense Logistics Agency Medical-Surgical Prime Vendor pilot, including criteria for assessing pilot success and scalability, as well as performance metric targets, and use these criteria and metrics to inform the department's future decision on whether the program should be deployed to all medical centers. (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 Secretary of Veterans Affairs should ensure the Executive Director of the Veterans Health Administration's Office of Procurement and Logistics seeks input from stakeholders within the agency, such as the Office of Small and Disadvantaged Business Utilization and medical center staff, on operation of the Defense Logistics Agency Medical-Surgical Prime Vendor pilot to help inform any needed improvements as the pilot progresses. (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: The Secretary of Veterans Affairs should ensure the Executive Director of the Veterans Health Administration's Office of Procurement and Logistics works with the Office of Small and Disadvantaged Business Utilization to provide written guidance to VA logistics officials at facilities participating in the Defense Logistics Agency Medical-Surgical Prime Vendor pilot program on how to prioritize veteran-owned small businesses when purchases are made through the pilot program, to achieve VA's goal of providing opportunities for these firms to participate in the pilot program. (Recommendation 8)

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 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 ensure the RCS Chief Officer evaluates Vet Center productivity expectations for counselors, including (1) obtaining systematic feedback from counselors on any potentially negative effects on client care, and (2) determining whether directors and counselors need additional training or guidance on how the expectations are calculated. (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 ensure the RCS Chief Officer develops a plan and time frames for periodically reassessing its productivity expectations for counselors, and implementing any needed changes as appropriate. (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 the RCS Chief Officer develops and implements a Vet Center staffing model that incorporates key practices in the design of staffing models. (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 the RCS Chief Officer establishes a plan and time frames for assessing and updating its staffing model regularly, and for implementing any needed changes as warranted. (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 Benefits should work with State and SSA to identify and implement ways to help ensure that embassy staff and RFBOs are made aware of relevant changes in VA policy and standard operating procedures in a timely and consistent manner and can more readily identify available resources so they can efficiently help veterans living abroad with VA's disability claims 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 for Benefits should identify and implement an interim strategy to consistently document the complete contact information for veterans living abroad within VBMS, while OIT and VBA continue to explore a long-term solution. (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 Benefits should systematically assess the quality of embassy-referred exams and use the results of this review to identify whether there are common problems related to the use of these exams, and, if necessary, take steps to address those problems, such as by developing tailored technical assistance for embassy-referred examiners. (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 Benefits and Under Secretary for Health—in concert with the General Counsel—should assess and decide whether to reimburse beneficiaries for travel to disability medical exams in foreign countries. (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, working with the Under Secretary of Benefits, should identify ways to reimburse examiners who conduct disability medical exams via direct deposit in the local currency, assess the cost-effectiveness of these options, and implement the method it selects. (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, 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 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 Under Secretary for Health should ensure VA's key offices, such as OAA and ORD, provide VA medical centers with examples of successful practices for strengthening research relationships with academic affiliates and that such information reflects the lessons learned from VA medical centers that have successfully cultivated these relationships. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with this recommendation. VA stated that they will establish a working group with representatives from both VA's Central Office and the field to identify and share best practices by December 31, 2020.

Recommendation: The Under Secretary for Health should ensure ORD, in consultation with the field, develops tools, such as a decision tree and successful practices, to help local VA medical center officials decide which entity—NPCs or academic affiliates—should administer extramural funding based on providing optimal support for the research. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with this recommendation. VA stated that the working group established to address GAO's first recommendation, which will include representatives from both VA's Central Office and the field, will develop and share tools to assist VA medical centers and their academic affiliates in determining how federal awards should be administered by December 31, 2020.

Recommendation: The Director of the Office of Personnel Management should assist the 24 CFO Act agencies by using OPM FEVS data to analyze the key drivers of retention for veterans in the agencies' workforces to identify strategies for improving veteran retention. OPM should also be available to non-CFO Act agencies that request assistance with the veteran retention analysis.

Agency: Office of Personnel Management
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: The Secretary of Veterans Affairs should incorporate key elements of a performance assessment system, such as establishing performance goals and taking steps to assess outcomes, for the Educational and Vocational Counseling (or Chapter 36), Veterans Integration to Academic Leadership, and VetSuccess on Campus programs. (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 Education should develop performance goals for the Iraq and Afghanistan Service Grant program. (Recommendation 2)

Agency: Department of Education
Status: Open

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

Recommendation: The Commandant of the Coast Guard should develop formal performance goals and measures for its Spouse Employment Assistance Program. (Recommendation 3)

Agency: Department of Homeland Security: United States Coast Guard
Status: Open

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

Recommendation: VA's Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness should realign VA's EEO Director position to adhere to the applicable EEOC directive by ensuring the position is not responsible for personnel functions. (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: VA's Deputy Assistant Secretary for Resolution Management should complete VA's EEO Program Manager realignment initiative at VBA and VHA in accordance with VA policy. (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: VA's Deputy Assistant Secretary for Resolution Management should ensure that ORM reviews all existing VA and administration policies and information documents to make sure they are current, complete, and aligned with VA's sexual harassment policy. (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: VA's Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness, in consultation with ORM, should finalize the HPP directive and handbook to formalize HPP. (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: VA's Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness, in consultation with ORM, should require managers to report all sexual harassment complaints they receive to ORM and ORM should use this information—and other available data about sexual harassment prevalence at VA—to assess and improve its efforts to prevent and address sexual harassment. (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: VA's Deputy Assistant Secretary for Resolution Management should develop and implement policies and procedures to ensure that, for sexual harassment complaints addressed through the management process, any corrective actions decided on are implemented, including requiring managers and supervisors to provide evidence to ORM that these actions occurred. (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: VA's Deputy Assistant Secretary for Resolution Management should require additional training for all VA employees on identifying and addressing sexual harassment, including the HPP process. For instance, VA could make training that is currently offered in some facilities mandatory for all employees (e.g., Prevention of Sexual Harassment) or develop new mandatory training. (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: VA's Under Secretary for Health should provide additional information, such as best practices, about how VA medical centers and service providers participating in Coordinated Entry can collaborate with local partners on key activities (for example, making referrals and sharing data) and ensure that this information and other resources are accessible to VA medical center staff and service providers. (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 Secretary for DOL's Veterans' Employment and Training Service should document its data quality validation processes for performance data for the Homeless Veterans' Reintegration Program and disseminate these processes to service providers. (Recommendation 2)

Agency: Department of Labor
Status: Open

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

Recommendation: VA's Under Secretary for Health should clearly communicate with local VA staff and service providers about how it measures performance and how to obtain and provide feedback about performance measures. (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 direct GEC leadership to develop measurable goals for its efforts to address key long-term care challenges: workforce shortages, geographic alignment of care, and difficulty meeting veterans' needs for specialty care. (Recommendation 1)

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 VA should direct GEC leadership to set time frames for and implement a consistent GEC structure at the VAMC level. (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 VA should direct GEC leadership to set time frames for and implement a VAMC-wide standardization of the tool for assessing the noninstitutional program needs of veterans. (Recommendation 3)

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 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 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: The Secretary of Veterans Affairs should ensure that the Office of Enterprise Integration develops a plan—including milestones and roles and responsibilities for OEI, VBA, and VHA—to address identified challenges that have hindered research on the health care outcomes for service-connected conditions of veterans receiving disability compensation. To align VA's efforts with the goals of its 2018-2024 Strategic Plan, VA's development of this plan should be completed and ready for implementation by June 1, 2020. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA agreed with this recommendation. VA stated that the Office of Enterprise Integration (OEI) will coordinate with VBA and the Veterans Health Administration (VHA) to create an operational plan that addresses challenges that have hindered research on health care outcomes for service-connected conditions of veterans receiving disability compensation. As of March 2020, VA anticipates completing this plan by June 2020. We will consider closing the recommendation when that effort is complete.

Recommendation: The Under Secretary for Benefits should develop and implement a periodic analysis of program management data for trends in the individual service-connected conditions being reevaluated as well as data on the outcomes of reevaluations. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA stated in March 2020 that it plans to develop requirements to augment its capacity to analyze reevaluation trends. According to officials, VA has determined the necessary requirements for the data needed to analyze the outcomes of reevaluations. VBA will review 12 months of data to assess trends and make recommendations based on the review. VA plans to complete the trend analysis by the end of June 2020 and will establish a process for periodic analysis of data trends. We will consider closing this recommendation when VA has analyzed multiple data points to assess trends in reevaluations on a periodic basis.

Recommendation: The Under Secretary for Benefits should implement the two recommendations in VBA's May 2018 consistency study to provide training on how to determine when a reevaluation is needed and review reevaluation decisions for accuracy at the lowest-scoring offices and take corrective action as needed. (Recommendation 3)

Agency: Department of Veterans Affairs
Status: Open

Comments: In November 2019, VA stated that VBA provided a reminder to all regional offices about the availability of training resources on how to determine when a reevaluation is needed. VA also stated that VBA conducted another consistency study on this issue in August 2019 and plans to use that study's results to guide its review of the lowest-scoring regional offices. This study recommended inspecting claims processed at the two lowest-scoring offices, because they may have high numbers of errors related to reevaluation requirements. VA stated that VBA would devise a statistically valid sample of claims based on the August 2019 study. In April 2020, VA provided information from national accuracy reviews and individual claims processor quality reviews for these two offices. However, these reviews were not specifically designed to assess the quality of decisions on reevaluations, and as such, do not provide generalizable information on all reevaluations decided by these two offices. To help close this recommendation, VA should take steps to focus its review on claims with reevaluations, in order to identify and correct root causes of any deficiencies, such as through additional training or the improvement of training. Using the results of both the 2018 and 2019 studies would allow VBA to more fully assess this issue.

Recommendation: The Under Secretary for Benefits should clarify guidance in its procedures manual regarding the knowledge, skills, and abilities needed to make decisions on whether to reevaluate veterans for changes in their service-connected conditions. (Recommendation 4)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA agreed with this recommendation in principle, acknowledging the importance of having appropriately skilled and trained employees to process reevaluations and other claims. VA stated that it believes the procedures outlined in its manual accurately describe the steps necessary for claims adjudicators to make the decision whether to reevaluate veterans for changes in their service-connected conditions. It further stated that regional office management ensures compliance with the procedures through the quality assurance program, and makes the decisions about which claims processors are best suited to perform the work. Accordingly, as of March 2020, VBA plans to assess the quality of routine future examinations requested by non-raters. Based on the results of this new quality review, VBA will determine if any additional actions are needed. VBA plans to complete this effort by October 2020. We are encouraged by VA's interest in conducting this analysis, and we will consider closing the recommendation when that effort is complete.

Recommendation: The Under Secretary for Benefits should align training requirements with the knowledge, skills, and abilities needed for reviewing claims to decide whether to conduct a reevaluation. (Recommendation 5)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA agreed with this recommendation in principle. As noted in recommendation 4, as of March 2020, VBA plans to assess the quality of routine future examinations requested by non-raters, and determine if any additional actions are needed. VA also stated that if any refresher training is warranted for raters, local quality review team members can provide focused training locally. VBA plans to complete this effort by October 2020. We will consider closing the recommendation when that effort is complete.

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 VA should ensure that the Director of VR&E assesses the consistency of VR&E plans among counselors and takes mitigating steps if results warrant. For example, as part of its training efforts, VA could have counselors respond to identical hypothetical veteran cases and, if unfair inconsistencies in plans result, the agency could enhance training on plan development. (Recommendation 1)

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

Comments: In February and March 2020, VA's Vocational Rehabilitation & Employment (VR&E) conducted a consistency study of VR&E plan development. The study identified areas that warrant refresher training for counselors. VR&E plans to roll out this training to all counselors by August 2020. We will consider closing this recommendation when VR&E completes this effort.

Recommendation: The Under Secretary for Benefits should systematically solicit and collect information on potential financial exploitation from VA's Pension Management Centers and other relevant VA components, including VA's Office of General Counsel, and assess this information to inform plans to address the potential exploitation of veterans receiving pension benefits. Such plans could also address the broader population of veterans with disabilities. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: As of July 2020, VA reported taking steps to share data on potential financial exploitation threats, but further opportunities to collect information exist. In February 2020, VA updated its policy manual, instructing Pension Management Centers to send copies of any OIG fraud referrals to VA's Fraud, Waste, and Abuse Incident Team. This team plans to use the information to identify trends in potential fraud, and recommend changes to VA laws, policies, or procedures, as needed. VA also plans to use this data to coordinate with other Government agencies and offices to help prevent financial exploitation. However, VA has not reported taking steps to collect information from its Office of General Counsel, Pension Management Centers, and other components on threats to veterans that do not result in fraud referrals to OIG. VA asserts that collecting additional information on suspicious activities that do not meet the level of fraud that can be referred to OIG would be inappropriate because VA lacks investigative authority. As GAO noted in its report, not all suspicious activity or complaints rise to the level of fraud. Collecting additional information could improve VA's ability to understand threats to veterans and develop responses, such as outreach, and could build on VA efforts already underway with its Fraud, Waste, and Abuse Incident Team.

Recommendation: The Under Secretary for Benefits should place additional warnings on paper and electronic documents, including on benefit applications, regarding fees which veterans cannot be charged. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

Comments: As of July 2020, VA reports that it plans to include warnings on its pension applications to clarify which fees attorneys and others may charge veterans for representing them when applying for pension benefits. According to VA, information collection requests were published in the Federal Register in June 2020, and VA expects its application forms to be revised by the end of calendar year 2020. GAO will close this recommendation once VA's applications are revised.

Recommendation: The Under Secretary for Benefits should explore the costs and benefits of additional steps claims processors could take to verify that the direct deposit information provided by claimants on their applications is for the appropriate party. (Recommendation 4)

Agency: Department of Veterans Affairs
Status: Open

Comments: In August 2020 VA reported that it is in the process of updating its application forms to require claimants to submit documentation, such as a voided check or deposit slip, when applying for pension benefits. GAO will close this recommendation once changes to these applications are complete.

Recommendation: The Secretary of Veterans Affairs should ensure that the Under Secretary for Memorial Affairs update its cost-estimating procedures for cemetery construction projects to fully incorporate the 12 steps identified in the GAO Cost Estimating and Assessment Guide: Best Practices for Developing and Managing Capital Program Costs.

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 VA Under Secretary of Health should use workload data from the most recently completed fiscal year as part of the models that inform VISNs' and medical centers' general purpose funding needs, when doing so would not significantly delay the allocation of funds. (Recommendation 1)

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

Comments: April 2020: GAO will update the status of this recommendation when VA provides additional information.

Recommendation: The VA Under Secretary of Health should establish a formal process to document VHA's review of VISNs' adjustments to medical center allocation levels. (Recommendation 2)

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

Comments: April 2020: GAO will update the status of this recommendation when VA provides additional information.

Recommendation: The VA Under Secretary of Health should revise VHA's existing guidance to require VISNs to provide information on how they determined how much and for what reasons they made adjustments to medical center allocation levels. (Recommendation 3)

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

Comments: April 2020: GAO will update the status of this recommendation when VA provides additional information.

Recommendation: The VA Under Secretary of Health should revise its existing guidance to require VISNs—in conjunction with medical centers—to develop and submit approaches to improve efficiency at medical centers with declining workload that received adjusted funding levels. These approaches could include adjusting the level of services offered. (Recommendation 4)

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

Comments: April 2020: GAO will update the status of this recommendation when VA provides additional information.

Recommendation: The VA Under Secretary of Health should require VISNs to provide explanations on the amount of funds redistributed between VISNs and medical centers and VHA to document its review of these redistributions. (Recommendation 5)

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

Comments: April 2020: GAO will update the status of this recommendation when VA provides additional information.

Recommendation: The Secretary of the VA should direct the Under Secretary for Health to collect complete staffing data for the Family Caregiver Program that includes Caregiver Support Program Office funded staff, VAMC funded staff, and staff that assist the program as a collateral duty at each VAMC. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with this recommendation. The Veterans Health Administration (VHA) has reported that the Caregiver Support Program Office had identified a solution for identifying VHA Family Caregiver Program staff in the Human Resource (HR) Smart system. VHA reported that current full- and part-time employees funded by the Caregiver Support Program Office will be identified with a specific specialty code in HR Smart. However, as of April 2020, this capability was not yet available in HR Smart and staffing for the program continued to be manually updated and tracked. Further, the proposed use of HR Smart will still not result in complete information that the Caregiver Support Program Office can use to track all staff who support the program because according to VHA, staff that assist the program as a collateral duty and VAMC-funded staff who support the program will not be tracked through HR Smart. As of July 2020, this recommendation remains open pending further updates from VHA.

Recommendation: The Secretary of the VA should direct the Under Secretary for Health to establish a process to ensure that the Family Caregiver Program staffing data that are collected and reported to the Caregiver Support Program Office are accurate. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

Comments: VHA concurred with this recommendation. In February 2020, the Veterans Health Administration (VHA) reported that the Caregiver Support Program Office had identified a solution for identifying full-time VHA Family Caregiver Program staff in the Human Resource (HR) Smart system through the use of a specific specialty code. VHA reported that once implemented, the use of the HR SMART specialty code would provide more accurate information regarding staffing. In April 2020, VHA stated that were would also be a static field called "position skill type" that would track positions with a skill type category of caregiver and that Veterans Integrated Service Network (VISN) leads for the Family Caregiver Program would use this field to cross check the new specialty code and identify and correct any reporting inconsistencies. As of July 2020, this recommendation remains open pending further updates from VHA.

Recommendation: The Under Secretary for Health should document same-day services objectives and develop performance goals and related performance measures to facilitate the periodic assessment of the impact of same-day services on veterans' access to care. (Recommendation 1)

Agency: Department of Veterans Affairs: Veterans Health Administration
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 direct the Under Secretary for Health and the Assistant Secretary for Information and Technology/Chief Information Officer to develop and implement a methodology for reliably identifying and reporting the total costs of VistA. The methodology should include steps to identify the definition of VistA and what is to be included in its sustainment activities, as well as ensure that comprehensive costs are corroborated by reliable data. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: The Department of Veterans Affairs (VA) generally agreed with our conclusions and concurred with our recommendation. In a January 2020 update, the department described steps it planned to take to address the recommendation including establishing a team of experts to formulate a comprehensive taxonomy for VistA and all of its components, identifying authoritative and reliable data sources to assign costs to those components, and developing a methodology for ongoing cost tracking and reporting. The department expects these steps to be implemented by September 30, 2020. We will continue to monitor the department's progress to address this recommendation.

Recommendation: The Under Secretary of Health should require that all failures to meet quality standards are cited as deficiencies on SVH inspections. (Recommendation 2)

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

Comments: VA concurred with this recommendation and, as of July 2020, had taken some initial steps to address the recommendation such as modifying the SVH contractor's contract to stop the practice of using 'recommendations' for low-level deficiencies and beginning the process of revising a VA policy to address this practice.

Recommendation: The Under Secretary of Health should develop guidance for Veterans Affairs Medical Center staff conducting optional onsite CNH reviews. (Recommendation 3)

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

Comments: VA concurred in principle with this recommendation and indicated in January 2020 that it had begun taking actions to address this recommendation such as developing a memo of clarification and planning the release of additional guidance for staff.

Recommendation: The Under Secretary of Health should provide information on the quality of all SVHs that is comparable to the information provided on the other nursing home settings on its Access to Care website. (Recommendation 4)

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

Comments: VA concurred in principle and, as of July 2020, had begun taking some steps to address this recommendation such as exploring options for presenting SVH quality measure data.

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: The Veterans Health Administration should disseminate guidance for VISNs and VAMCs that more clearly reflects its expectation that mental health providers in specialty care should record mental health treatment plans within veterans' medical records in an easily identifiable way. (Recommendation 1)

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

Comments: VHA concurred with this recommendation and provided an update on its progress in implementing it. In December 2019, VHA reported that it had developed a new memorandum regarding mental health treatment planning that explicitly states the requirement for mental health providers in specialty care to record mental health treatment plans as a separate, easily identifiable document in the medical record. According to this memorandum, these treatment plans are expected to ensure that it is clear what treatment is being provided, that different treatments were considered, and that ongoing assessments are used to determined whether treatment changes are needed for the patient. VHA also reported that the memorandum states that facilities must either use the current treatment planning software or another method to create such a plan. Finally, VHA noted that the memorandum requires VAMCs to attest to full implementation of these requirements. According to VHA, the memorandum was distributed in May 2019 and the implementation process is currently underway across VAMCs. As of March 2020, this recommendation remains open pending further updates from VHA.

Recommendation: The Veterans Health Administration should develop and implement an approach for monitoring treatment plans for veterans with mental health conditions to ensure that such plans include documentation that different evidence-based treatment options were considered. (Recommendation 2)

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

Comments: VHA concurred with this recommendation and provided an update on its progress in implementing it. In December 2019, VHA reported that it had developed a new memorandum regarding mental health treatment planning that explicitly states the requirement for mental health providers in specialty care to record mental health treatment plans that include (among other things) an indication that different treatments were considered. VHA stated that the memorandum requires VAMCs to implement ongoing chart reviews to ensure providers were meeting treatment planning expectations. Specifically, VHA stated that the memorandum requires all VAMCs to ensure that each licensed independent provider had 5 treatment plans reviewed biannually to determine whether treatment planning expectations were achieved, including whether different evidence-based treatments were considered. Finally, VHA noted that the memorandum requires VAMCs to attest to full implementation of this process. According to VHA, the memorandum was distributed in May 2019 and the implementation of this process is currently underway across VAMCs. As of March 2020, this recommendation remains open pending further updates from VHA.

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 Director of ICE should take action to ensure consistent implementation of ICE's policies for handling cases of potentially removable veterans. (Recommendation 1)

Agency: Department of Homeland Security: United States Immigration and Customs Enforcement
Status: Open

Comments: In June 2019, we reported on U.S. Immigration and Customs Enforcement's (ICE) efforts to handle, track, and monitor cases related to veterans. We found that ICE has developed policies for handling cases of potentially removable Veterans, but does not consistently adhere to those policies. Therefore, some veterans who were removed may not have received the level of review and approval that ICE has determined is appropriate for cases involving veterans. We recommended that ICE take action to ensure consistent implementation of its policies for handling cases of potentially removable veterans. ICE agreed with this recommendation. In November 2019, ICE reported that it had established a working group to gather requirements for ERO officer and HSI agent training and will identify all of the lesson plans, practice exercises, and checklists to ensure veteran status information is collected during the booking process. In July 2020, ICE reported that the efforts of the working group were ongoing. We will continue to monitor ICE's efforts to address this recommendation.

Recommendation: The Director of ICE should develop and implement a policy or revise its current polices to ensure that ICE agents and officers identify and document veteran status when interviewing potentially removable individuals. (Recommendation 2)

Agency: Department of Homeland Security: United States Immigration and Customs Enforcement
Status: Open

Comments: In June 2019, we reported on U.S. Immigration and Customs Enforcement's (ICE) efforts to handle, track, and monitor cases related to veterans. We found that ICE has not developed a policy to identify and document all military veterans it encounters. Without such a policy, ICE has no way of knowing whether it has identified all of the veterans it has encountered and, therefore, does not have reasonable assurance that it is consistently implementing its policies and procedures for handling veterans' cases. We recommended that ICE develop and implement a policy or revise its current policies to ensure that ICE offices and agents identify and document veteran status when interviewing potentially removable individuals. ICE agreed with this recommendation. In November 2019, ICE reported that its internal working group is gathering requirements to systematically collect and maintain veteran status information. ICE noted that once the requirement gathering is complete it will revise existing ICE guidance on the issuance of issuing Notices to Appear for individuals with U.S. military service. In July 2020, ICE reported that the working group reviewed and updated its current policy and the Office of Policy and Planning is in the process of reviewing the updates. However, ICE was unable to provide an estimated completion date for finalizing the policy. We will continue to monitor ICE's efforts to address this recommendation.

Recommendation: The Director of ICE should collect and maintain complete and electronic data on veterans in removal proceedings or who have been removed. (Recommendation 3)

Agency: Department of Homeland Security: United States Immigration and Customs Enforcement
Status: Open

Comments: In June 2019, we reported on U.S. Immigration and Customs Enforcement's (ICE) efforts to handle, track, and monitor cases related to veterans. We found that ICE does not maintain complete electronic data on veterans who have been placed in removal proceedings or removed. As a result, ICE does not know exactly how many veterans have been placed in removal proceedings or removed, or if their cases have been handled according to ICE's policies. We recommended that ICE collect and maintain electronic data on veterans in removal proceedings or who have been removed. ICE agreed with this recommendation. In November 2019, ICE reported that its internal working group is analyzing systems and processes used by ICE officers and agents to identify the components in need of updating to properly capture veteran status. As of July 2020, the working group has identified fields that will be added to its integrated database to capture and maintain veterans' status information. Once the working group is done gathering systems, procedural, and training requirements, this work will also identify updates needed for ICE policies for handling cases of potentially removable veterans. We will continue to monitor ICE's efforts to address this recommendation.

Recommendation: As VA and IHS revise the MOU and related performance measures, the Secretary of Veterans Affairs should ensure these measures are consistent with the key attributes of successful performance measures, including having measurable targets. (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 Veterans Affairs should, in consultation with IHS and tribes, establish and distribute a written policy or guidance on how referrals from IHS and Tribal Health Program (THP) facilities to VA facilities for specialty care can be managed. (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: As VA and IHS revise the MOU and related performance measures, the Director of IHS should ensure these measures are consistent with the key attributes of successful performance measures, including having measurable targets. (Recommendation 3)

Agency: Department of Health and Human Services: Public Health Service: Indian Health Service
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: The Administrator of General Services should take steps to improve agency-wide monitoring of exchange/sale activities within GSA by specifying the Office of Administrative Services' responsibilities and by defining the scope of its authority. (Recommendation 2)

Agency: General Services Administration
Status: Open

Comments: As of February 2020, GSA developed and distributed a Standard Operating Procedure that established the Office of Administrative Services as having jurisdiction and program oversight for all internal agency exchange/sale transactions. GSA's Office of Administrative Services had also taken steps to coordinate with other GSA offices to coordinate annual exchange/sale data reporting for the agency. We will continue to monitor GSA's actions in addressing the recommendation.

Recommendation: The VA's Deputy Assistant Secretary of Acquisition and Logistics, in collaboration with the Veterans Health Administration's Office of Procurement and Logistics, should revise VA's policy to include details on the exchange/sale authority, particularly those related to monitoring by Regional Offices and use of the authority for medical centers, and establish time frames with milestones for communicating such information. (Recommendation 3)

Agency: Department of Veterans Affairs
Status: Open

Comments: As of February 2020, VA's Office of Acquisition and Logistics, in conjunction with Veterans Health Administration's Procurement and Logistics Office, was working on updating the status of two policy notices to amend existing policy to include details on the exchange/sale authority and to collect data on exchange/sale usage within the agency as a basis for reviewing progress and compliance with VA utilization officers. We will continue to monitor the status of VA's actions to address our recommendation.

Recommendation: The Under Secretary for Benefits should develop and implement a plan for how VBA will use data from the new exam management system to oversee contractors, including how it will capture accurate data on the status of exams and use it to (1) assess contractor timeliness, (2) monitor time spent correcting inadequate and insufficient exams, and (3) verify proper exam invoicing. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with this recommendation and outlined improvements in the information collected through VBA's new exam management system. VBA is testing a mechanism to validate exam invoices submitted by contractors. It will be important for VBA to take the next step of developing and implementing a plan for how it will use information from the new system to ensure both accurate timeliness data and proper exam invoicing.

Recommendation: The Under Secretary for Benefits should regularly monitor and assess aggregate performance data and trends over time to identify higher-level trends and program-wide challenges. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA agreed with this recommendation. The agency stated that VBA will use improved data in the new exam management system to regularly monitor and assess aggregate performance data, identify error trends, and monitor contractor performance and program-wide challenges.

Recommendation: The Under Secretary for Benefits should document and implement a plan and processes to verify that contracted examiners have completed required training. (Recommendation 3)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA agreed with this recommendation. The agency stated that VBA has started developing a training plan for contractors, as well as a new training delivery system, to validate that required training has been completed and to assess the effectiveness of this training through feedback from trainees, contractors, and quality review staff in VBA's contract exam program office. VBA intends to use this information to improve the implementation and content of training. VBA expects to fully implement its new training system before the end of fiscal year 2020. Once implemented, GAO will be able to close both of its recommendations related to training verification and assessment.

Recommendation: The Under Secretary for Benefits should collect information from contractors or examiners on training and use this information to assess training and make improvements as needed. (Recommendation 4)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA agreed with this recommendation. The agency stated that VBA has started developing a training plan for contractors, as well as a new training delivery system, to validate that required training has been completed and to assess the effectiveness of this training through feedback from trainees, contractors, and quality review staff in VBA's contract exam program office. VBA intends to use this information to improve the implementation and content of training. VBA expects to fully implement its new training system before the end of fiscal year 2020. Once implemented, GAO will be able to close both of its recommendations related to training verification and assessment.

Recommendation: The Under Secretary for Benefits should develop and implement a new regional office performance measure that allows it to better measure the accuracy of each regional office's work. (Recommendation 3)

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

Comments: VBA is working to develop and implement a new measure to assess the accuracy of each regional office. We will close this recommendation once VA has finalized and implemented the new measure.

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 Secretary of the VA should direct the Undersecretary for Health to designate a focal point for overseeing VAMCs' pharmacy inventory management system-wide and define the focal point's responsibilities. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA officials provided documentation showing approval as of September 2019 for the procurement of a perpetual inventory management system that would allow VA medical facilities to keep track of inventory for all prescription drugs and assist VA with system-wide oversight. As of January 2020, this contract has yet to be awarded. In January 2020, VA officials also stated that Pharmacy Benefits Management (PBM) Services has been designated as the focal point for overseeing VA medical facilities' inventory management system-wide. VA officials stated that PBM is responsible for developing VA medical facility inventory management policy; however, VA did not provide documentation on PBM's defined responsibilities for system-wide oversight in the absence of an inventory system and once the system is procured. We plan to keep this recommendation open until we receive documentation of PBM's defined responsibilities for overseeing VAMC's pharmacy inventory management system-wide.

Recommendation: The Secretary of Veterans Affairs should ensure that VA's Director of the Office of Acquisition and Logistics, in consultation with VA's Office of Small and Disadvantaged Business Utilization, takes measures to ensure that VA contracting staff adhere to the requirements for documenting the required Vendor Information Pages searches in contract files. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with this recommendation and is taking steps to implement it. In August 2020, VA reported that it was beginning a process to update its contracting system to automate the inclusion of documentation of Vendor Information Pages searches in contract files. VA is also now tracking compliance rates. VA plans to provide GAO an update in fall 2020.

Recommendation: The Secretary of Veterans Affairs should ensure that the Director of the Office of Acquisition and Logistics conducts a fraud risk assessment for the Veterans First program. (Recommendation 5)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with this recommendation and is taking steps to implement it. In August 2020, VA provided GAO with a draft fraud risk assessment, and also reported that it is developing measures to mitigate identified risks. VA has not yet provided a date by which it plans to finalize its risk assessment and risk mitigation measures.

Recommendation: The Secretary of Veterans Affairs should ensure that the Director of the Office of Acquisition and Logistics directs the Risk Management and Compliance Service to share, through guidance, training, or other methods, subcontracting limitation risks and monitoring practices with contracting officers and their management. (Recommendation 6)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with this recommendation and is taking steps to implement it. In August 2020, VA provided draft lists of subcontracting limitations risks, as well as draft monitoring guidance and tools. After these items are finalized, VA plans to post them on a portal accessible to all VA contracting staff, but has yet to provide a date by which it expects to take this step.

Recommendation: The Secretary of Veterans Affairs should ensure that the role and responsibilities of the Interagency Program Office are clearly defined within the governance plans for acquisition of the department's new electronic health record system. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: The Department of Veterans Affairs (VA) concurred with our recommendation to ensure that the role and responsibilities of the Interagency Program Office (IPO) were clearly defined within the governance plans for acquisition of the department's new electronic health record system. As of December 2019, VA and the Department of Defense (DOD) have replaced the IPO with a new joint governance body. Specifically, the Federal Electronic Health Record Modernization (FEHRM) program office has been established to serve as the single point of accountability in the delivery of a common health record between the departments and the advancement of interoperability with the private sector. In its charter, the FEHRM was described as a single decision-making authority to manage issues in support of the departments' integrated electronic health record objectives and its leadership is responsible for, among other things, working to formulate, oversee, de-conflict, and ensure adherence to electronic health record-related VA and DOD policies. However, the corresponding Implementation Plan that is intended to document how the FEHRM executes its full responsibilities has yet to be issued. To fully implement this recommendation, VA needs to document the role and responsibilities of the FEHRM with respect to VA's acquisition of its new electronic health record system, explaining the role, if any, the FEHRM will have in the governance process. We will continue to monitor the departments' incorporation of the FEHRM into the plans for the ongoing acquisition.

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 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 Department of Veterans Affairs (VA) Inspector General should revise its policy to include a requirement to verify whether evidence produced in senior-official case referrals demonstrates that the six elements required in VA Directive 0701 have been addressed. (Recommendation 6)

Agency: Department of Veterans Affairs
Status: Open

Comments: The VA Office of the Inspector General updated VA Directive 0701 to require a written or electronic signature from the person preparing the response that the specific requirements of the directive were met. The updated version of the directive was submitted to the Department, the concurrence was signed on November 16, 2018. As of January 2019, the VA OIG was working with the VA to finalize and publish the directive. On February 15, 2019, the VA OIG contacted GAO with revised language for VA Directive 0701. The language clarified the requirement to include a signature and attestation by the person preparing the response. As of June 2020, the VA OIG is in the process of working with the VA administration to finalize and publish the directive. In September 2020, GAO requested an update from the VA OIG on the status of publishing the directive.

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: The Undersecretary for Health should ensure that Central Office, Veterans Integrated Service Networks (VISN), and medical facilities document the actions they take towards achieving OSI goals. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with the recommendation. To fully implement this recommendation, VHA needs to provide information about the new documentation requirements described in the November 2019 update.

Recommendation: The Undersecretary for Health should ensure that any OSI goals that have not been met have clearly defined, measurable outcomes, including milestones or numerical targets, as appropriate, and timeframes. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with the recommendation. To fully implement this recommendation, VHA needs to provide information about specific actions, described in the November 2019 update, taken to address the recommendation including documentation showing the actions taken to review the OSI goals and documentation of new OSI goals, metrics, and timelines.

Recommendation: To ensure that all eligible Coast Guard servicemembers are provided the opportunity to complete the Transition Assistance Program (TAP), the Commandant of the Coast Guard should issue an updated Commandant Instruction that establishes policies and procedures to improve the reliability and completeness of TAP data by including when and by whom data should be recorded and updated. (Recommendation 1)

Agency: Department of Homeland Security: United States Coast Guard
Status: Open

Comments: The Department of Homeland Security agreed with our recommendation and reported that a Commandant Instruction had been drafted, which will include a policy on the duties and requirements for recording TAP data. The Commandant Instruction is anticipated to be issued by October 31, 2018. We will consider this recommendation closed when the Commandant Instruction is officially issued.

Recommendation: To ensure that all eligible Coast Guard servicemembers are provided the opportunity to complete the Transition Assistance Program (TAP), the Commandant of the Coast Guard should establish a formal performance goal with a measurable target for participation rates in VOW Act-mandated portions of TAP. (Recommendation 2)

Agency: Department of Homeland Security: United States Coast Guard
Status: Open

Comments: The Department of Homeland Security (DHS) agreed with our recommendation and reported that the Coast Guard, Department of Defense (DOD), and other partners collaborated to identify measurable and specific performance goals that are compliant with VOW requirements. In addition, the these goals will be measured using the DOD's TAP-IT Enterprise tracking system once it becomes fully functional to the Coast Guard by October 31, 2018. We will close this recommendation when DHS provides documentation of its measures and goals.

Recommendation: To ensure that all eligible Coast Guard servicemembers are provided the opportunity to complete the Transition Assistance Program (TAP), the Commandant of the Coast Guard should issue an updated Commandant Instruction that defines the roles and responsibilities of the personnel who administer the program and ensure servicemembers' participation. (Recommendation 5)

Agency: Department of Homeland Security: United States Coast Guard
Status: Open

Comments: The Department of Homeland Security agreed with our recommendation and reported that a Commandant Instruction has been drafted, which will identify the duties of personnel who administer TAP. The Commandant Instruction is anticipated to be issued by October 31, 2018. We will consider this recommendation closed when the Commandant Instruction is officially issued.

Recommendation: To ensure that all eligible Coast Guard servicemembers are provided the opportunity to complete the Transition Assistance Program (TAP), the Commandant of the Coast Guard should, once reliable data are available by installation or unit, enable unit commanders and the higher-level commanders to whom they report to access TAP performance information specifically for the units they oversee so that they can monitor compliance with all TAP requirements. (Recommendation 6)

Agency: Department of Homeland Security: United States Coast Guard
Status: Open

Comments: The Department of Homeland Security agreed with our recommendation and reported the Coast Guard expects to fully transition to DOD's TAP-IT Enterprise System by October 31, 2018, which is expected to facilitate tracking of servicemember attendance within all TAP components. The agency also stated that following the transition and release of the new Commandant Instruction, Commanding Officers will be able to monitor their compliance with TAP performance and requirements. Both these efforts are expected to be completed by October 31, 2018. We will consider this recommendation closed when the Commandant Instruction has been issued and documentation is provided of the ability to track performance information by unit.

Recommendation: The VHA Undersecretary for Health should provide updated guidance to VAMCs on the governance of the patient advocacy program, including clear definitions of reporting lines. (Recommendation 1)

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

Comments: VHA concurred with this recommendation and has provided regular updates on its progress in implementing it. As of April 2019, VHA's Office of Patient Advocacy (OPA) partnered with VA's Center for Healthcare Organization and Implementation Research (CHOIR) to better understand the current state of patient advocacy services in VHA, focusing on position descriptions, grade levels, and reporting structures. VA medical center staff completed questionnaires about the patient advocacy program in January 2019 and VHA analyzed the results. CHOIR officials are conducting site visits to interview key staff directly to identify the benefits and opportunities for improvements with patient advocacy services, including reporting structure. Upon completion of site visits to validate questionnaire findings, CHOIR will present their final recommendations to OPA. OPA will develop reporting structure guidance and work with workforce management and VHA senior leaders to communicate and implement the guidance. VHA's target completion for these efforts is December 2019.

Recommendation: The VHA Undersecretary for Health should assess and provide guidance to VAMCs on appropriately staffing the patient advocacy program, including guidance on how to determine the appropriate number and type of staff. (Recommendation 2)

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

Comments: VHA concurred with this recommendation and has provided regular updates on its progress in implementing it. As of April 2019, VHA's Office of Patient Advocacy (OPA) partnered with VA's Center for Healthcare Organization and Implementation Research (CHOIR) and VHA's Workforce Management to develop an evidence-based patient advocacy staffing model that accounts for facility size, complexity and geographic region. A set of questions was distributed to all VAMCs in December 2018. Responses to these questions have been analyzed by CHOIR, and on-site interviews at select facilities are in progress to validate the report findings. VHA's Workforce Management is working with CHOIR and OPA to use the results to develop a recommended and validated staffing model. This guidance will also be incorporated in the future revision of the VHA directive. The target completion of these efforts is December 2019.

Recommendation: The VHA Undersecretary for Health should monitor PATS data-entry practices to ensure all complaints are entered into PATS and that veterans' feedback is coded consistently. (Recommendation 5)

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

Comments: VHA concurred with this recommendation and has provided regular updates on its progress in implementing it. As of April 2019, VHA's Office of Patient Advocacy (OPA) receives a weekly report from both the Patient Advocate Tracking System (PATS) and PATS-Replacement (PATS-R) Systems reporting on the number of new cases entered at every VA medical center (VAMC). With development of the PATS-R web-based tool, OPA, the Veterans Experience Office and the PATS-R developers have conducted a review of existing codes and are currently working with various VHA program offices to standardize codes across various data systems. VA plans to develop an auditing toolkit to ensure standardized, timely documentation of complaints, including accurate coding within PATS. The target completion date for these efforts is December 2019.

Recommendation: The Secretary of Veterans Affairs should clearly articulate in VA's appeals plan how VA will monitor and assess the new appeals process compared to the legacy process, including specifying a balanced set of goals and measures--such as timeliness goals for all VBA appeals options and Board dockets, and measures of accuracy, veteran satisfaction, and cost--and related baseline data. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: VA concurred with this recommendation and, as of March 2020, addressed some but not all aspects of it. Regarding monitoring, VA has made progress in monitoring and addressing workload changes in its new and legacy appeals processes. For example, VA has developed sensitivity models and other analyses to monitor and forecast future VBA and Board workloads, production, and staffing requirements to help VA manage the new and legacy appeals processes. Further, the Board is aiming to complete non-remanded legacy appeals by December 2022 by first addressing hearing-requested appeals. However, VBA and the Board have yet to specify a complete set of balanced goals for monitoring the new and legacy appeals processes (e.g., timely and accurate processing of appeals while ensuring veteran satisfaction). For example, the Board will not establish timeliness goals for all new Board options until after collecting additional data during implementation of the new appeals process, thus delaying VA's vision for what successful implementation should look like and hindering awareness of resources required to achieve that vision. Regarding comparing the performance of the new and legacy appeals processes, VA officials have previously reported that they intend to use timeliness and productivity metrics from section 5 of the Appeals Modernization Act. Further, VBA and Board officials have articulated steps they are taking to collect, through surveys, comparable information on veterans' satisfaction with the new and legacy appeals processes. However, VA has not fully articulated detailed steps and timeframes for assessing the relative performance of the new and legacy appeals processes. For example, VA has not indicated how it will assess whether or the extent to which the new process, which also allows for multiple appeal opportunities, will achieve final resolution of veterans' appeals sooner, on average, than the legacy process, as we recommended in GAO-17-234. We will consider closing this recommendation when VA provides documentation indicating how it will assess the new appeals process against the legacy process vis a vis balanced measures.

Recommendation: The Secretary of Veterans Affairs should augment the master schedule for VA's appeals plan to reflect all activities--such as modifications to information technology (IT) systems--as well as assigned responsibilities, interdependencies, start and end dates for key activities for each workgroup, and resources, to establish accountability and reduce overall risk of implementation failures. (Recommendation 3)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with this recommendation. Since our report was issued, VA took significant action on its project plan and in February 2019, implemented the Veterans Appeals Improvement and Modernization Act of 2017. VA provided increasingly more details in updates to its plan about sub-activities related to processing legacy appeals, monitoring implementation, drafting Board policies, training, and testing of the new process. For example, VA added activities related to the Rapid Appeals Modernization Program (RAMP) test of the VBA-only options as well as the test of the new Board options. In spring and summer 2018, according to VA officials, VA set a baseline schedule for implementing appeals reform in response to the potential February 2019 implementation date established in the Act. In October 2018, VA provided us with lower-level schedules and other related information that allowed us to conduct a more detailed assessment of VA's IMS against applicable best practices criteria. However, as of December 2018, VA's schedule did not fully align with best practices. For example, VA's schedule did not contain a work breakdown structure that defines the work, activities, and resources necessary to accomplish implementation-details that would inform resources and time needed for the project. (For details on this assessment, see GAO-19-272T.) While VA fully implemented appeals reform in February 2019, incorporating such lessons learned into future project planning could help VA improve its project scheduling capabilities. Specifically, in February 2020 VA reported that Caseflow-VA's replacement system intended to support appeals reform-had "minimal functionality," with many functionalities yet to be implemented. We will consider closing this recommendation when VA has produced a more complete plan for-and that establishes accountability and reduces risk of failure related to-developing, implementing, and integrating remaining key functionality envisioned under Caseflow. We will also continue tracking whether the Board addresses long-term Caseflow planning under recommendation 2 in GAO-17-234.

Recommendation: The Secretary of Veterans Affairs should ensure that the appeals plan more fully addresses risk associated with appeals reform--for example, by assessing risks against a balanced set of goals and measures, articulating success criteria and an assessment plan for RAMP, and testing or conducting sensitivity analyses of all appeals options--prior to fully implementing the new appeals process. (Recommendation 4)

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: The Department of Veterans Affairs (VA) concurred with our recommendation to more fully address risks associated with implementing a new appeals process. As of March 2020, VA has taken many steps to address our recommendation, although key steps are remaining for VA to better assess risks associated with implementing appeals reform and managing appeals workloads in the legacy process. Specifically, since May 2018, VBA and Board officials reported developing and using new sensitivity analyses that would allow the agency to project potential budget needs and staffing requirements. Further, VBA is using these analyses to more accurately predict resolution of legacy appeals given certain assumptions. Furthermore, in addition to testing two appeal options available within VBA through its Rapid Appeals Modernization Program (RAMP), VA conducted small-scale testing of the three new Board appeals options through the Board's Early Applicability of Appeals Modernization (BEAAM) pilot, testing that was missing from VA's original November 2017 plan. VA also reported using lessons learned from testing all appeals options to update the implementation process. However, as designed, RAMP and BEAAM lacked well-defined, measurable criteria for assessing lessons learned from its testing, and the agency did not fully test all aspects of the appeals options before moving to full implementation in February 2019. Even though VA has fully implemented the new disability appeals process without addressing these aspects of our recommendation, many of the other principles of sound planning practices that informed our recommendation remain relevant, even after implementation, to ensure the new process meets veterans' needs. Specifically, VA has not developed mitigation strategies for all identified risks, such as veterans appealing to the Board at higher rates than expected or choosing more resource-intensive Board options, such as those involving new evidence or a hearing. As of January 2020, the more resource-intensive hearing option accounted for over 50 percent of new appeals inventory. At the same time, the Board reported it plans to prioritize resources on reducing the legacy appeals inventory and on the least resource intensive appeal option for which it established a timeliness goal. Although the Board has increased productivity, addressing legacy hearings will take several years as veterans may continue choosing the new hearing option at high rates and the Board prioritizes other workloads. This circumstance could subject veterans to longer wait times and increasing backlogs under the hearing option. As of March 2020, VA also has not established a complete and balanced set of goals and measures for the new appeals options, which are a necessary pre-condition to effectively assessing risk. Lacking a complete set of goals and measures, VA may not have comprehensively identified key risks.

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: The Under Secretary for Health should specify in VHA policy that reviews of providers' clinical care after concerns have been raised should be documented, including retrospective and comprehensive reviews. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA agreed with the recommendation and indicated plans to revise policy to codify requirements to document reviews. As of April 2020, VA estimates completing these and other revisions to the policy in August 2020.

Recommendation: The Under Secretary for Health should specify in VHA policy a timeliness requirement for initiating reviews of providers' clinical care after a concern has been raised. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA agreed with the recommendation and indicated plans to revise policy to incorporate timeline expectations for initiating reviews after clinical care concerns have been raised. As of April 2020, VA estimates completing these and other revisions to the policy in August 2020.

Recommendation: The Director of the MSPV-NG program office should, with input from the Strategic Acquisition Center (SAC), develop, document, and communicate to stakeholders an overarching strategy for the program, including how the program office will prioritize categories of supplies for future phases of requirement development and contracting. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: The Department of Veterans Affairs (VA) agreed with GAO's November 2017 recommendation. VA planned to implement a new Medical-Surgical Prime Vendor (MSPV) program, called MSPV 2.0, by March 2020; however, this program has been delayed to at least January 2021. MSPV 2.0 includes a process where clinicians review requirements for a set list of products. As of August 2020, VA is beginning the national rollout of this clinician review process, but the results of this process won't be implemented until after MSPV 2.0 begins. VA's strategy for its MSPV program depends on full implementation of this clinician review process.

Recommendation: The Director of the MSPV-NG program office should provide complete guidance to medical centers for matching equivalent supply items, which could include defining the roles of clinicians and local Clinical Product Review Committees. (Recommendation 4)

Agency: Department of Veterans Affairs
Status: Open

Comments: The Department of Veterans Affairs (VA) agreed with GAO's November 2017 recommendation. VA implemented a tool-the Medical Product Data Bank's eZSAVE application-to improve the matching of equivalent supply items. In November 2018, VA reported that it holds monthly meetings with selected clinical and logistics staff to obtain their input on the matching process. However, as of August 2020, VA has not provided documentation showing how it has defined the role of clinical staff, including Clinical Product Review Committees, in this process. Without documentary support, GAO cannot assess the extent of the clinical staff role in the matching process. If the roles of clinicians are not clearly defined, it increases the risk of inconsistent involvement in the matching process.

Recommendation: The VHA Chief Procurement and Logistics Officer should use input from national clinical program offices to prioritize its MSPV-NG requirements development and standardization efforts beyond Phase 2 to focus on supply categories that offer the best opportunity for standardization and cost avoidance. (Recommendation 8)

Agency: Department of Veterans Affairs
Status: Open

Comments: The Department of Veterans Affairs (VA) agreed with GAO's November 2017 recommendation. VA's planned Medical-Surgical Prime Vendor (MSPV) 2.0 program includes engaging selected clinicians in its requirement development for a set list of products, known as Clinician-Driven Strategic Sourcing. In April 2019, VA began a pilot for this clinician review process, including input from national clinical program offices. As of August 2020, VA is beginning the national rollout of this process. VA does not plan to incorporate the results of this clinician review process in the list of available supplies until after MSPV 2.0 is implemented, which has been delayed until at least January 2021. Until VA implements MSPV 2.0 and incorporates the results of the Clinician-Driven Strategic Sourcing process, it will not be able to achieve its goals of cost savings and improved clinical consistency.

Recommendation: The VHA Chief Procurement and Logistics Officer should direct Veterans Integrated Service Network (VISN) Network Contracting Offices to work with medical centers to identify any opportunities to more strategically purchase goods and services frequently purchased on an emergency basis. For example, offices could do this by analyzing existing data. (Recommendation 9)

Agency: Department of Veterans Affairs
Status: Open

Comments: The Department of Veterans Affairs (VA) agreed with GAO's November 2017 recommendation. In August 2019, senior VA acquisition officials agreed to conduct an analysis of its spending to identify items that the department frequently purchases on an emergency basis and to develop plans to purchase those goods and services more strategically, such as by issuing a national contract or adding the items to the formulary as needed. As of August 2020, these officials indicated they would provide this analysis to GAO by the end of 2020.

Recommendation: VHA Chief Procurement and Logistics Officer should analyze data on items that are frequently purchased on an emergency basis, determine whether such items are suitable to be added to the MSPV-NG formulary, and work with SAC to make any suitable items available via MSPV-NG. (Recommendation 10)

Agency: Department of Veterans Affairs
Status: Open

Comments: The Department of Veterans Affairs (VA) agreed with GAO's November 2017 recommendation. VA reported that it added thousands of items to the Medical-Surgical Prime Vendor (MSPV) formulary from June 2018 through December 2018, some of which had previously been purchased on an emergency basis. VA also reported in June 2018 and updated in March of 2020 that it is tracking items purchased on an emergency basis. However, as of August 2020, VA has not provided documentation showing whether and how this analysis has informed its selection of which products to add to the formulary. Without documentary support, GAO cannot assess the extent to which items that VA added to the formulary were previously purchased on an emergency basis. If VA does not use analysis of emergency procurements to help inform which items should be added to the MSPV formulary, it will miss opportunities to avoid emergency procurements and increase efficiency.

Recommendation: The Undersecretary for Health should develop and implement a process to accurately count all physicians providing care at each medical center, including physicians who are not employed by VHA. (Recommendation 1)

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

Comments: As of January 2020, VHA continues to disagree with the recommendation and has not taken any action. Although VA responded to our report by stating that the ability to count physicians does not affect its ability to assess workload, we maintain that an accurate count of all physicians providing care at each medical center is necessary for accurate workforce planning. To implement the first recommendation, VHA needs to develop a system-wide process to collect information on all physicians providing care at VAMCs, including physicians that are not employed by VHA. This information should be available at the local level for workforce planning purposes.

Recommendation: The Undersecretary for Health should develop and issue guidance to the VAMCs on determining appropriate staffing levels for all mission-critical physician occupations. (Recommendation 2)

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

Comments: VHA concurred with this recommendation. In November 2017, VHA's Executive in Charge chartered the Specialty Care Provider Staffing and Network Model Workgroup to develop a methodology for determining the scope and complexity of specialty care services. The Workgroup also developed an analytical tool to support local decision-making around specialty staffing levels. According to VHA, the Specialty Care Services Staffing model has been validated across some VHA regions. The Workgroup was directed to develop an Executive Decision Memorandum for an official determination as to implementation of the model. As of January 2020, VHA was awaiting the results of the Governing Board's decision on the Executive Decision Memorandum, the guidance documents, and analytical template. VHA reported the target date for completion is March 2020.

Recommendation: The Undersecretary for Health should establish a system-wide method to share information about physician trainees to help fill vacancies across VAMCs. (Recommendation 4)

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

Comments: VHA concurred with this recommendation. VHA is working to develop the necessary capacity to enable a system-wide method for sharing information about physician trainees to help fill vacancies. In April 2019, VHA anticipated having this system in place by the end of fiscal year 2019. However, VHA has not submitted any additional information since April 2019. VHA has also created a VHA-Trainee Recruitment and Hiring Workgroup (the Workgroup). The Workgroup serves as the advisory group on trainee recruitment and hiring, for the purpose of developing a permanent Trainee Recruitment and Hiring Function. The Workgroup is holding Virtual Trainee Recruitment Events for critical occupations. Until GAO sees evidence of a system-wide method for sharing information about physician trainees, this recommendation will remain open.

Recommendation: The Undersecretary for Health should take additional steps to ensure that VA's website reports health care quality measures that cover a broad range of health care services, highlights key differences in the clinical quality of care, and presents this information in an easily accessible and understandable way (Recommendation 1).

Agency: Department of Veterans Affairs
Status: Open

Comments: As of January 2020, VA provided information that they had updated information on its website to include more quality measures, particularly as they relate to outpatient care. While VA has made progress in reporting on additional measures, we reviewed VA's website-specifically, their Access and Quality webpage which is the primary webpage for veterans to access information on quality-as of February 2020 and found that VA has still yet to report on a broad range of quality measures that would assist veterans in making health care decisions for inpatient care. For example, VA does not report any quality measures related to readmissions and mortality; length-of-stay; or efficiency. VA also continues to report only one timely and effective care measure for inpatient care. With regards to presentation of its quality measures, VA no longer links its Access and Quality webpage to the homepage of VA's website, making it more difficult to find. Additionally, for the new outpatient measures that VA has added to its website, VA has not presented these measures in an easily understandable way as there is little explanation of what they are measuring and how veterans can use these measures to make healthcare decisions. We will keep this recommendation open until VA has made further updates to its website.

Recommendation: The Undersecretary for Health should direct VA Central Office to conduct a systematic assessment of the completeness and accuracy of patient clinical information across VAMCs that is used to calculate the health care quality measures VA reports and address any deficiencies that affect the accuracy of these measures (Recommendation 2).

Agency: Department of Veterans Affairs
Status: Open

Comments: As of January 2020, VA has said they have focused on three main efforts as it relates to documenting information on VA quality of care, including: timeliness of access information (e.g., wait times) to health care within VA facilities; timeliness and accuracy of payments to community care providers; and accuracy of coding and documentation within VA and from community providers. In particular, VA has conducted several efforts to improve education and training on clinical documentation and coding, particularly for providers. VA has also said it has made efforts in requiring programs across regional networks aimed at improving clinical documentation and coding. While these efforts can help with improving documentation of care to veterans, it is unclear how VA Central Office has assessed whether these efforts have actually achieved its goals and improved the accuracy of its quality measures. As we stated in our report, VA Central Office has not conducted a systematic assessment of the completeness and accuracy of the clinical data recorded in VA patient medical records across all VAMCs. The results of such a systematic analysis could help identify the deficiencies, if any, in the recording of patient clinical information and what steps, if any, VA Central Office may need to take to address them. We will keep this recommendation open until VA provides information on a systematic assessment of clinical documentation.

Recommendation: The Under Secretary for Health should further clarify when and for what purposes each national policy and guidance document type should be used, including whether guidance documents, such as program office memos, should be vetted and recertified. (Recommendation 1)

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

Comments: VA agreed with our recommendation. In October 2019, VHA issued an interim policy on program office memos (also known as "operational memos") that described how these guidance documents should be vetted and recertified. For example, operational memos issued after VHA's new interim policy will expire 2 years after publication if no further action is taken. In November 2019, VHA further clarified in another interim policy the purpose of all national policy and guidance documents, including the purpose and audience for each document type. Because VHA interim policy, by definition, is automatically rescinded after 1 year unless incorporated into a national policy directive, VHA needs to provide us with the finalized version of its recertified national policy directive in order to fully implement this recommendation. The recertified national policy directive should include the framework outlined in its interim policy documents.

Recommendation: The Under Secretary for Health should develop standard processes for consistently maintaining and disseminating guidance documents to each level of the organization. (Recommendation 2)

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

Comments: VA agreed with our recommendation. VHA reported that it added a program office memo (also known as "operational memo") section to its internal publications website in November 2017. Uploading operational memos to this website allowed VHA to identify 327 outdated documents that it has since rescinded, as well as numerous other documents that may require rescission. In October 2019, VHA issued an interim policy requiring all operational memos to be maintained on its publications website. Because interim policy is automatically rescinded after 1 year, VHA needs to provide us with the finalized version of its recertified national policy directive that includes the process it established to maintain these documents. In addition, VHA has not provided documentation of how it will disseminate operational memos so that VHA program offices, VISNs, and VAMCs are aware of new or rescinded guidance.

Recommendation: The Under Secretary for Health should establish a mechanism by which program offices systematically obtain feedback from VISNs and VAMCs on national policy after implementation and take the appropriate actions. (Recommendation 4)

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

Comments: VA agreed with our recommendation. In June 2018, VHA reported that it had formed a Field Advisory Workgroup to provide continuing advice on national policy. VHA reported its findings and recommendations from the first workgroup meeting in December 2017 to senior leadership, and held another series of interviews in Summer 2018 to gain additional feedback about how national policy changes affect local facilities. In November 2019, VHA noted that it is developing a standardized process for collecting feedback from the field on published policies. To fully implement this recommendation, VHA should provide documentation of the mechanism by which program offices systematically obtain feedback from VISNs and VAMCs on national policy after implementation and how it will take the appropriate actions.

Recommendation: The Under Secretary for Health should establish a standard policy exemption waiver process and centrally track and monitor approved waivers. (Recommendation 5)

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

Comments: VA agreed with our recommendation. In October 2018, VHA reported that it had collected information on the waiver procedures and areas of improvement that exist at both the national and local levels. Based on this information, VHA's Waiver Workgroup was finalizing its recommendations for implementing a formal waiver process. As of November 2019, VHA had not yet reached a decision on how to proceed. To fully implement this recommendation, VHA should provide us with documentation of a process that standardizes policy exemptions waivers, including tracking and monitoring those that are approved.

Recommendation: The Under Secretary for Health should establish a standard process, including designated oversight roles, to periodically monitor that local policies established by VISNs and VAMCs align with national policies. (Recommendation 6)

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

Comments: VA agreed with our recommendation. In June 2018, VHA reported that it had identified approximately 55,000 local policies and included them in a SharePoint database, which will serve as a baseline for removing redundant or conflicting local policy. In November 2019, VHA issued an interim policy that established business rules for oversight and monitoring local policy development at the VISN and VAMC levels. Specifically, VHA will assess the number of local policies every 6 months as well as identify patterns of non-compliance. In addition, the interim policy includes standardized templates, a recertification requirement of 5 years to mirror the national policy requirement, and restricts VHA program offices from creating requirements for local policy development. VHA also established resources for the new interim policy, such as a list of local policies as required by national policy. Because VHA interim policy, by definition, is automatically rescinded after 1 year unless incorporated into a national policy directive, VHA needs to provide us with the finalized version of its recertified national policy directive in order to fully implement this recommendation.

Recommendation: To ensure that the financial benefits of EULs that the Department of Veterans' Affairs reports in its annual Consideration Report on the EUL program are transparent and reliable, the Secretary should revise its Enhanced-Use Leasing Post Transaction Handbook (Handbook 7454) and specify that VA will: (1) Report consistently the enhanced services benefits from its EULs separately from other financial benefits that directly affect VA's budget, and (2) Include an explanation in its reporting on estimated EUL enhanced services that its estimates may not adequately capture all benefits of the EUL project and that certain costs associated with providing such benefits that are incurred by parties outside VA are not included in the analysis.

Agency: Department of Veterans Affairs
Status: Open

Comments: In August 2020, VA stated that the handbook was out for concurrences and received significant feedback/edits. VA is currently working through those edits and plans on submitting the revised version for internal concurrences in the next two weeks. VA said it will follow back up with GAO to provide a status on the handbooks approval and subsequent publishing

Recommendation: To assist VA in improving key IT management processes to ensure that investments support the delivery of health care services, the Secretary of Veterans Affairs should direct the Under Secretary for Health and the Chief Information Officer to ensure that the department-level investment review structure is implemented as planned and that guidance on the IT governance process is documented and identifies criteria for selecting new investments, and reselecting investments currently operational at VHA.

Agency: Department of Veterans Affairs
Status: Open

Comments: In its comments on our report, VA concurred with our recommendation and provided meeting minutes for its Portfolio Investment Management Board and documentation describing the proposed alignment and interdependencies between information technology (IT) governance boards. According to VA officials, as of September 2019, the department had continued to further evolve its IT governance framework, reworked the committee structure and related working groups that oversee IT investments, and refined the process for prioritizing investments. A draft IT Governance Policy that describes an updated governance structure intended to implement IT solutions and an agile workforce was to be implemented by March 2020. The department has yet to report on the status and results of this implementation. We will continue to monitor VA's actions to ensure that the implementation is consistent with planned actions.

Recommendation: To assist VA in improving key IT management processes to ensure that investments support the delivery of health care services, the Secretary of Veterans Affairs should direct the Under Secretary for Health and the Chief Information Officer to identify additional performance metrics to align with VHA's core business functions, and then use these metrics to determine the extent to which the department's IT systems support performance of VHA's mission.

Agency: Department of Veterans Affairs
Status: Open

Comments: In its comments on our report, VA concurred with our recommendation. In addition, the department outlined steps it intends to take to address our recommendation, including developing a set of metrics to provide continuous input into investment portfolio decisions and establishing a methodology for ensuring that IT investments are aligned to business needs and that expected outcomes are defined prior to making the investments. According to department officials, VA issues a Joint Business Plan that identifies annual milestones associated with initiatives agreed upon by both VHA and OIT. As of September 2020, we are reviewing additional documentation related to the underlying processes that support the compilation of the plan and any related metrics for the associated investments that are to support VHA's mission. We will continue to monitor progress in this area.

Recommendation: To assist VA in improving key IT management processes to ensure that investments support the delivery of health care services, the Secretary of Veterans Affairs should direct the Under Secretary for Health and the Chief Information Officer to ensure that unmet IT needs identified by key program areas--pharmacy benefits management, scheduling, and community care--are addressed appropriately and that related business functions are supported by IT systems to the extent required.

Agency: Department of Veterans Affairs
Status: Open

Comments: In its comments on our report, VA concurred with our recommendation. The department described its intention to ensure that unmet IT needs for the pharmacy benefits management, scheduling, and community care program areas were addressed appropriately during fiscal year 2018 budget formulation. In March 2020, we met with officials from the Pharmacy Benefits Management program office, the Office of Veterans Access to Care, and the Community Care program to discuss the status of new service requests and the extent to which IT needs have been met since our report. While there was a slight decrease in the total number of new service requests that remained open for 5 years or more, officials from each office did not consistently report improvements in how IT needs were being addressed. For example, Pharmacy Benefits Management officials still waited for improvements that may come with the deployment of the new electronic health record system, but they continued to report that updates to industry standards should be addressed sooner and often IT needs did not make it through the prioritization process at the Veterans Health Administration to be considered by the Office of Information and Technology. Community Care officials reported a general improvement in the IT governance process and a more engaged relationship with the Office of Information Technology; however, the list of open new service requests still included long-term VistA-related enhancements, some of which had not yet been prioritized by the department. The Office of Veterans Care has not yet provided an updated list of open new service requests, but officials were satisfied with a new maintenance contract that allowed them to address a number of IT issues. We will continue to monitor the number of new service requests in each program area and the extent to which the IT needs are being met by the IT governance process.

Recommendation: To provide clinicians and pharmacists with improved tools to support pharmacy services to veterans and reduce risks to patient safety, the Secretary of Veterans Affairs should direct the Assistant Secretary for Information and Technology and the Under Secretary for Health to establish and implement a plan for updating the pharmacy system to address the inefficiencies with viewing patient medication data in the Outpatient Pharmacy application and between the pharmacy application and viewers.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with our recommendation and in August 2017 stated that it had identified $4 million in fiscal year 2018 to establish a pharmacy graphical user interface. As of September 2020, VA was still in the process of implementing the pharmacy graphical user interface, which it estimated it would deploy in December 2020. We will continue to monitor the situation.

Recommendation: To provide clinicians and pharmacists with improved tools to support pharmacy services to veterans and reduce risks to patient safety, the Secretary of Veterans Affairs should direct the Assistant Secretary for Information and Technology and the Under Secretary for Health to complete a plan for the implementation of an approach to data standardization that will support the capability for clinicians and pharmacists to view complete DOD data and receive order checks that consistently include DOD data.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred in principle with our recommendation and in May 2018 awarded a contract to implement the same electronic health record system that is being deployed by DOD, which is intended to present VA clinicians with complete DOD data and the ability to perform order checks on DOD data. In parallel, the department is continuing and expanding the implementation of data standardization. According to the department's September 2020 update, the agency had updated its pharmacy system to improve data standardization. However, the agency had not submitted sufficient documentation to close the recommendation. We will continue to monitor the situation.

Recommendation: To provide clinicians and pharmacists with improved tools to support pharmacy services to veterans and reduce risks to patient safety, the Secretary of Veterans Affairs should direct the Assistant Secretary for Information and Technology and the Under Secretary for Health to conduct an assessment to determine to what extent interoperability of VA's pharmacy system with DOD's pharmacy system is impacting transitioning service members.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with our recommendation and in May 2017 stated that the health executive committee would complete an assessment to determine the extent interoperability with DOD's pharmacy system is impacting transitioning service members. In October 2017, VA conducted an assessment, however it was limited to one part of its system, the Joint Legacy Viewer (JLV), and read-only data. In September 2020, the agency provided a written response to supplement its October 2017 assessment with additional data regarding the potential impact of failures of its system to exchange pharmacy and allergy data with DOD. However, VA had not submitted sufficient documentation to close the recommendation. We will continue to monitor the situation.

Recommendation: To provide clinicians and pharmacists with improved tools to support pharmacy services to veterans and reduce risks to patient safety, the Secretary of Veterans Affairs should direct the Assistant Secretary for Information and Technology and the Under Secretary for Health to develop and execute a plan for implementing the capability to send outbound e-prescriptions to non-VA pharmacies, in accordance with National Council for Prescription Drug Programs standards.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with our recommendation and in August 2017 stated that it will review its plan for e-prescribing functionality after it has signed a contract to adopt the electronic health record system that is being deployed by DOD. Although VA awarded the contract for the new electronic health record system in May 2018, VA had not submitted sufficient documentation to close the recommendation as of September 2020. We will continue to monitor the situation.

Recommendation: To provide clinicians and pharmacists with improved tools to support pharmacy services to veterans and reduce risks to patient safety, the Secretary of Veterans Affairs should direct the Assistant Secretary for Information and Technology and the Under Secretary for Health to ensure that the department's evaluation of alternatives for electronic health records includes consideration for additional generation level 3 capability such as navigating from an alert to medication order in the electronic health record system.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with our recommendation and in August 2017 stated that it had entered into contract negotiations to acquire and deploy a level 3 electronic health record system that is expected to address pharmacy functions. As of September 2020, the agency had not submitted sufficient documentation to close the recommendation. We will update the status of this recommendation when VA provides documentation of its evaluation of alternatives to us.

Recommendation: To provide clinicians and pharmacists with improved tools to support pharmacy services to veterans and reduce risks to patient safety, the Secretary of Veterans Affairs should direct the Assistant Secretary for Information and Technology and the Under Secretary for Health to reassess the priority for establishing an inventory management capability to monitor and update medication levels and track when to reorder medications.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with our recommendation and in August 2017 stated that it will reassess the prioritization of medication inventory management after a contract for adoption of the electronic health record system is signed. As of September 2020, VA had not submitted sufficient documentation to close the recommendation. We will continue to monitor the situation.

Recommendation: To increase its assurance that PTSD and TBI are appropriately considered prior to separating certain servicemembers from the military for misconduct, the Secretary of Defense should direct the Air Force and Navy to address inconsistencies with DOD policy in their policies related to training servicemembers, including officers, on how to identify mild TBI symptoms in the deployed setting.

Agency: Department of Defense
Status: Open

Comments: At the time of report publication DOD indicated it did not concur with this recommendation. However after publication, the department indicated it concurred with the recommendation. As of September 2020, DOD is continuing to take actions to address this recommendation. When actions have been completed, GAO will update the status of the recommendation.

Recommendation: To increase its assurance that PTSD and TBI are appropriately considered prior to separating certain servicemembers from the military for misconduct, the Secretary of Defense should ensure that the military services routinely monitor adherence to policies related to screening certain servicemembers for PTSD and TBI prior to separation for misconduct.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of July 2018, the department indicated that it was addressing the recommendation by requiring the military services to submit a report in March 2018 and March 2019 on how they are monitoring adherence to policies related to screening certain servicemembers for PTSD and TBI prior to separation for misconduct. In August 2020, the department indicated it completed a cycle of compliance reporting by the military services in April 2020. DOD stated it would conduct a final compliance reporting cycle in March 2021. GAO maintains that monitoring of compliance on a routine basis (i.e., ongoing) is necessary and will keep the recommendation open until the department indicates that routine monitoring will occur.

Recommendation: To increase its assurance that PTSD and TBI are appropriately considered prior to separating certain servicemembers from the military for misconduct, the Secretary of Defense should ensure that the military services routinely monitor adherence to policies related to training servicemembers, including officers, on how to identify mild TBI symptoms in the deployed setting.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of September 2020, the department is continuing to take actions to address this recommendation. When actions have been completed, GAO will update the status of the recommendation.

Recommendation: To increase its assurance that PTSD and TBI are appropriately considered prior to separating certain servicemembers from the military for misconduct, the Secretary of Defense should ensure that the military services routinely monitor adherence to policies related to counseling about VA benefits and services during the process of separating certain servicemembers for misconduct.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of July 2018, the department indicated that it was addressing the recommendation by requiring the military services to submit a report in March 2018 and March 2019 on how they are monitoring adherence to policies related to counseling about VA benefits and services during the process of separating certain servicemembers for misconduct. In August 2020, the department indicated it completed a cycle of compliance reporting by the military services in April 2020. DOD stated it would conduct a final compliance reporting cycle in March 2021. GAO maintains that monitoring of compliance on a routine basis (i.e., ongoing) is necessary and will keep the recommendation open until the department indicates that routine monitoring will occur.

Recommendation: To further align efforts to address appeals workload and improve timeliness of decisions, and reduce the risk that efforts will not go as planned, the Secretary of Veterans Affairs should direct the Under Secretary for Benefits; the Chairman, Board of Veterans' Appeals; and the Chief Information Officer, as appropriate, to develop a schedule for IT updates that explicitly addresses when and how any process reform will be integrated into new systems and when Caseflow will be ready to support a potential streamlined appeals process at its onset.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred in principle with this recommendation. Moreover, since our March 2017 report, Congress passed the Veterans Appeals Improvement and Modernization Act of 2017, which required VA to develop a comprehensive appeals plan that included, among other things, descriptions of modifications to, cost estimates of and timelines for information technology that the agency needs to carry out appeals reform. However, more than a year after implementation of appeals reform, VA's February 2020 updated plan and FY 2021 budget request indicate that Caseflow has "minimal functionality", with many functionalities yet to be implemented. Further, VA's February 2020 updated plan and its FY 2021 budget request do not include specific steps or goals related to achieving overall functionality, integrated testing, or IT training for staff on new functionality still to be implemented in 2020 or beyond. While the VA's use of the agile process for IT development can help mitigate risks and avoid cost overruns and delays, VA's plans do not signal when Caseflow will support all of the Board's workflow needs for processing appeals under the new process. Such longer-term planning also could help ensure that all potential changes are anticipated in the plans of various VA components. For example, VA's February 2020 updated plan states that VHA cannot use Caseflow to efficiently and effectively manage its appeals workload. Longer-term planning could also ensure more transparency around additional resources needed to fully implement Caseflow versus other appeals-related technologies enterprise wide. We will consider closing this recommendation when VA has produced a longer-term plan for developing, implementing and integrating Caseflow functionality in support of a streamlined appeals process, including clear definitions of initial/minimal operating capability and full operational capability.

Recommendation: To better understand whether appeals process reform, in conjunction with other efforts, has improved timeliness, the Secretary of Veterans Affairs should direct the Under Secretary for Benefits; the Chairman, Board of Veterans' Appeals; and the Chief Information Officer, as appropriate to develop a strategy for assessing process reform--relative to the current process--that ensures transparency in reporting to Congress and the public on the extent to which VA is improving veterans' experiences with its disability appeals process.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred in principle with this recommendation. Moreover, since our March 2017 report, Congress passed the Veterans Appeals Improvement and Modernization Act of 2017, which required VA to produce a comprehensive appeals plan that required VA, among other things, to periodically publish a range of metrics, including timeliness, related to the processing of appeals under the new and legacy system. As of February 2019, VA implemented appeals reform; however VA has not indicated how it will assess whether or the extent to which the new process, which also allows for multiple appeal opportunities, will achieve final resolution of veterans' appeals sooner, on average, than the legacy process. We will consider closing this recommendation when the Board establishes timeliness goals for all new appeals options and VA has produced a plan for analyzing whether the new process is an improvement. Closure of this recommendation is related to recommendation 2 in GAO-18-352.

Recommendation: To improve VA's ability to accurately track employees' use of official time, the Secretary of Veterans Affairs should direct the Assistant Secretary for Human Resources and Administration to increase efforts to ensure timekeepers at all facilities receive training and consistent guidance on recording official time in VATAS.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA stated that the Office of Labor Management Relations (LMR) revised its policy in December 2016 to include specific directions to human resource offices to begin recording official time in the VA Time and Attendance System (VATAS) once VATAS has been implemented at their respective facilities. The formal concurrence process, which precedes the final publication of the policy, is ongoing. We will consider closing this recommendation when the agency provides documentation of the revised policy.

Recommendation: To improve VA's ability to accurately track employees' use of official time, the Secretary of Veterans Affairs should direct the Assistant Secretary for Human Resources and Administration to standardize the methods used by facilities for determining the amount of official time used prior to the agency-wide implementation of VATAS by encouraging facilities to rely on time and attendance records when calculating the amount of official time used at the facility level.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA stated that the Office of Human Resources and Administration is in the process of developing a memo directing facilities to rely on time and attendance records when calculating the amount of official time used at the facility level. We will consider closing this recommendation when the agency has provided documentation that they have completed this effort.

Recommendation: To improve VA's ability to accurately track employees' use of official time, the Secretary of Veterans Affairs should direct the Assistant Secretary for Human Resources and Administration to, in preparation for the full implementation of VATAS, take steps to transition from using the LMR system to VATAS to collect and compile information on the amount of official time used agency-wide.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA stated that the Office of Labor Management Relations (LMR) will transition from using the LMR Official Time Tracking System to collect and compile data on official time and will coordinate with the Financial Services Center to use VATAS to create a report on the agency-wide use of official time. VA is still in the process of rolling out VATAS and standardizing the input of official time requests within VATAS. We will consider closing this recommendation when the agency has demonstrated efforts to use VATAS for capturing the use of official time and producing reports.

Recommendation: To accelerate efforts to develop a modern, credible, and effective performance management system the Assistant Secretary for HR&A should, with input from VHA stakeholders, ensure that meaningful distinctions are being made in employee performance ratings by (1) developing and implementing a standardized, comprehensive performance management training program for supervisors of Title 5, Title 38, and Title 38-Hybrid employees based on leading practices and ensuring procedures are in place to support effective performance conversations between supervisors and employees; (2) reviewing and revising Title 5 and Title 38 performance management policies consistent with leading practices (e.g., require definition of all performance levels); and (3) developing and implementing a process to standardize performance plan elements, standards, and metrics for common positions across VHA that are covered under VA's Title 5 performance management system.

Agency: Department of Veterans Affairs: Assistant Secretary for Human Resources and Administration
Status: Open
Priority recommendation

Comments: VA partially agreed with GAO's December 2016 recommendation. As of January 2020, VA has made progress toward addressing this recommendation. VA officials described a new pilot performance management system that is being used to develop an enterprise-wide performance management solution. VA officials also stated that they were developing policy revisions for performance management that are scheduled to be completed later this year. These actions, when fully implemented, should help VA make meaningful distinctions in performance and hold employees accountable.

Recommendation: To accelerate efforts to develop a modern, credible, and effective performance management system, the Assistant Secretary for HR&A should, with input from VHA stakeholders, develop a plan for how and when it intends to implement a modern information technology (IT) system to support employee performance management processes.

Agency: Department of Veterans Affairs: Assistant Secretary for Human Resources and Administration
Status: Open
Priority recommendation

Comments: The Department of Veterans Affairs (VA) partially agreed with GAO's December 2016 recommendation and as of January 2020 has made progress toward implementing the recommendation. For example, VA officials told GAO that they implemented a pilot project to develop a standard IT performance management system that started with about 12,000 employees and has expanded to about 67,00 employees. They told GAO that they are currently in the process of developing an enterprise-wide performance management IT solution. Activities such as finalizing a business case and analyzing alternatives are still in progress. GAO will continue to monitor VA's progress on this effort. Successful planning and implementation of a modern IT system should help VA capture reliable, timely, department-wide employee performance information and may also help VA realize cost savings by eliminating inefficient paper-based procedures.

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

Recommendation: In order to ensure that contracting officers have clear and effective policies as soon as possible, the Secretary of Veterans Affairs should direct the OAL to identify measures to expedite the revision of the Veterans Affairs Acquisition Regulation (VAAR), which has been ongoing for many years, and the issuance of the VA Acquisition Manual.

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: VA concurred with this recommendation and has made progress in finalizing the update to its acquisition regulations and manual. In August 2020, VA reported that 31 of the 41 parts in its new acquisition regulations had been issued as draft or final rules. The remainder are at an earlier stage of the rulemaking process. VA also stated that it remains on track to release the final VA Acquisition Regulations in April 2021.

Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to monitor the full amount of time newly enrolled veterans wait to be seen by primary care providers, starting with the date veterans request they be contacted to schedule appointments. This could be accomplished, for example, by building on the data collection efforts currently being implemented under the "Welcome to VA" program.

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: In March 2016, GAO recommended that VA monitor the full amount of time newly enrolled veterans wait to be seen by primary care providers, starting with the date veterans request they be contacted to schedule appointments. VA concurred with this recommendation, and in June 2017, reported to GAO that it had taken actions to address it. Specifically, VA indicated that it revised an internal report to help identify and document all newly enrolled veterans and monitor their appointment request status. The report is intended to enable VHA and its medical centers to oversee the enrollment and appointment process by tracking the following timeframes: (1) application to enrollment, (2) enrollment to initial contact, (3) initial contact to primary care appointment, and (4) total time from application to primary care appointment. However, VA also indicated in its response that it did not have data that captures application dates for all newly enrolled veterans. As such, the report could not be used to consistently monitor the full amount of time these veterans wait to be seen by primary care providers. In January 2018, VA reported developing and implementing technical enhancements to its electronic systems that will enable it to capture the application date for all newly enrolled veterans. In April 2018 and December 2018, VA reported making continued efforts to implement technical enhancements to its electronic system. In its February 2020 update, VA identified several steps that the agency was completing to fully implement the revised internal report and noted that following a successful piloting of the report, the agency would implement it system-wide. VA reported that it expects to fully address this recommendation by October 2020.

Recommendation: The Secretary of Defense should direct the Secretary of the Army to implement processes to review and monitor the Army military treatment facility prescribing practices for medications discouraged under the PTSD guideline and address identified deviations.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation and stated that any policy that it may issue related to the monitoring of prescribing practices would be directed toward all of the military services. In May 2018 DOD stated that it planned to (1) conduct a comprehensive review of existing prescribing practices for the treatment of PTSD; (2) develop policy guidance for addressing prescribing practices for the management of PTSD that deviate from the clinical practice guideline; and (3) implement an automated dashboard that will flag medications that the PTSD guideline discourages from use. In its February 26, 2020 response, DOD stated that July 30, 2020 is the estimated completion date for these planned actions. To close this recommendation, DOD needs to implement its planned actions and provide documentation showing that the Department is monitoring medications discouraged from use under the PTSD guideline and addressing identified deviations.

Recommendation: To improve the administration of the Post-9/11 GI Bill, reduce the occurrence of overpayments, and increase debt collections, the Secretary of Veterans Affairs should address overpayments resulting from enrollment changes by identifying and implementing a cost-effective way to allow Post-9/11 GI Bill beneficiaries to verify their enrollment status each month, and require monthly reporting.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA officials reported in August 2020 that the agency was in the latter stages of developing a pilot program to verify beneficiaries' attendance using text messaging. This pilot, scheduled for release in November 2020, will initially be limited to beneficiaries receiving the Rogers STEM Scholarship to extend their Post-9/11 GI Bill benefits, but would eventually be expanded to all Post-9/11 GI Bill beneficiaries if it is successful. VA expects to complete these efforts by December 2021.

Recommendation: To improve the administration of the Post-9/11 GI Bill, reduce the occurrence of overpayments, and increase debt collections, the Secretary of Veterans Affairs should improve efforts to notify veterans and schools about overpayment debts by identifying and implementing other methods of notifying veterans and schools about debts to supplement the agency's mailed notices (e.g., email, eBenefits).

Agency: Department of Veterans Affairs
Status: Open

Comments: VA officials reported in August 2020 that the agency has taken action to move away from a reliance on mailed letters, including the eventual use of email notifications for debt letters and other GI Bill correspondence. The agency plans to implement these changes December by 2020.

Recommendation: To improve the administration of the Post-9/11 GI Bill, reduce the occurrence of overpayments, and increase debt collections, the Secretary of Veterans Affairs should revise policy for calculating overpayments to increase collections by prorating tuition overpayments when veterans reduce their enrollment during the term based on the actual date of the enrollment change rather than paying additional benefits through the end of the month during which the reduction occurred.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA officials reported in August 2020 that the agency is revising its tuition overpayment regulations to address the recommendation in GAO's 2015 report. VA officials said that these revisions are part of its broader regulatory proposal that has experienced delays due to 2017 legislative changes and other legal developments. They expect these proposed regulations to be published by December 2020.

Recommendation: To improve the administration of the Post-9/11 GI Bill, reduce the occurrence of overpayments, and increase debt collections, the Secretary of Veterans Affairs should ensure it is recovering the full amount of tuition and fee payments if a school does not charge a veteran for any tuition or fees after dropping a class or withdrawing from school. For example, VA could adjust its overpayment calculation to account for these situations or provide schools with guidance on how to account for school refund policies when reporting enrollment and tuition changes.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA officials reported in August 2020 that the agency plans to amend its procedures to account for school refund policies when calculating veterans' overpayment debts, as we recommended. VA plans to incorporate this change in its information technology (IT) upgrades by December 2021. Earlier plans to implement this recommendation were put on hold so the department could prioritize other IT updates that it said are necessary to implement certain legislative changes to the GI Bill program.

Recommendation: To improve VA's efforts to effectively complete the development and implementation of VBMS, the Secretary of Veterans Affairs should direct the Under Secretary for Benefits and the Chief Information Officer to develop an updated plan for VBMS that includes (1) a schedule for when VBA intends to complete development and implementation of the system, including capabilities that fully support disability claims, pension claims, and appeals processing and (2) the estimated cost to complete development and implementation of the system.

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: The Department of Veterans Affairs (VA) concurred with our recommendation and as of January 2020, is continuing to develop requirements for VBMS in order to develop functionality to replace legacy information systems. In addition, the department subsequently provided us with expected completion dates for implementation of claims and appeals processing, but has not provided a schedule for the implementation of pension claims processing. To fully implement this recommendation, the department needs to provide the expected completion date for pension claims processing and an estimate of the cost to complete remaining development and implementation of VBMS.

Recommendation: To improve VA's efforts to effectively complete the development and implementation of VBMS, the Secretary of Veterans Affairs should direct the Under Secretary for Benefits and the Chief Information Officer to reduce the incidence of high- and medium-priority level defects that are present at the time of future VBMS releases.

Agency: Department of Veterans Affairs
Status: Open

Comments: The Department of Veterans Affairs (VA) concurred with this recommendation and reiterated its plans and procedures for decreasing the incidences of defects in each system release. However, while the most recent VBMS release (i.e., May 2019) showed a decrease in the number of high- and medium-priority level defects, the release in February 2019 showed an increase in the number of high- and medium-priority defects. In addition, both the February 2019 and May 2019 releases showed the presence of the highest severity defects--critical--which have extensive user impact and workarounds do not exist. We will continue to monitor VA's actions and progress in response to this recommendation.

Recommendation: To inform decisions on any potential future iterations of the veterans' employment workshop, the Secretary of Labor should assess and report to Congress the extent to which further delivery of employment workshops to veterans and their spouses could fill a niche not fully served by existing federal programs. Such an assessment could involve collaboration with VA and other stakeholder organizations.

Agency: Department of Labor
Status: Open

Comments: In April 2019, DOL restated its assertion that the employment services most needed by veterans and spouses were already available to them through the state workforce system and should not be offered through another mechanism. DOL pointed to changes in the employment workshops under its Transition Assistance Program, though those changes do not inform the need for any additional services such as Off Base Transition Training workshops. Additionally, DOL noted that Section 502 of the Veterans Health Care and Benefits Improvement Act of 2016 called for a 5-year longitudinal study of veteran workforce services. DOL concluded a feasibility study in December 2018 and said it will produce a plan to conduct the 5-year longitudinal study, which will inform the extent to which further delivery of employment workshops to veterans and their spouses could fill a niche not fully served by existing federal programs. While completing the feasibility study and planning to conduct the longitudinal study are important steps, DOL has not yet completed that study, nor has it reported to Congress on the extent to which employment workshops might fill a niche not currently served by existing federal programs.

Recommendation: To ensure reliable measurement of veterans' wait times for medical appointments, the Secretary of VA should direct the Under Secretary for Health to take actions to improve the reliability of wait time measures either by clarifying the scheduling policy to better define the desired date, or by identifying clearer wait time measures that are not subject to interpretation and prone to scheduler error.

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: VA agreed with our recommendation. VA has taken actions intended to address the reliability of appointment wait times through improvements in appointment scheduling, including issuing a revised scheduling policy, providing and documenting scheduler training and improving oversight through scheduler audits. While the revised scheduling policy and subsequent guidance changed the terminology of wait time measures, it did not substantively clarify or define the desired date, one of the dates used for measuring appointment wait times. Therefore, we continue to believe that the desired date is still subject to interpretation and prone to scheduler error, which poses concerns for the reliability of wait times measured using the patient's desired date. Furthermore, in its internal audit report dated February 2019, VA reported it was unable to evaluate the accuracy and reliability of its wait-time data due to the lack of business rules for calculating them, indicating that additional efforts are needed to address this issue. In January 2020, VA reported to us that the internal audit did not test whether schedulers entered the patient's desired date into the scheduling system in compliance with VHA policy because of the lack of verifiable source documentation. Given our continued concerns about VA's ability to ensure the reliability of the wait-time data, we have requested additional information from VA about its wait time methodology and assessment of evidence underlying the audit findings.

Recommendation: To improve timely medical appointments and to address patient and staff complaints about telephone access,the Secretary of VA should direct the Under Secretary for Health to ensure that all VAMCs provide oversight of telephone access and implement best practices outlined in its telephone systems improvement guide.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with this recommendation and stated that VISN and VA Medical Center leadership would use best practices to develop and implement improved telephone service plans. As of March 2015, VA had developed a standardized telephone assessment tool and requested that facilities that care for 5,000 or more veterans complete the assessment and select actions for improvement based on its existing telephone systems improvement guide. Based on this request, VA received telephone assessment and improvement plans from 286 facilities that care for 5,000 or more veterans. VA is monitoring the facilities' telephone performance and is re-baselining call center infrastructure at each facility with a survey and new performance goals. In September 2015, VA issued an updated Telephone Access and Contact Management Improvement Guide. VA has also drafted an update to its directive on telephone access to outpatient care. As of July 2019, VA decided not to advance the draft policy for review and approval at this time, because of the significant uncertainty due to ongoing development of VA clinical contact centers and telehealth services. VA stated that it remains committed to developing sound policy related to virtual (telephone, video, and web-chat) access to clinical care.

Recommendation: To ensure that major steady state IT investments are being adequately analyzed, the Secretaries of Defense, Veterans Affairs, and the Treasury should direct appropriate officials to develop an OA policy, annually perform OAs on all investments, and ensure the assessments include all key factors.

Agency: Department of Veterans Affairs
Status: Open

Comments: For fiscal years 2013, 2014, and 2016, the Department of Veterans Affairs provided its operational analyses to GAO for its major information technology investments. These operational analyses addressed a majority of the key factors identified in Office of Management and Budget guidance. Nevertheless, in February 2019, the department was still in the process of finalizing its operational analysis policy and identified a target completion date of September 2019 for when the policy would be complete and ready for publication.

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.

Recommendation: In order to better inform future budget requests, the Secretary of Veterans Affairs should develop a sound methodology for estimating savings from new operational improvements. This methodology should include: (1) an explanation of how savings from each operational improvement will be achieved; (2) an explanation for the basis of any assumptions included in the savings estimates; and (3) an implementation plan that includes a realistic timeline for implementation, to help ensure that savings can be achieved within the targeted time frame.

Agency: Department of Veterans Affairs
Status: Open

Comments: In February 2012, we recommended that the Department of Veterans Affairs (VA) develop a sound methodology for estimating savings from new operational improvements in future budget submissions. While VA concurred with this recommendation, in June 2016, VA reported that it intends to implement this recommendation when new operational improvements are proposed in the budget. However, recent budget submissions have not included operational improvements.

Recommendation: The Secretary of Veterans Affairs should develop a detailed process for tracking VA's actual savings resulting from those operational improvements for which we identified concerns. This process should provide detailed written guidance for those responsible for tracking the savings, which outlines the methodology for calculating savings.

Agency: Department of Veterans Affairs
Status: Open

Comments: In February 2012, we recommended that the Department of Veterans Affairs (VA) develop a detailed process for tracking VA's actual savings resulting from those operational improvements for which we identified concerns. While VA partially concurred with this recommendation, in June 2016, VA reported that it has no future plans to fully implement this recommendation.

Recommendation: To help DOD obtain reasonable assurance that all active and Reserve component servicemembers to whom the PDHRA requirement applies are provided the opportunity to have their health concerns identified, the Assistant Secretary of Defense for Health Affairs and the military services should take steps to ensure that PDHRA questionnaires are included in DOD's central repository for each of these servicemembers.

Agency: Department of Defense
Status: Open

Comments: In its comments to this report, the Department of Defense (DOD) concurred with this recommendation. On October 2009, DOD's Force Health Protection and Response Office sent a memo to each of the military service Surgeons General emphasizing the need for the post-deployment health reassessment (PDHRA) to be offered to all service members who are eligible to complete the assessment. In 2010, DOD's noted that the services would work with the Armed Forces Health Surveillance Center (AFHSC) repository to ensure PDHRAs are submitted correctly, without transmission errors. DOD's 2011 case records showed that the Air Force and Army had developed data verification processes to ensure that AFHSC received PDHRAs. Further, the Defense Medical Data Center (DMDC) had planed to create a file consisting of the date of deployment for deployed personnel, and that the file would be available to the services in order to match DMDC with data from each of the service-specific systems, in accordance to requirements. In September 2011, although DMDC and the services had agreed to match rosters of deployed service members, there were still inconsistencies in deployment dates. In March 2012, DOD was still verifying data inconsistencies which, until resolved, leads to inaccurate reporting based on errors in the deployment dates. As of September 2019, DOD has not provided information or documentation to address this recommendation.