VA Medical Centers
Internal Control over Selected Operating Functions Needs Improvement
Gao ID: GAO-04-755 July 21, 2004
The Department of Veterans Affairs (VA) provides health care to veterans through the $27 billion Veterans Health Administration (VHA) medical programs. VHA administers and operates VA's medical system, providing care to nearly 5 million patients in 2003. As of September 2003, VHA operated 160 hospitals, 847 outpatient clinics, 134 nursing homes, 42 domiciliaries, and 73 comprehensive home care programs, including facilities in every state, Puerto Rico, the Philippines, and Guam. VHA is responsible for effective stewardship of the resources provided to it by Congress, which asked GAO to review internal controls in three areas of operation at selected VHA medical centers. GAO conducted a review to assess the effectiveness of control activities over (1) personal property, (2) drugs returned for credit, and (3) part-time physician time and attendance.
GAO's review found that six selected VA medical centers lacked a reliable property control database. The property databases for the six medical centers contained incomplete information. As a result, GAO could not select a statistical sample of test items so that results could be projected to each location's entire property universe. Key policies and procedures established by VA to control personal property provided facilities with substantial latitude in conducting physical inventories and maintaining their property management systems, which resulted in reduced property accountability. For example, VA's Materiel Management Procedures handbook allowed the person responsible for custody of VA property to attest to the existence of that property rather than requiring independent verification. Also, personnel at some locations interpreted a policy that established a $5,000 threshold for property that must be inventoried as a license to ignore VA requirements to account for lower cost items that are susceptible to theft or loss, such as personal computers and peripheral equipment. These weak practices, combined with lax implementation, resulted in low levels of accountability and heightened risk of loss. VHA personnel located fewer than half of the 100 items GAO selected at each of five medical centers and 62 of 100 items at the sixth medical center. The process for obtaining credit for recalled, expired, or deteriorated drugs was, in essence, an honor system. Each of the six pharmacies GAO visited used a contractor to return drugs to the manufacturer for credit, but only one of the pharmacies inventoried non-narcotic drugs before they were turned over to the contractor. None of the pharmacies had enough information about which drugs qualified for credit to be able to reconcile the credits they received with the drugs they had turned over to the contractor. There was no agency-level oversight of returned drug information to help identify improvements that might increase the credits that VA receives. At four of the six facilities, non-narcotic drugs held for return were stored in unsecured open bins accessible to anyone in the pharmacy. The combined lack of record keeping and physical controls over non-narcotic drugs held for return exposed them to potential loss, theft, or unauthorized use. Scheduled and actual hours worked by part-time physicians at the six locations GAO visited were not always documented in accordance with a January 2003 VHA directive. Five of the six locations had not prepared written work schedules for all part-time physicians as required. GAO found that latitude provided in the directive resulted in wide variation in procedures used by the six medical centers to verify physician compliance with work schedules. While some timekeepers used informal notes to record daily attendance, one facility required physicians to sign in. However, on the day of GAO's review, only two of 15 scheduled physicians had signed in. Attendance monitoring procedures at the six locations varied in frequency and included monitoring all part-time physicians once per quarter at one location and 5 percent of part-time physicians each month at another.
Recommendations
Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
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GAO-04-755, VA Medical Centers: Internal Control over Selected Operating Functions Needs Improvement
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Report to the Chairman:
Subcommittee on Oversight and Investigations:
Committee on Veterans' Affairs:
House of Representatives:
July 2004:
VA MEDICAL CENTERS:
Internal Control over Selected Operating Functions Needs Improvement:
GAO-04-755:
GAO Highlights:
Highlights of GAO-04-755, a report to the Chairman, Subcommittee on
Oversight and Investigations, Committee on Veterans‘ Affairs, House of
Representatives
Why GAO Did This Study:
The Department of Veterans Affairs (VA) provides health care to
veterans through the $27 billion Veterans Health Administration (VHA)
medical programs. VHA administers and operates VA‘s medical system,
providing care to nearly 5 million patients in 2003. As of September
2003, VHA operated 160 hospitals, 847 outpatient clinics, 134 nursing
homes, 42 domiciliaries, and 73 comprehensive home care programs,
including facilities in every state, Puerto Rico, the Philippines, and
Guam. VHA is responsible for effective stewardship of the resources
provided to it by Congress, which asked GAO to review internal controls
in three areas of operation at selected VHA medical centers. GAO
conducted a review to assess the effectiveness of control activities
over (1) personal property, (2) drugs returned for credit, and (3) part-
time physician time and attendance.
What GAO Found:
GAO‘s review found that six selected VA medical centers lacked a
reliable property control database. The property databases for the six
medical centers contained incomplete information. As a result, GAO
could not select a statistical sample of test items so that results
could be projected to each location‘s entire property universe. Key
policies and procedures established by VA to control personal property
provided facilities with substantial latitude in conducting physical
inventories and maintaining their property management systems, which
resulted in reduced property accountability. For example, VA‘s
Materiel Management Procedures handbook allowed the person responsible
for custody of VA property to attest to the existence of that property
rather than requiring independent verification. Also, personnel at
some locations interpreted a policy that established a $5,000 threshold
for property that must be inventoried as a license to ignore VA
requirements to account for lower cost items that are susceptible to
theft or loss, such as personal computers and peripheral equipment.
These weak practices, combined with lax implementation, resulted in low
levels of accountability and heightened risk of loss. VHA personnel
located fewer than half of the 100 items GAO selected at each of five
medical centers and 62 of 100 items at the sixth medical center.
The process for obtaining credit for recalled, expired, or deteriorated
drugs was, in essence, an honor system. Each of the six pharmacies GAO
visited used a contractor to return drugs to the manufacturer for
credit, but only one of the pharmacies inventoried non-narcotic drugs
before they were turned over to the contractor. None of the pharmacies
had enough information about which drugs qualified for credit to be
able to reconcile the credits they received with the drugs they had
turned over to the contractor. There was no agency-level oversight of
returned drug information to help identify improvements that might
increase the credits that VA receives. At four of the six facilities,
non-narcotic drugs held for return were stored in unsecured open bins
accessible to anyone in the pharmacy. The combined lack of record
keeping and physical controls over non-narcotic drugs held for return
exposed them to potential loss, theft, or unauthorized use.
Scheduled and actual hours worked by part-time physicians at the six
locations GAO visited were not always documented in accordance with a
January 2003 VHA directive. Five of the six locations had not prepared
written work schedules for all part-time physicians as required. GAO
found that latitude provided in the directive resulted in wide
variation in procedures used by the six medical centers to verify
physician compliance with work schedules. While some timekeepers used
informal notes to record daily attendance, one facility required
physicians to sign in. However, on the day of GAO‘s review, only two of
15 scheduled physicians had signed in. Attendance monitoring procedures
at the six locations varied in frequency and included monitoring all
part-time physicians once per quarter at one location and 5 percent of
part-time physicians each month at another.
What GAO Recommends:
GAO makes 17 recommendations to improve internal controls over personal
property, drugs returned for credit, and part-time physician time and
attendance, including (1) revision of property policies,
(2) providing oversight for drugs returned by pharmacies, and
(3) assessing time and attendance best practices for part-time
physicians. In written comments on a draft of this report, VA agreed
with GAO‘s conclusions and recommendations.
www.gao.gov/cgi-bin/getrpt?GAO-04-755.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact McCoy Williams at
(202) 512-6906 or williamsm1@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Scope and Methodology:
Property Management Policies and Procedures Provided Inadequate Control
over Medical Center Personal Property:
VHA Controls over Process for Returning Drugs for Credit Was Weak :
Controls over Part-time Physician Time and Attendance Could Be
Strengthened Further:
Conclusions:
Recommendations for Executive Action:
Agency Comments:
Appendixes:
Appendix I: General Background Information for Selected VA Medical
Centers, Fiscal Year Ended September 30, 2003 (Unaudited):
Appendix II: Comments from the Department of Veterans Affairs:
Appendix III: GAO Contacts and Staff Acknowledgments:
GAO Contacts:
Acknowledgments:
Tables:
Table 1: Results of Personal Property Physical Observation Tests:
Table 2: Categories of Sensitive Assets Not Located by Property
Officials:
Table 3: Estimated Credits for Non-Narcotic Drugs Returned September
2002:
Table 4: Part-time Physician Schedule Documentation:
Letter July 21, 2004:
The Honorable Steve Buyer:
Chairman:
Subcommittee on Oversight and Investigations:
Committee on Veterans' Affairs:
House of Representatives:
Dear Mr. Chairman:
In fiscal year 2003, the Department of Veterans Affairs (VA) provided
health care to veterans through the Veterans Health Administration
(VHA) medical programs at a cost of $27 billion. VHA's medical programs
include medical care, research, and medical administration and
miscellaneous operating expenses. VHA administers and operates VA's
medical care system, the nation's largest integrated health care
system, providing care to nearly 5 million patients with over 741,000
inpatient episodes treated and over 50 million outpatient visits in
2003. To carry out its medical care mission, VHA operated (as of
September 2003) 160 hospitals, 847 outpatient clinics, 134 nursing
homes, 42 domiciliaries, and 73 comprehensive home care programs,
including facilities in every state, Puerto Rico, the Philippines, and
Guam.
VHA is responsible for effective stewardship of the resources provided
to it by Congress. In conjunction with that responsibility, you asked
us to review internal control activities in three areas of operation at
selected VHA medical centers to assess whether those controls were
designed and implemented effectively. Specifically, you asked that we
assess the effectiveness of control activities regarding (1)
accountability over personal property, (2) drugs returned for credit,
and (3) part-time physician time and attendance. We evaluated whether
procedures used in these three areas of operation at the selected VHA
medical centers incorporated effective controls regarding
accountability for agency resources.
To gain an understanding of VHA's policies and procedures and the
related internal controls for the three areas of operation, we obtained
and reviewed VA and VHA policy guidance and interviewed cognizant VHA
personnel on topics related to the scope of this report. We reviewed
our previous reports and reports issued by VA's Office of the Inspector
General (OIG).[Footnote 1] Using a case study approach to assess the
effectiveness of the key control activities that we identified, we
reviewed transaction documentation at six VA medical centers. We
conducted our review from February 2003 through March 2004 in
accordance with U.S. generally accepted government auditing standards.
Results in Brief:
Internal control over the three areas of operation that we reviewed at
six selected VA medical centers did not provide reasonable assurance
that agency resources were safeguarded and that waste, fraud, or abuse
was prevented or would be detected in a timely manner. Specifically,
the medical centers we visited lacked reliable property control records
as well as controls over credits for returned drugs. In addition, part-
time physicians' scheduled and actual hours worked were not always
documented in accordance with VHA's policy.
The property control databases for the six medical centers we visited
contained incorrect or incomplete information, including property
location and acquisition cost information. As a result, we were unable
to select a statistical sample of items to test so that our results
could be projected to the entire property universe at each location we
visited. Instead, we performed a case study of 100 property items
selected from each location's property control record. Of the 600 items
that we selected from the property control records of the six medical
centers, property officials were able to locate only 201. VA's policies
on inventory procedures and property accountability[Footnote 2]
contributed to the lack of reliable property records by allowing the
custodian of property to attest to the existence of assets without
independent verification. In addition, VA's property handbook
established a $5,000 threshold for property that must be inventoried.
For sensitive items, which are subject to loss or theft, it required
accountability regardless of cost. Some property managers, however,
lost accountability over these assets because they concluded that they
were only accountable for items costing $5,000 or more. Noncompliance
with other VA property management requirements also reduced the
possibility of control over larger items. Lack of proper bar code
labeling, for instance, combined with omission of serial numbers from
the property records, prevented us from verifying 17 items with a total
cost of more than $29 million at four medical centers.
The process used for obtaining credit for recalled, expired, or
deteriorated drugs returned to drug manufacturers (returned drugs) at
the six medical centers we visited was, in essence, an honor system.
All six pharmacies used a contractor to return drugs and relied on the
drug manufacturers to determine the amount credited to VA. Only one of
the six locations inventoried non-narcotic drugs before they were
turned over to the contractor, and none had sufficient information to
determine which drugs qualified for credit. Accordingly, while we
understand from VA officials that contracting return drug services has
yielded larger credits for VA than the previous in-house return system,
medical centers did not have enough information available to conclude
whether the credits received were reasonable based on the drugs that
were returned. Also, four of six facilities we visited lacked adequate
security over non-narcotic drugs held for return. These drugs were
stored in unsecured open bins accessible to anyone within the
pharmacies. This access, combined with the lack of an inventory record,
made these drugs highly vulnerable to undetected loss, theft, or
unauthorized use involving potentially dangerous substances.
We found that scheduled and actual hours worked by part-time physicians
were not always documented in accordance with a January 2003 VHA
directive[Footnote 3] and related local medical center policies. Five
of the six locations had not prepared required written work schedules
for part-time physicians in advance of the pay period, and the record
of specific hours worked sometimes differed between the payroll system
and the time and attendance form signed by the physician, though total
hours worked per the two records agreed in all test cases. We found
that the latitude afforded by the January 2003 directive resulted in
substantial variation in how the six centers attempted to confirm part-
time physician adherence to work schedules and variation in the
effectiveness of the implemented procedures. While some timekeepers
relied on informal notes to record daily attendance of part-time
physicians, one facility required physicians to sign in daily. However,
the sign-in log was signed by only 2 of 15 physicians scheduled to work
on the day of our review. Effectiveness of the various attendance
monitoring procedures that were implemented at the six medical centers
depended on how often they were used. These procedures included
monitoring attendance of 5 percent of part-time physicians one day each
month at one center and monitoring all part-time physicians at least
once each quarter at another.
Without improvements to its internal controls, VHA's ability to prevent
and detect waste, fraud, or abuse in these three areas of operation at
the six medical centers we visited will continue to be impaired.
Accordingly, we are making 17 recommendations to address the internal
control weaknesses discussed in this report.
In commenting on a draft of our report VA concurred with our
conclusions and recommendations and reported that it is developing an
action plan to implement them.
Background:
To meet property management requirements and provide data for personal
property reporting needs, VA field facilities use an inventory
accounting system, the Automated Engineering Management System/Medical
Equipment Reporting System. The system was originally designed to
schedule preventive maintenance. In 1996, the system was expanded to
incorporate the agency's previously separate property management
function, becoming the agency's official record of inventory for
capitalized and noncapitalized equipment. VHA's Acquisition and
Materiel Management (A&MM) service maintains the property management
portion of the system while Engineering Services operates the property
maintenance portion. The property management system includes a detailed
listing of the agency's personal property, providing information that
among other things, is (1) a control for the accuracy of property cost
information presented in the agency's financial report, (2) the basis
for physical inventories of agency personal property, and (3) the
primary control record for accountability over the agency's personal
property. The system is used to prepare bar code labels that are
affixed to nonexpendable property acquired by VHA to identify items as
VHA property and to provide for efficient physical inventories using
portable bar code readers. The property management software has been
updated occasionally to incorporate, for example, the addition of a
disposal date capability and changes in the agency's cost thresholds
for property accountability and capitalization. A VHA official told us
that once a property item is entered in the system's database, a system
application control retains the record, even after disposal of the
item.
Pharmaceutical manufacturers allow VA a credit for certain drugs that
are returned. Each manufacturer establishes its own criteria for
issuing credit, which can change at any time and differ among a single
manufacturer's products. The differing criteria can include such
attributes as units of packaging and length of time between the return
date and the expiration date. Some drugs are not returnable and must be
destroyed if not used before the expiration date. To obtain available
credits with minimal agency resources, VA has arranged contracts with
pharmaceutical returns vendors that individual VHA medical facilities
may utilize. One hundred forty of VHA's 160 medical centers use the
services of Devos, Ltd., doing business as Guaranteed Returns, to
assist them in returning drugs for credit or disposing of nonreturnable
drugs in accordance with environmental standards and preparing required
paperwork to monitor the movement of narcotic drugs. Guaranteed Returns
receives a percentage of credits issued for returnable drugs and a fee
based on weight for destruction of nonreturnable drugs.
VHA also uses the services of part-time physicians where necessary to
alleviate recruitment difficulties or when practicality would not
indicate full-time employees. While VA policy states a part-time
appointment requires a tour of duty scheduled in advance that normally
does not significantly change from one pay period to another, it also
provides that a part-time physician whose other responsibilities make
adherence to the same schedule every pay period impractical may have an
adjustable work schedule. Part-time physicians with adjustable tours of
duty have a biweekly work requirement consisting of non-core hours that
may be adjusted at the request of the employee and core hours that are
the days and times when the employee must be present unless granted an
appropriate form of leave or excused absence. VA policy requires core
hours to be at least 25 percent of total scheduled hours. In April
2003, the OIG reported[Footnote 4] that part-time physicians were not
working the hours established in their VA appointments. A February 2004
follow-up report[Footnote 5] by the OIG stated that while most part-
time physicians were on duty as required, 8 percent of the part-time
physicians tested were not on duty or on approved leave or authorized
absence as scheduled.
Scope and Methodology:
To gain an understanding of VHA's policies and procedures and the
related internal controls for the three areas of operation we assessed,
to identify key control activities, and to assess the design
effectiveness of those controls, we obtained and reviewed VA and VHA
directives, handbooks, and other policy guidance and reports issued by
VA's OIG. We also conducted interviews and system walk-throughs with
VHA personnel and reviewed our previous reports. To assess the
implementation effectiveness of the key control activities for the
three areas of operation, we used a case study approach, reviewing
transaction documentation at six VA medical centers selected based on
size and medical specialization diversity of the location's part-time
physicians and other factors.
For personal property management, we discussed requirements and
procedures with VHA headquarters and medical center personnel. We
performed tests of each medical center's property records to assess
their accuracy. Because our initial review disclosed incomplete and
inaccurate information in property database records from each location
we visited, we could not design our work to make a statistically based
projection on the results of our work. Instead, we tested a
nonstatistical selection of 100 items from each location's property
records to verify property existence by locating the item and comparing
bar code, serial number, and item description information in the
records to the item that we observed.
For drugs returned for credit, we discussed requirements and procedures
for managing turned-in drugs with personnel at VHA headquarters, the
selected medical centers, and a pharmaceutical return contractor. Also,
for each of the six medical centers we visited, we obtained and
reviewed inventory lists of returned drugs for one contractor pickup of
drugs held for return and vendor credit documents.
For part-time physician time and attendance, we discussed policy
requirements with VHA headquarters personnel and asked medical center
staff about the processes for collecting, approving, and recording time
and attendance data for part-time physicians. We reviewed time and
attendance and corresponding payroll documentation for a judgmental
selection of 10 part-time physicians for two biweekly pay periods
ending in September 2003 at each of the six medical centers that we
visited. We also reviewed medical center procedures for monitoring
part-time physician attendance.
We reviewed and used as guides, our Standards for Internal Control in
the Federal Government[Footnote 6] and the Internal Control Management
and Evaluation Tool.[Footnote 7] The Comptroller General issued these
standards to provide the overall framework for establishing and
maintaining internal control. According to these standards, internal
control, also referred to as "management control," comprises the plans,
methods, and procedures used to meet the missions, goals, and
objectives of an organization. Internal control also serves as the
first line of defense in safeguarding assets and preventing and
detecting errors and fraud. Our Management and Evaluation Tool provides
a systematic, organized, and structured approach to assessing internal
control.
We performed our work at VA medical centers in Atlanta, Houston, Los
Angeles, San Francisco, Tampa, and Washington, D.C; at VA
headquarters; and for drugs returned for credit, at a return
contractor's facility in East Setauket, New York. Our work was
performed using a case study approach, and therefore, results of our
study cannot be projected beyond the locations and transactions we
reviewed.
We conducted our review from February 2003 through March 2004 in
accordance with U.S. generally accepted government auditing standards.
We requested comments on a draft report from the Secretary of Veterans
Affairs or his designee. Written comments were received from the
Secretary of Veterans Affairs and are reprinted in appendix II.
Property Management Policies and Procedures Provided Inadequate Control
over Medical Center Personal Property:
We found that VHA's property control databases did not provide a
complete and accurate record of personal property on hand, compromising
effective management and security of agency assets at the six locations
we visited. Our tests to determine whether the six medical centers had
adequate control over items that were recorded in the property control
databases showed that property officials could locate only about one-
third of the 600 items we selected. We found that in addition to
noncompliance with VA property management requirements, current VA
physical inventory and property accountability policies were a major
cause of unreliable property records and reduced the opportunity to
adequately control personal property at five of the six medical centers
we visited.
Medical Centers Lacked a Reliable Property Control Database:
Standards for Internal Control in the Federal Government[Footnote 8]
requires that agencies establish physical control to secure and
safeguard vulnerable assets such as equipment, periodically count those
assets, and compare the counts to control records. However, through our
initial reviews, we found that the property control records for the six
locations we visited contained incomplete or incorrect information,
such as missing property location or acquisition cost information. The
property control records were such that we could not select a
statistical sample of test items that would allow our results to be
projected to the location's entire property universe. We proceeded
instead with a case study approach, reviewing 100 property items
selected from each of the six medical centers' databases using a
nonstatistical selection method. Medical center property officials told
us that some of the incorrect or incomplete information in the
databases resulted from the incorrect transfer of some information from
the previous property control system to the current system in 1996. The
lack of accurate property control records hampered medical center
property managers' efforts to effectively safeguard and manage VHA
personal property.
Property Managers Found about One-Third of the Property Items Selected
for Testing:
Property officials located only 201 of 600 items (or about one-third)
that we selected from the six medical centers' property control records
to observe and verify. At five locations, VHA officials found from 13
to 39 of the 100 items we tested at each location to determine if they
were on hand, while at the sixth medical center, Atlanta, 62 of 100
items were found. The 600 assets we selected to observe were recorded
at a total value of $104,220,868 in the property control system.
However, because 125 of the 600 test items selected had no acquisition
cost entered in the databases, the total cost of our selection could
not be determined. Table 1 summarizes the results of our property
observation tests at all locations we visited. Each category of items
not observed is discussed below.
Table 1: Results of Personal Property Physical Observation Tests:
Number of items tested;
Atlanta: 100;
Houston: 100;
Los Angeles: 100;
San Francisco: 100;
Tampa: 100;
Washington, D.C.: 100;
Total: 600.
Items observed;
Atlanta: 62;
Houston: 38;
Los Angeles: 25;
San Francisco: 24;
Tampa: 39;
Washington, D.C.: 13;
Total: 201.
Items not observed;
Atlanta: 38;
Houston: 62;
Los Angeles: 75;
San Francisco: 76;
Tampa: 61;
Washington, D.C.: 87;
Total: 399.
Items not observed due to: Database errors/omissions;
Atlanta: 24;
Houston: 10;
Los Angeles: 14;
San Francisco: 36;
Tampa: 27;
Washington, D.C.: 45;
Total: 156.
Items not observed due to: Inadequate label;
Atlanta: N/A;
Houston: N/A;
Los Angeles: 8;
San Francisco: 3;
Tampa: 5;
Washington, D.C.: 1;
Total: 17.
Items not observed due to: Mobile/portable assets;
Atlanta: 3;
Houston: 13;
Los Angeles: 10;
San Francisco: 6;
Tampa: 7;
Washington, D.C.: 3;
Total: 42.
Items not observed due to: Unexplained;
Atlanta: 11;
Houston: 39;
Los Angeles: 43;
San Francisco: 31;
Tampa: 22;
Washington, D.C.: 38;
Total: 184.
Source: GAO analysis of test findings.
[End of table]
Database errors or omissions represented 156 items that were not
observed ostensibly because of insufficient database information. These
errors included assets for which the property database did not (1)
indicate a disposal date, though property officials told us the item
had been disposed of, or (2) did not indicate a location for the
property item. One property official said the predecessor property
control system had not included a field for a disposal date, and when
the program was modified to add that capability, then-existing records
were not updated. Other database errors included records that did not
accurately identify the asset as building service equipment, which
represent items that are essentially part of facility buildings rather
than personal property, or entries with one equipment identification
number that represented several component items constituting one
system.
At the Washington medical center, we could not locate three property
items, each valued at over $1 million, because of other data entry
errors. The explanation for two of the three items was that the assets
were on order but had not yet been received. Center officials
attributed these errors to property personnel entering these assets
into the property control system prior to receipt. For the third item,
center officials informed us that one bar code number had been issued
for a system of several pill dispensing machines, the components of
which were at various locations throughout the medical center and had a
combined value over $1 million, rather than bar coding each component
and entering it in the property record to provide a means of
controlling each item.
Inadequate labeling of property items prevented us from verifying the
identity of 17 items with a total acquisition cost of $29,463,952
selected from the property records at four medical centers. According
to VA officials, nonexpendable property costing $5,000 or more must be
bar coded and recorded in the property system. However, none of these
17 items had bar code labels attached, and either serial number
labeling was also not attached to the asset or the serial number was
not entered in the property records. For example, at the Tampa medical
center, five property items totaling $9,996,491, including a telephone
operating system, two X-ray systems, and two components of an X-ray
system, were inadequately labeled. Although items that we observed
matched the general description and location indicated by the property
records for these items, we were unable to specifically verify their
identity because bar codes had not been placed on the items and serial
number information could not be compared between the property records
and the physical items. When both bar code and serial number
information cannot be compared between the property records and the
property item, the physical inventory process is impaired and property
accountability is compromised. Under these circumstances, even the most
effective physical inventory procedure cannot provide the requisite
assurance that assets are controlled adequately.
Forty-two mobile or portable items, such as a wheelchair, adjustable
bed, and Intensive Care Unit module, also could not be located.
Officials stated that these items are moved from one location to
another within the medical centers to meet patients' needs. At the
Houston medical center, from our selection of 100 items, property
officials were unable to locate 13 portable assets, totaling $19,997,
before the end of our visit. Some of these items included patient beds,
patient feeding pumps, and a portable defibrillator.
Regarding the remaining 184 items, property officials at the six
medical centers could neither locate them at the time of our visits nor
provide documentation supporting the disposal, loan, or loss of the
items, or otherwise explain why they were not found.
A 1997 addition to VA's Handbook 7127, "Materiel Management
Procedures,"[Footnote 9] established a $5,000 threshold for property
that must be inventoried. The handbook stated that it is a local
decision to maintain inventory on "other" nonexpendable equipment not
capitalized or accounted for and also required accountability for
sensitive property regardless of cost. Referring to the inventory
provisions, A&MM staff at four of the six locations we visited told us
they were only accountable for property items costing $5,000 or more
and items in the four categories of sensitive assets specifically
identified by VA policy: handguns, ammunition, canines, and
automobiles. By ignoring VA's general requirement to account for
sensitive property regardless of cost, property managers at those
locations did not keep the property control database current for most
items costing less than $5,000 and lost control of the items not
tracked. Medical center property officials at two centers said we
should not expect to locate items with a cost lower than $5,000 because
they do not inventory these assets. This practice means that some
items, such as computers, monitors, and other sensitive equipment,
which by their nature are subject to theft, loss, or conversion to
personal use, are not inventoried or tracked. Of the 184 items that
were neither found nor had plausible explanations for not being found,
over half (95) were sensitive assets. Table 2 shows the nature of these
95 sensitive items categorized as personal computers, laptop computers,
scanners, printers, monitors, facsimile or copier machines, and
videocassette recorders.
Table 2: Categories of Sensitive Assets Not Located by Property
Officials:
Fax machines or copiers;
Atlanta: N/A;
Houston: N/A;
Los Angeles: 1;
San Francisco: N/A;
Tampa: N/A;
Washington, D.C.: 1;
Total: 2.
VCRs;
Atlanta: N/A;
Houston: N/A;
Los Angeles: 1;
San Francisco: N/A;
Tampa: N/A;
Washington, D.C.: N/A;
Total: 1.
Computer printers;
Atlanta: N/A;
Houston: 3;
Los Angeles: 3;
San Francisco: 6;
Tampa: 2;
Washington, D.C.: 3;
Total: 17.
Computer monitors;
Atlanta: 3;
Houston: 11;
Los Angeles: N/A;
San Francisco: 2;
Tampa: 1;
Washington, D.C.: 11;
Total: 28.
Laptop computers;
Atlanta: N/A;
Houston: 2;
Los Angeles: N/A;
San Francisco: 2;
Tampa: N/A;
Washington, D.C.: 1;
Total: 5.
Scanners;
Atlanta: 1;
Houston: N/A;
Los Angeles: N/A;
San Francisco: 1;
Tampa: 1;
Washington, D.C.: 2;
Total: 5.
Personal computers;
Atlanta: N/A;
Houston: 11;
Los Angeles: 11;
San Francisco: 6;
Tampa: 2;
Washington, D.C.: 7;
Total: 37.
Total number of assets;
Atlanta: 4;
Houston: 27;
Los Angeles: 16;
San Francisco: 17;
Tampa: 6;
Washington, D.C.: 25;
Total: 95.
Total acquisition cost;
Atlanta: $1,354;
Houston: $35,896;
Los Angeles: $26,195;
San Francisco: $27,589;
Tampa: $5,978;
Washington, D.C.: $21,677;
Total: $118,689.
Source: GAO analysis of test findings.
[End of table]
The Information Resources Management department (IRM) at the six
medical centers we visited had developed alternative procedures to
maintain accountability for computer equipment that cost less than
$5,000. However, we found many instances in which these procedures were
not used effectively. For example, a separate listing prepared by the
Los Angeles center's IRM was not used to update the property location
information in the property control record, which showed the initial
IRM storage room instead of the final location to which computer
equipment was assigned. Further, the IRM record was not kept up to
date, a factor in IRM personnel being unable to locate 22 of the 30 IRM
items we selected for observation.
Our standards for internal control require that key duties be divided
or segregated among different people to reduce the risk of error or
fraud. However, one of the methods for taking physical inventory of
property established in VA's handbook provides that each party
responsible for property items will (1) receive a listing of
accountable property items charged to him or her according to the
property management system; (2) conduct a physical count; and (3) sign
and date the listing, certifying the existence of and continuing need
for the property for which he or she was responsible. Allowing the
party responsible for the custody of property assets to attest to the
existence of those same assets is contrary to the segregation of duties
standard and compromises the control provided by taking an independent
physical inventory. To illustrate the minimal value of such procedures,
property officials at two medical centers told us that some service
line managers just sign the inventory list without verifying the
existence of the equipment. These practices would result in creating or
perpetuating property control record errors if listed items had been
lost, stolen, loaned, transferred, or otherwise disposed of. VA's
handbook also requires the involvement of A&MM officials in quarterly
spot checks to verify inventory accuracy, but A&MM officials at only
two of the locations we visited indicated they perform regular spot
checks.
A&MM staff at the Atlanta medical center told us they conducted
periodic inventories of personal property rather than delegating that
control function to parties responsible for the property. They also
told us that the Atlanta facility considers computer equipment to be
sensitive and, therefore, accountable. At this location, we observed 62
of 100 test items compared to from 13 to 39 of the 100 items at each of
the other five locations we visited, all of which performed physical
inventories primarily by using equipment lists certified by property
custodians.
Subsequent to our visit, property officials from the San Francisco
medical center told us that they had located all equipment items with
an acquisition cost of $5,000 or more that we had selected for testing,
and officials from the Washington medical center told us they had
located 10 additional items that we selected for observation, one of
which was over $5,000. However, because we were no longer on site and
could not verify the existence of these items, the additional found
items are not incorporated in the statistics we present.
Agency officials provided us with a copy of proposed revisions to VA's
property policy guidance that address some of the weaknesses we
identified. While the draft policy adds 27 specific categories of
equipment that would require accountability regardless of cost,
including computer equipment, it reduces the frequency of spot checks
from quarterly to semiannually and addresses the physical inventory
segregation of duties issue only minimally by requiring that 5 percent
of inventory be verified by disinterested parties.
VHA Controls over Process for Returning Drugs for Credit Was Weak:
Internal control over drugs held for return credit, which according to
VHA officials is left to the discretion of medical center management,
provided no assurance that the six pharmacies we visited were receiving
the proper amount of credits for returned drugs. All six of the
pharmacies used contractors to return the drugs, and agency officials
said that using contractors had increased the amount of credits VA
received for returned drugs. However, all six locations lacked
information about which drugs qualified for credit, and only one
pharmacy inventoried non-narcotic drugs before they were turned over to
the contractor. Accordingly, none of the pharmacies had the basic
information needed to verify that credits received were correct and
complete. We also found that no analytical review of credits for
returned drugs, focused on maximizing the amount of credits received,
was performed at the location, network, or agency level. In addition,
we identified security weaknesses. Non-narcotic drugs held for return
without a control listing were stored in unsecured open bins readily
accessible to anyone within the pharmacy at each facility except the
San Francisco and Tampa medical centers.
VHA Relies on Others to Determine the Amount of Credits for Returned
Drugs:
Standards for Internal Control in the Federal Government[Footnote 10]
states that internal control should provide reasonable assurance that
effective and efficient use of the entity's resources is achieved. VHA
officials told us that controls over returned drugs and related credits
were left up to pharmacy managers at individual medical centers.
However, we found that each of the six medical centers we visited
essentially used an honor system for returning drugs to manufacturers
for credit, relying on contractors that collected and processed
recalled, expired, or deteriorated drugs. The contractors packaged the
drugs at the medical centers and shipped them either to the
contractors' processing facilities or, if required by the
manufacturers, to the manufacturers' processing facilities. For drugs
shipped to the contractors' facilities, the contractors (1) determined
which drugs were returnable; (2) returned drugs qualified for credit to
the manufacturers and destroyed the nonreturnable drugs; and (3)
provided the pharmacy an itemized list of drugs collected, and their
disposition, and an itemized estimate of credits to be received. The
drug manufacturers determined the final amount of credits issued. While
reviewing documentation for drugs that were returned by the six medical
centers in September 2002, we found none of the pharmacies had
determined if they received appropriate credit for the drugs they
turned over to the contractor. Further, none of the pharmacies could
determine if the credits received were complete or correct because all
lacked detailed information about which drugs the manufacturers
accepted for credit. In addition, none of the medical centers except
Tampa maintained lists of non-narcotic drugs turned over to the return
drug contractor.
Medical center pharmacy staff told us there are over 1,000 drug
manufacturers, each with its own policies for returning drugs for
credit. For example, one drug manufacturer might require that a drug be
returned 30 days prior to its expiration to qualify for credit, another
drug manufacturer might allow a credit for a drug 30 days past its
expiration, and another might not allow credits at all. Furthermore, a
VA pharmaceutical return contractor informed us that the manufacturers
frequently change their policies. Consequently, medical center pharmacy
managers lacked information that would enable them to determine whether
the credits they received for returned drugs were correct. As a result,
the pharmacies relied on the contractors' determination of the type and
quantity of drugs that were returnable and relied solely on the drug
manufacturers' determination of the final amount of credits issued for
returned drugs.
In addition to establishing a return policy for drugs, each drug
manufacturer set its own requirements for the process of returning the
drugs and issuing credits. Some drug manufacturers allowed the
pharmacy's contractor to process returned drugs and issued a credit
through the pharmacy's prime vendor.[Footnote 11] Other manufacturers
would only accept returned drugs directly from VHA. Our review of the
estimated credits for non-narcotic drugs returned in September 2002
showed most were processed through each pharmacy's prime vendor. Table
3 shows the contractors' estimated value of credits to be received by
the six medical center pharmacies we visited for non-narcotic drugs
returned during September 2002.
Table 3: Estimated Credits for Non-Narcotic Drugs Returned September
2002:
Through prime vendor;
Atlanta: $28,213;
Houston: $30,678;
Los Angeles: $64,957;
San Francisco: $13,511;
Tampa: $31,861;
Washington, D.C.: $65,710.
Direct from manufacturers;
Atlanta: $6,353;
Houston: N/A[A];
Los Angeles: $16,609;
San Francisco: $2,747;
Tampa: $4,595;
Washington, D.C.: $4,111.
Total;
Atlanta: $34,566;
Houston: $30,678;
Los Angeles: $81,566;
San Francisco: $16,258;
Tampa: $36,456;
Washington, D.C.: $69,821.
Source: GAO analysis of pharmaceutical returns contractors' data
(unaudited).
[A] The Houston medical center's pharmaceutical returns contractor did
not distinguish between credits received from the prime vendor and from
manufacturers.
[End of table]
The return contractor informed us that if pharmacies requested, it
could provide a report on the actual credits issued through the prime
vendor for specific returned drugs. None of the pharmacies we visited
indicated they were aware of this capability. Using these reports might
facilitate the pharmacies' reconciliation of credits received with
drugs returned. As shown in table 3, analyzing the credits processed
through the prime vendor could account for 80 percent or more of
estimated credits.
Pharmacies and VHA Managers Performed No Analysis of Drugs Returned for
Credit:
Standards for Internal Control in the Federal Government[Footnote 12]
calls for establishing performance measures that facilitate analysis so
appropriate actions are taken. None of the six medical centers had
established performance measures or any kind of mechanism to oversee
credits received for returned drugs. For example, medical center
pharmacy managers we interviewed did not review the lists of drugs
processed for credit provided by the pharmaceutical return contractor
to determine if unusual trends occurred that might indicate an
opportunity to increase credits received. Periodic analysis of drugs
turned in throughout the year could reveal whether specific drugs were
not accepted for credit on a recurring basis. For instance, drugs being
consistently turned in too late to receive credit would indicate a need
to process the drugs differently. If pharmacy managers reviewed actual
returned drugs and credit data and took necessary corrective action to
optimize returns, the net cost of pharmaceutical operations might be
reduced. For example, at the Los Angeles pharmacy we found that 23
percent, or more than $60,000, of the $274,000 estimated value of drugs
returned in September 2002 did not receive a credit because the drug
expiration dates exceeded the manufacturers' requirements.
Medical center pharmacy officials stated that it was not cost effective
to perform any of these control activities for returned drugs. However,
the pharmacies had done no studies or analyses to document this
conclusion. In fact, at one pharmacy, we noted that the chief
pharmacist was not aware of the value of his pharmacy's yearly credits
from returned drugs. Having initially told us that his pharmacy's
yearly credits from returned drugs were only about $10,000, he
subsequently reviewed the return documentation and told us his pharmacy
received over $124,000 in returned drug credits for fiscal year 2003.
We inquired of VA's Pharmacy Benefit Management staff whether any
agencywide analysis or study had been done to determine the reasons why
more returned drugs had not qualified for credit. They stated that they
had not undertaken such an analysis but believed credits had greatly
increased through the use of a contractor to return drugs to
manufacturers. They also told us that under their previous system, the
material management staff of each medical center returned the drugs to
the manufacturers and credits received for returned drugs had been
minimal. Guaranteed Returns, contractor for five of the six medical
centers we visited, reported that of the $21.5 million estimated return
value of drugs it processed for VHA in fiscal year 2003, VHA received
$5.7 million in credits for returned drugs.
Without review and analysis of return drug documentation, the
pharmacies cannot determine what control procedures would be cost
effective. Further, despite the improved results obtained from using
pharmaceutical return contractors, without agency oversight of returned
drugs and related credits based on established performance measures as
called for in our standards for internal control, VHA cannot be
reasonably assured that stewardship of agency resources is effective.
Lack of Security Made Non-Narcotic Drugs Held for Return Vulnerable to
Fraud:
Standards for Internal Control in the Federal Government[Footnote 13]
states that access to resources should be limited to authorized
individuals. We found that at four of the six pharmacies visited,
physical control over non-narcotic drugs held for return was lacking.
The San Francisco pharmacy stored such drugs in a locked bin and the
Tampa facility limited access to a secured area, but the other four
locations used open, unsecured bins. Anyone with access to the pharmacy
also had access to the drugs. Thefts would be very difficult, if not
impossible, to detect because the pharmacies did not maintain lists of
the non-narcotic drugs held for return. The drugs were simply deposited
in the bin. The lack of physical control over non-narcotic drugs held
for return represents a potential lost opportunity to maximize return
credits and to reduce the risk of theft or misuse of these drugs.
During our review, lapses in security at two of the pharmacies we
visited were reported. The VA OIG reported that three employees of the
Houston medical center were convicted of conspiring to steal large
amounts of non-narcotic pharmaceutical drugs from the pharmacy. These
employees had stolen over $1.3 million of drugs over 3 years. At the
Washington, D.C., medical center, as discussed in our recent report on
VHA personnel screening procedures,[Footnote 14] we found that one
employee of the pharmacy had been convicted for possession of illegal
drugs prior to VHA employment. While these incidents may not relate
directly to drugs held for return to manufacturers, they indicate the
risks involved and underscore the clear need for effective control over
these drugs. The combination of weaknesses in record keeping and
physical controls over non-narcotic drugs held for return exposed them
to potential loss, theft, or unauthorized use.
Controls over Part-time Physician Time and Attendance Could Be
Strengthened Further:
Our review of part-time physician time and attendance documentation for
the two pay periods ending in September 2003 showed that scheduled and
actual hours worked were not always documented according to policy at
the six medical centers we visited. Also, specific hours worked
recorded by physicians on their time and attendance reports sometimes
differed from information entered in the payroll system. We also found
that latitude provided in VHA's Directive 2003-001,[Footnote 15] issued
in January 2003, on time and attendance of part-time physicians was a
factor in the various ways the six locations carried out part-time
physician attendance monitoring responsibilities. While newly
emphasized policies stressed the importance of this matter, compliance
in some cases had been slow to develop and oversight processes varied
and were not fully effective.
Scheduled and Actual Hours Worked Were Not Always Documented in
Accordance with Policy:
Our standards for internal control state that control activities, such
as approvals and authorizations, are integral to an entity's
accountability for stewardship of resources. Consistent with that
management control objective, VHA's January 2003 directive called for
specifying work schedules in writing in advance of the biweekly pay
period, showing the specific days and hours that part-time physicians
were to work, including core hours when employees working adjustable
shifts must be present. Our review showed that schedules were not
always established in advance of the pay period as required by VHA. For
the two pay periods ending in September 2003, our review of records for
10 part-time physicians at each of the six locations we visited
revealed that only the Houston medical center had documented
preapproved schedules for all physicians whose records we tested. A
contributing factor for this weakness was that an official at one
location told us part-time physicians with fixed schedules did not
require a documented preapproved schedule. Almost one-third of the
part-time physician records that we reviewed did not include the
required documented schedule. However, all those who had documented
schedules also had core hours established as required. Table 4
summarizes the results of our work regarding part-time physician
policies and their schedules at the centers we visited.
Table 4: Part-time Physician Schedule Documentation:
Part-time policy established;
Atlanta: Yes;
Houston: Yes;
Los Angeles: Yes;
San Francisco: Yes;
Tampa: Yes;
Washington, D.C.: Yes.
Number of part-time physicians reviewed;
Atlanta: 9[A];
Houston: 10;
Los Angeles: 10;
San Francisco: 10;
Tampa: 10;
Washington, D.C.: 10.
Work schedules and core hours established;
Atlanta: 7;
Houston: 10;
Los Angeles: 5;
San Francisco: 6;
Tampa: 9;
Washington, D.C.: 3.
Core hours equal 25 percent or more;
Atlanta: 7;
Houston: 10;
Los Angeles: 5;
San Francisco: 6;
Tampa: 9;
Washington, D.C.: 3.
Source: GAO analysis of VA medical center data.
[A] One of the 10 physicians selected for testing worked full time
during the test period.
[End of table]
Failure to document schedules can lead to confusion about when a
physician should be at work. The VA OIG's February 2004 report on VA
medical center part-time physician time and attendance stated that 15
of 58 part-time physicians who were not present when scheduled during a
1-day test said they had changed their hours without getting written
approval.
Our internal control standard regarding accurate recording of
transactions and events applies to the entire process or life cycle of
a transaction or event from initiation and authorization through its
final classification in summary records. Our comparison of manually
prepared time and attendance records with computerized payroll system
timecards indicated no differences between total hours worked and total
hours entered in the payroll system for the cases we tested. However,
we found that when part-time physicians temporarily modified their
approved work schedules, the changes they noted on their forms 4-5631a,
used to document, review, and approve actual hours worked, were
sometimes not entered in the computerized payroll system. At five of
the six medical centers,[Footnote 16] we compared information shown on
the payroll system timecards to the forms 4-5631a that were signed by
the part-time physicians, timekeepers, and the physicians' supervisors.
At four of those five medical centers, we noted at least one instance
of a difference between the specific days and hours worked shown on a
part-time physician's form 4-5631a and that information shown on the
corresponding payroll system timecard.
Timekeepers and other medical center officials told us that recording
temporary changes for actual time worked in VHA's computerized payroll
system is difficult because the system is inflexible. As a result, if
total hours that a part-time physician actually worked during a pay
period equaled the total hours scheduled, timekeepers often entered the
physician's scheduled hours into the computerized payroll system rather
than the actual hours worked. However, accurate payroll system
information about specific hours worked is important to satisfy VHA's
need to document whether part-time physicians fulfill their core hour
requirements.
Monitoring Part-time Physician Attendance Varied by Location and
Service:
Our standards for internal control[Footnote 17] state that an entity's
documentation of transactions and other significant events must be
complete and accurate. At the six medical centers we visited, we found
variation in the design and effectiveness of medical center procedures
concerning the way supervisors and timekeepers checked and documented
daily employee attendance and how facility management periodically
monitored employee compliance with time and attendance requirements.
VHA's January 2003 directive on part-time physician time and attendance
referred to VA's underlying policy manual that established requirements
for supervisors or timekeepers to have personal knowledge that part-
time physicians worked the hours or days shown on their time and
attendance forms. Timekeeping procedures that included keeping a record
of each physician's daily attendance throughout a pay period provided
greater reliability than those that relied on the physicians', their
timekeepers', or their supervisors' memories. With working arrangements
of part-time physicians, their supervisors, and timekeepers that vary
among the service centers within a medical center, we found that the
timekeepers at the medical centers we visited accounted for daily
attendance of physicians using a wide variety of procedures. While the
Houston medical center established a sign-in procedure for all part-
time physicians, the other five medical centers relied primarily on the
timekeepers' observation of physicians' daily attendance. At those
facilities, the procedures often differed among service centers and
included activities such as timekeepers making informal notes on their
personal calendars or preparing calendar-like worksheets to check off
the names of each part-time physician when he or she was observed at
the center during a scheduled workday. While each process offered a
level of control over time and attendance, they all had limitations and
none provided assurance that part-time physicians were on duty during
their core hours.
For example, on the surface, a sign-in procedure would seem to offer
more definitive assurance; however, effectiveness depends on how well
the procedure is implemented. On the day we reviewed part-time
physician sign-in sheets at the Houston medical center, we noted that
only 2 of 15 physicians scheduled to work had signed in. Timekeepers
told us they observed 5 other physicians in the facility and 1 had
advance approval to attend a lecture. However, the timekeepers also
told us 2 other part-time physicians scheduled to work had called in
and stated that they were "accounted for," and the remaining 5 had not
reported in or otherwise confirmed their attendance. Houston's failure
to enforce its sign-in procedures for its part-time physicians is an
example of compromised control effectiveness that impaired medical
center management's ability to know if part-time physicians worked when
scheduled.
While VHA's January 2003 directive identified medical center
management's responsibility for monitoring compliance with part-time
physician time and attendance policy, the methodology for implementing
that responsibility was left to the discretion of facility management.
Some of the methodologies adopted were less effective than others. For
example, while the Atlanta medical center service areas checked
attendance for 5 percent of part-time physicians one day each month, at
the San Francisco center service areas checked attendance of all part-
time physicians at least one day per quarter, and its Office of Human
Resource Management made random spot checks. In addition to physical
observation, other methods used for making these periodic surveys of
attendance at the six locations included monitoring doctors logging
into the facility's computer network, monitoring doctors' notes entered
into VHA's patient records system, and paging doctors to determine if
physicians used medical center telephones to respond.
The wide variety of part-time physician time and attendance procedures
that have been developed by the medical centers we visited reduces VHA
management's level of assurance that controls are effective and agency
objectives are being achieved. We believe an opportunity exists for the
agency to study the various medical center and service area procedures
so that VHA can provide more specific direction about the most
effective ways to improve control over part-time physician time and
attendance agencywide.
Conclusions:
The weaknesses in internal control that we identified at the six VA
medical centers we visited leave the agency vulnerable to waste, fraud,
and abuse. Improving the design and implementation of policies
regarding personal property will help improve accountability for agency
assets, especially sensitive property. VHA managers performed no
analytical oversight of credits for returned drugs, and the six medical
centers had no effective control over the amount of credits for drugs
returned to manufacturers. Some analysis of drug return transactions
would provide management with a basis to determine what control
activities would provide an appropriate cost/benefit ratio. Current
policies and procedures for monitoring part-time physician time and
attendance, if implemented more effectively, may provide reasonable
assurance that management's objectives will be met. In addition, the
wide range of physician attendance monitoring procedures developed by
the various medical centers and service areas provides an opportunity
to improve controls agencywide if their relative effectiveness is
studied. While some medical centers have already taken positive steps
to improve controls over these areas, appropriate direction from
management will spur action agencywide and help reduce vulnerability to
waste, fraud, and abuse.
Recommendations for Executive Action:
We are making the following 17 recommendations to improve the internal
controls over the operating areas that were the subject of our work.
Some of these recommendations require attention of VA management at the
department level, others VHA, and still others VA medical center
management. We recommend that the Secretary of Veterans Affairs direct
the Assistant Secretary for Management to:
* clarify existing guidance and establish consistent parameters for
personal property that is required to be accounted for in the property
control records and that is subject to physical inventory to include
sensitive property,
* provide a more comprehensive list of the type of personal property
assets that are considered sensitive for accountability purposes,
* direct that physical inventories of personal property be performed by
the A&MM staff or other parties who are independent of those with
property custodian responsibilities, and:
* reinforce VA's requirement to attach bar code labels to agency
personal property.
To improve accuracy of VA's time and attendance records for part-time
physicians, we recommend that the Secretary of Veterans Affairs direct
the Assistant Secretary for Management to coordinate all time and
attendance system changes with VHA, in order to ensure that the time
and attendance system facilitates entry of actual hours and days worked
by part-time physicians into VA's permanent electronic time and
attendance record.
To improve oversight of medical center operations, we recommend that
the Acting Under Secretary for Health:
* designate a headquarters-level staff office to monitor medical
facilities' credits for returned drugs;
* review returned drug credits and related pertinent information for VA
medical facilities and determine, especially for those with unusual
performance patterns, whether there might be additional opportunities
for credits;
* develop procedures to periodically test whether the amount of credits
received for returned drugs is correct;
* implement procedures to periodically test whether the amount of
credits that medical centers received for returned drugs is correct;
* conduct a best practices review of procedures implemented by VA
medical centers and service areas to identify those most effective in
documenting daily attendance of part-time physicians and periodically
monitoring employee compliance with time and attendance requirements;
and:
* use the results of the best practices review to provide more
definitive policy guidance to improve control effectiveness over part-
time physician attendance monitoring.
To address the weaknesses noted during our visits to six VA medical
centers, we recommend that the Acting Under Secretary for Health
require the directors of those medical centers to:
* determine the location or disposition of personal property items not
found during our site visits;
* review property records to identify and correct erroneous or
incomplete data fields;
* prepare a running list of all non-narcotic drugs held for return in
facility pharmacies as they are removed from current supplies to
compare with contractor-prepared lists of returned drugs;
* improve physical security over non-narcotic drugs held for return in
facility pharmacies as they are removed from current supplies; and:
* analyze information regarding drugs returned to manufacturers to
identify potential improvements that might increase the amount of
credits received, such as improving the timeliness of returning drugs
consistently turned in too late to qualify for credit.
We also recommend that the Acting Under Secretary for Health determine
whether the above recommendations pertaining to the facilities we
visited are applicable to all VA medical facilities.
Agency Comments:
VA provided written comments on a draft of this report. In its
response, VA agreed with our conclusions and recommendations and
reported that it is developing an action plan to implement them.
Additionally, VA's response stated that it is pursuing a number of
strategies to improve the processing of expired medications held for
credit, the monitoring of part-time physician time and attendance, and
the inventory records of all equipment. VA also provided technical
clarifications, which we incorporated where appropriate. VA's written
comments are reprinted in appendix II.
We are sending copies of this report to the Ranking Minority Member,
Subcommittee on Oversight and Investigations, House Committee on
Veterans' Affairs; the Chairman and Ranking Minority Member, House
Committee on Veterans' Affairs; the Chairman and Ranking Minority
Member, Senate Committee on Veterans' Affairs; the Secretary of
Veterans Affairs; the Acting Under Secretary for Health, Veterans
Health Administration; and other interested parties. We will also make
copies available to others upon request. In addition, the report will
be available at no charge on the GAO Web site at [Hyperlink, http://
www.gao.gov]
Should you or your staff have any questions on matters discussed in
this report, please contact me at (202) 512-6906 or by e-mail at
[Hyperlink, williamsm1@gao.gov] or Jack Warner, Assistant Director, at
(202) 512-4679 or by e-mail at [Hyperlink, warnerj@gao.gov] Major
contributors to this report are acknowledged in appendix III.
Sincerely yours,
Signed by:
McCoy Williams:
Director:
Financial Management and Assurance:
[End of section]
Appendixes:
Appendix I: General Background Information for Selected VA Medical
Centers, Fiscal Year Ended September 30, 2003 (Unaudited):
VA medical centers: Full-time employees;
Atlanta: 1,893;
Houston: 2,704;
Los Angeles: 3,761;
San Francisco: 1,542;
Tampa: 3,753;
Washington, D.C.: 1,759.
VA medical centers: Part-time employees;
Atlanta: 105;
Houston: 179;
Los Angeles: 785;
San Francisco: 254;
Tampa: 250;
Washington, D.C.: 122.
VA medical centers: Inpatient admissions;
Atlanta: 6,447;
Houston: 10,744;
Los Angeles: 8,421;
San Francisco: 2,669;
Tampa: 10,901;
Washington, D.C.: 6,412.
VA medical centers: Outpatient visits;
Atlanta: 498,511;
Houston: 651,203;
Los Angeles: 921,778;
San Francisco: 357,833;
Tampa: 592,117;
Washington, D.C.: 455,308.
VA medical centers: Operating beds;
Atlanta: 285;
Houston: 475;
Los Angeles: 887;
San Francisco: 251;
Tampa: 619;
Washington, D.C.: 150.
VA medical centers: Pharmacy prescriptions filled;
Atlanta: 1,152,121;
Houston: 1,947,149;
Los Angeles: 1,268,535;
San Francisco: 647,887;
Tampa: N/A[A];
Washington, D.C.: 761,224.
VA medical centers: Fiscal year 2003 budget;
Atlanta: $195,982,752;
Houston: $350,126,771;
Los Angeles: $460,971,988;
San Francisco: $228,717,772;
Tampa: $450,306,564;
Washington, D.C.: $210,143,108.
VA medical centers: Fiscal year 2003 drug expenditures;
Atlanta: 37,317,098;
Houston: 52,747,012;
Los Angeles: 47,594,623;
San Francisco: 23,600,000;
Tampa: 78,049,310;
Washington, D.C.: 26,200,000.
VA medical centers: Net estimated value of returned drugs;
Atlanta: 131,965;
Houston: 154,178;
Los Angeles: 211,302;
San Francisco: 106,026;
Tampa: 131,647;
Washington, D.C.: 141,975.
VA medical centers: Credits for returned drugs;
Atlanta: 105,364;
Houston: 100,134;
Los Angeles: 140,901;
San Francisco: 60,593;
Tampa: 74,903;
Washington, D.C.: 104,863.
VA medical centers: Estimated cost of nonreturnable drugs;
Atlanta: 57,277;
Houston: 154,432;
Los Angeles: 260,140;
San Francisco: 60,299;
Tampa: 41,380;
Washington, D.C.: 76,348.
Source: GAO presentation of VHA medical center data (unaudited).
[A] The Tampa medical center tracks inpatient drugs on a unit dose
basis rather than a prescription basis. Therefore, this information was
unavailable.
[End of table]
[End of section]
Appendix II: Comments from the Department of Veterans Affairs:
THE SECRETARY OF VETERANS AFFAIRS:
WASHINGTON:
July 14, 2004:
Mr. McCoy Williams:
Director:
Financial Management and Assurance Team:
U. S. General Accounting Office:
441 G Street, NW:
Washington, DC 20548:
Dear Mr. Williams:
The Department of Veterans Affairs (VA) has reviewed the General
Accounting Office's (GAO) draft report, VA MEDICAL CENTERS; Internal
Control Over Selected Operating Functions Needs Improvement (GAO-04
755) and agrees with your conclusions. VA concurs with GAO's
recommendations and has already provided under separate cover a
suggested rewording of the recommendation on time and attendance of
part-time physicians.
Although the current pharmaceutical inventory management system reduces
the amount of inventory and potential for expired medications, VA
recognizes there is additional opportunity for improving the management
of expired medications within the Veterans Health Administration (VHA).
Based on the findings in your report, VHA's Pharmacy Benefits
Management-Strategic Health Group will develop and implement a national
policy regarding the processing, handling and security of expired
medications and their destruction and/or credit. Network officials will
provide oversight of this policy and will compare medical center
pharmacies with accepted industry standards. VHA will begin
implementing this action early in FY 2005, with full implementation to
be completed by September 30, 2005.
VHA has been working closely with the Assistant Secretary for
Management and the Office of Information Field Office (OIFO) staff to
resolve the policy and procedural issues related to monitoring part-
time physician:
attendance. In May 2004, the Change Control Board (CCB) approved this
project. New training materials for timekeeping staff are currently
being developed and are expected to be completed in early Fall 2004.
The information technology changes to VHA's Electronic Time and
Attendance (ETA) program will allow VHA to accurately monitor employee
compliance with time and attendance requirements.
VA will instruct VA Medical Center Directors to certify that a wall-to-
wall inventory of all equipment records has been completed, and
identify corrective actions. These certifications will be submitted to
VHA Clinical Logistics Officer by December 31, 2004. Additionally, VA
will instruct network directors and medical center directors to
properly identify and track personal property items.
Due to the limited amount of time to comment on GAO's draft report, VHA
is still developing an action plan to implement GAO's recommendations.
VA will provide the action plan in its comments to GAO's final report.
Thank you for the opportunity to review your draft report.
Sincerely yours,
Signed by:
Anthony J. Principi:
[End of section]
Appendix III: GAO Contacts and Staff Acknowledgments:
GAO Contacts:
McCoy Williams, (202) 512-6906:
Jack Warner, (202) 512-4679:
Acknowledgments:
In addition to those named above, the following individuals made
important contributions to this report: Kwabena Ansong, Sharon Byrd,
Cary Chappell, Lisa Crye, Fred Evans, Lou Fernheimer, Jeff Isaacs,
Julia Matta, Bonnie McEwan, Christina Quattrociocchi, Donell Ries,
Alana Stanfield, and Jason Strange.
(195005):
FOOTNOTES
[1] U.S. Department of Veterans Affairs, Office of Inspector General,
Audit of the Veterans Health Administration's Part-time Physician Time
and Attendance (Washington, D.C.: Apr. 23, 2003) and Follow-up of the
Veterans Health Administration's Part-time Physician Time and
Attendance (Washington, D.C.: Feb. 18, 2004).
[2] U.S. Department of Veterans Affairs, "Materiel Management
Procedures," VA Handbook 7127 (Washington, D.C.: Sept. 19, 1995).
[3] U.S. Department of Veterans Affairs, "Time and Attendance for Part-
time Physicians," VHA Directive 2003-001 (Washington, D.C.: Jan. 3,
2003).
[4] U.S. Department of Veterans Affairs, Office of Inspector General,
Audit of the Veterans Health Administration's Part-time Physician Time
and Attendance.
[5] U.S. Department of Veterans Affairs, Office of Inspector General,
Follow-up of the Veterans Health Administration's Part-time Physician
Time and Attendance.
[6] U.S. General Accounting Office, Standards for Internal Control in
the Federal Government, GAO/AIMD-00-21.3.1 (Washington, D.C.: November
1999).
[7] U.S. General Accounting Office, Internal Control Management and
Evaluation Tool, GAO-01-1008G (Washington, D.C.: August 2001).
[8] GAO/AIMD-00-21.3.1.
[9] U.S. Department of Veterans Affairs, "Materiel Management
Procedures," VA Handbook 7127.
[10] GAO/AIMD-00-21.3.1.
[11] The Pharmaceutical Prime Vendor Program provides VA and other
federal medical facilities a timely and economical method of acquiring
pharmaceutical products through use of contracted distributors, or
wholesalers, known as "prime vendors."
[12] GAO/AIMD-00-21.3.1.
[13] GAO/AIMD-00-21.3.1.
[14] U.S. General Accounting Office, VA Health Care: Improved Screening
of Practitioners Would Reduce Risk to Veterans, GAO-04-566 (Washington,
D.C.: Mar. 31, 2004).
[15] U.S. Department of Veterans Affairs, "Time and Attendance for
Part-time Physicians," VHA Directive 2003-001.
[16] At the Washington, D.C., medical center, all part-time physicians
were on fixed schedules and did not prepare time and attendance form 4-
5631a for the pay periods we tested.
[17] GAO/AIMD-00-21.3.1.
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