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Open Recommendations

Veterans Affairs: Actions Needed to Improve Access to Care in the U.S. Territories and Freely Associated States
GAO-24-106364
May 23, 2024
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6 Open Recommendations
Agency Affected Recommendation Status
Department of Veterans Affairs The Secretary of VA should assess the underlying data sources of its VetPop model to identify the extent to which known data limitations impact the accuracy of population estimates for veterans living in the U.S. territories and FAS. In doing so, VA should consult with local government officials and stakeholders to identify and validate available veteran data sources, and make changes as appropriate to VetPop's data sources. (Recommendation 1)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
Department of Veterans Affairs The VA Under Secretary for Health should clearly communicate in writing appropriate uses for the new capabilities within its VHA Support Service Center databases to generate utilization and timeliness of care data by veteran location. (Recommendation 2)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
Department of Veterans Affairs The Secretary of VA should assess whether it is feasible and advisable to expand travel reimbursement eligibility for any condition among service-connected disabled veterans in the U.S. territories, and as appropriate or consistent with that analysis, amend its regulations to do so. (Recommendation 3)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
Department of Veterans Affairs The Secretary of VA should ensure that the Director of VAPIHCS, in collaboration with DOD, identify and implement additional opportunities to share resources and solutions to address shared challenges affecting the implementation of their resource sharing agreements in the Pacific. (Recommendation 4)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
Department of Veterans Affairs The VA Under Secretary for Health, in coordination with the Executive Directors of the VA Office of Procurement, Acquisition, and Logistics, and the VHA Procurement and Logistics Office, should clarify in writing the appropriate processes, in line with VHA's Supply Chain Management Operations Directive, for VA Caribbean Healthcare System officials to communicate challenges receiving medical services or devices. (Recommendation 5)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
Department of Defense The Secretary of DOD should ensure that the Directors of the Defense Health Networks Indo-Pacific and Pacific Rim, in collaboration with VA, identify and implement additional opportunities to share resources and solutions to address shared challenges affecting the implementation of their resource sharing agreements in the Pacific. (Recommendation 6)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Veterans Health: VA Should Improve Its Monitoring of Severe Maternal Complications and Mental Health Screenings
GAO-24-106209
Jan 16, 2024
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2 Open Recommendations
Agency Affected Recommendation Status
Department of Veterans Affairs The Secretary of Veterans Affairs should ensure that as OWH begins monitoring SMM on an ongoing basis, it disaggregates and reviews data on trends in SMM by veteran characteristics, such as race and ethnicity, age, or whether veterans lived in a rural area. (Recommendation 1)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
Department of Veterans Affairs The Secretary of Veterans Affairs should ensure that OWH finalizes the development of and implements a systematic process to compile and review data on MCC screening of veterans for mental health conditions on an ongoing basis. This process should include data on MCCs' completion of required mental health screenings, as well as screening results. (Recommendation 2)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

VA Disability Benefits: Board of Veterans' Appeals Should Address Gaps in Its Quality Assurance Process
GAO-24-106156
Nov 28, 2023
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4 Open Recommendations
Agency Affected Recommendation Status
Board of Veterans Appeals The Chairman of the Board of Veterans' Appeals should develop written policies and procedures related to its accuracy rate measure, to require that OAI (1) involves more than one official in the calculation process; (2) documents its calculation of monthly and fiscal year accuracy rates; and (3) manages related error data. (Recommendation 1)
Open
The Board agreed in principle with this recommendation. Board officials stated the recommendation should clarify the Board's need for a policy and procedure to manage data: the loss of data was specific to fiscal years 2019 and 2020. However, we note that the data loss stemmed from not having policies and procedures and without them, these types of data management issues could occur again. We continue to believe that having policies and procedures are an important part of internal control. Without written policies and procedures, the Board could face further challenges such as additional data loss, improperly storing data, or using inconsistent methodologies.
Board of Veterans Appeals The Chairman of the Board of Veterans' Appeals should monitor how veteran law judges choose to incorporate the feedback they receive from the case review process—including whether errors are corrected—and use this data to inform decision making related to the case review process. (Recommendation 2)
Open
The Board agreed with this recommendation. We will monitor the agency's progress to implement it.
Board of Veterans Appeals The Chairman of the Board of Veterans' Appeals should develop and implement an evidence-based decision-making process that includes a plan outlining how it will build evidence to assess the underlying causes for the most common errors identified by the case review process and the most common reasons for CAVC remands. The Board should use this evidence to better target its interventions and assess their results. One option is to fold the development of this process into the Board's planned evaluation. (Recommendation 3)
Open
The Board agreed in principle with this recommendation. We will monitor the agency's efforts to implement it.
Board of Veterans Appeals The Chairman of the Board of Veterans' Appeals should study how to evaluate VLJ adjudicative decisional consistency. One option is to fold the development of this study into the Board's planned evaluation. (Recommendation 4)
Open
The Board disagreed with this recommendation. Board officials stated that it would be inappropriate to force consistency in VLJ decisions in a way that is inconsistent with codes of judicial conduct and other standards applicable to VLJs. They stated that there will and should be variance in how legal authority is applied to the individual facts and circumstances of each case appealed to the Board. Board officials further stated that VLJs should be independent and not subject to pressure and influence. They also stated that, as part of evaluating individual VLJs' adherence to performance standards, the Board evaluates the total number of decisions each VLJ has adjudicated and the manner in which they have adjudicated them, among other things. In addition, Board officials noted that the number of decisions remanded does not demonstrate whether such remands were warranted, and that the number of CAVC remands or reversals does not necessarily correlate with productivity, legal acumen, or even with performance. Finally, they said that the concept of "consistency" of decision-making among individual judges evaluating sets of facts and circumstances of each individual case is a difficult one to address at all levels of adjudication, not only at the Board, but also at CAVC. We acknowledge the importance of judicial independence, that some degree of variance is expected given that independence, and that variation is not necessarily an indicator of poor quality decision-making. In addition, the Board acknowledges that consistency among VLJs in the use of appropriate legal authority is appropriate. However, without studying consistency, the Board will remain unaware of whether systemic inconsistencies in VLJ decision-making exist, and the Board will be unable to target interventions, as appropriate. We continue to believe that the results of systematic study of VLJ adjudicative decisions for consistency could provide a basis for targeting interventions, such as training, to assist VLJs. As such, this recommendation is not intended to "force" consistency in any VLJ decisions, but rather is meant to help the Board assist VLJs. Our recommendation is worded to allow the Board the necessary latitude to implement it in a way that allows for the retention of judicial independence while meeting other goals it deems appropriate.

VA Disability Benefits: Actions Needed to Address Challenges Reserve Component Members Face Accessing Compensation
GAO-24-105400
Oct 30, 2023
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14 Open Recommendations
Agency Affected Recommendation Status
Department of Defense The Secretary of Defense should ensure the Director of ODEI conducts oversight reviews of the military services' Military Equal Opportunity programs, in accordance with DOD policy, to reduce medical bias, which in turn could help improve reserve component members' access to disability compensation. (Recommendation 7)
Open
DOD agreed with this recommendation. ODEI plans to coordinate with the Military Departments to establish a schedule to assess the effectiveness of the Military Services' MEO offices, starting in FY 2025. ODEI also plans to coordinate with the Defense Equal Opportunity Management Institute to develop a standardized assessment methodology to help ensure consistency in the assessment process. We will monitor DOD's progress on these efforts.
Department of the Army The Secretary of the Army should develop and document plans so the Army can implement the new DD Form 214-1 by February 2025. Such plans should fully apply sound planning practices, such as (1) identifying resources; (2) developing activities and timelines; (3) establishing roles, responsibilities, and coordination; (4) conducting a risk assessment; and (5) establishing performance management, such as goals and indicators to measure progress. (Recommendation 8)
Open
DOD agreed with this recommendation. We will monitor DOD's progress to implement it.
Department of the Air Force The Secretary of the Air Force should develop and document plans so the Air Force can implement the new DD Form 214-1 by February 2025. Such plans should fully apply sound planning practices, such as (1) identifying resources; (2) developing activities and timelines; (3) conducting a risk assessment; and (4) establishing performance management, such as goals and indicators to measure progress. (Recommendation 9)
Open
DOD agreed with this recommendation. We will monitor DOD's progress to implement it.
Department of the Navy The Secretary of the Navy should develop and document plans so the Navy can implement the new DD Form 214-1 by February 2025. Such plans should fully apply sound planning practices, such as (1) identifying resources; (2) developing activities and timelines; (3) establishing roles, responsibilities, and coordination; (4) conducting a risk assessment; and (5) establishing performance management, such as goals and indicators to measure progress. (Recommendation 10)
Open
DOD agreed with this recommendation. We will monitor DOD's progress to implement it.
Department of the Navy The Secretary of the Navy should ensure the Commandant of the Marine Corps develops and documents plans so the Marine Corps can implement the new DD Form 214-1 by February 2025. Such plans should apply sound planning practices, such as (1) identifying resources; (2) developing activities and timelines; (3) establishing roles, responsibilities, and coordination; (4) conducting a risk assessment; and (5) establishing performance management, such as goals and indicators to measure progress. (Recommendation 11)
Open
DOD agreed with this recommendation. We will monitor DOD's progress to implement it.
Department of Veterans Affairs VA's Under Secretary for Benefits should ensure that VBA develops a mechanism, such as a document that lists known reliability issues with VADIR, to better communicate to federal and non-federal users the limitations of its incomplete data, particularly the unreliable variables on military personnel records from before 1985. (Recommendation 1)
Open
VA agreed in principle with this recommendation. VA plans to work with DOD to produce documentation regarding the scope and limitations of the DOD data contained in VADIR to better communicate this information with federal and non-federal users. We will monitor the progress of these efforts.
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