Department of Veterans Affairs: Actions Needed to Address Employee Misconduct Process and Ensure Accountability

VA provides services and benefits to veterans through hospitals and other facilities nationwide. Misconduct by VA employees can have serious consequences for some veterans, including poor quality of care. GAO was asked to review employee misconduct across VA. This report reviews the extent to which VA (1) collects reliable information associated with employee misconduct and disciplinary actions, (2) adheres to documentation-retention procedures when adjudicating cases of employee misconduct, (3) ensures allegations of misconduct involving senior officials are reviewed according to VA investigative standards and these officials are held accountable, and (4) has procedures to investigate whistle-blower allegations of misconduct; and the extent to which (5) data and whistle-blower testimony indicate whether retaliation for disclosing misconduct occurs at VA.

GAO analyzed 12 information systems across VA to assess the reliability of misconduct data, examined a stratified random sample of 544 misconduct cases from 2009 through 2015, analyzed data and reviewed cases pertaining to senior officials involved in misconduct, reviewed procedures pertaining to whistle-blower investigations, and examined a nongeneralizable sample of whistle-blower disclosures from 2010 to 2014.

The Department of Veterans Affairs (VA) collects data related to employee misconduct and disciplinary actions, but fragmentation and data-reliability issues impede department-wide analysis of those data. VA maintains six information systems that include partial data related to employee misconduct. For example, VA's Personnel and Accounting Integrated Data system collects information on disciplinary actions that affect employee leave and pay, but the system does not collect information on other types of disciplinary actions. The system also does not collect information such as the offense or date of occurrence. GAO also identified six other information systems that various VA administrations and program offices use to collect specific information regarding their respective employees' misconduct and disciplinary actions. GAO's analysis of all 12 information systems found data-reliability issues—such as missing data, lack of identifiers, and lack of standardization among fields. Without collecting reliable misconduct and disciplinary action data on all cases department-wide, VA's reporting and decision making on misconduct are impaired.

VA inconsistently adhered to its guidance for documentation retention when adjudicating misconduct allegations, based on GAO's review of a generalizable sample of 544 out of 23,622 misconduct case files associated with employee disciplinary actions affecting employee pay. GAO estimates that VA would not be able to account for approximately 1,800 case files. Further, GAO estimates that approximately 3,600 of the files did not contain required documentation that employees were adequately informed of their rights during adjudication procedures—such as their entitlement to be represented by an attorney. The absence of files and associated documentation suggests that individuals may not have always received fair and reasonable due process as allegations of misconduct were adjudicated. Nevertheless, VA's Office of Human Resource Management does not regularly assess the extent to which files and documentation are retained consistently with applicable requirements.

VA did not consistently ensure that allegations of misconduct involving senior officials were reviewed according to investigative standards and these officials were held accountable. For example, based on a review of 23 cases of alleged misconduct by senior officials that the VA Office of Inspector General (OIG) referred to VA facility and program offices for additional investigation, GAO found VA frequently did not include sufficient documentation for its findings, or provide a timely response to the OIG. In addition, VA was unable to produce any documentation used to close 2 cases. Further, OIG policy does not require the OIG to verify the completeness of investigations, which would help ensure that facility and program offices had met the requirements for investigating allegations of misconduct. Regarding senior officials, VA did not always take necessary measures to ensure they were held accountable for substantiated misconduct. As the figure below shows, GAO found that the disciplinary action proposed was not taken for 5 of 17 senior officials with substantiated misconduct.

As a result of June 2017 legislation, a new office within VA—the Office of Accountability and Whistleblower Protection—will be responsible for receiving and investigating allegations of misconduct involving senior officials.

VA has procedures for investigating whistle-blower complaints, but the procedures allow the program office or facility where a whistle-blower has reported misconduct to conduct the investigation. According to the OIG, it has the option of investigating allegations of misconduct, or exercising a “right of first refusal” whereby it refers allegations of misconduct to the VA facility or program office where the allegation originated. VA does not have oversight measures to ensure that all referred allegations of misconduct are investigated by an entity outside the control of the facility or program office involved in the misconduct, to ensure independence. As a result, GAO found instances where managers investigated themselves for misconduct, presenting a conflict of interest.

Data and whistle-blower testimony indicate that retaliation may have occurred at VA. As the table below shows, individuals who filed a disclosure of misconduct with the Office of Special Counsel (OSC) received disciplinary action at a much higher rate than the peer average for the rest of VA in fiscal years 2010–2014.

Additionally, GAO's interviews with six VA whistle-blowers who claim to have been retaliated against provided anecdotal evidence that retaliation may be occurring. These whistle-blowers alleged that managers in their chain of command took several untraceable actions to retaliate against the whistle-blowers, such as being denied access to computer equipment necessary to complete assignments.

GAO makes numerous recommendations to VA to help enhance its ability to address misconduct issues (several of the recommendations are detailed on the following page).

GAO recommends, among other things, that the Secretary of Veterans Affairs

develop and implement guidance to collect complete and reliable misconduct and disciplinary-action data department-wide; such guidance should include direction and procedures on addressing blank fields, lack of personnel identifiers, and standardization among fields;

direct applicable facility and program offices to adhere to VA's policies regarding misconduct adjudication documentation;

direct the Office of Human Resource Management to routinely assess the extent to which misconduct-related files and documents are retained consistently with applicable requirements;

direct the Office of Accountability and Whistleblower Protection (OAWP) to review responses submitted by facility or program offices to ensure evidence produced in senior-official case referrals demonstrates that the required elements have been addressed;

direct OAWP to issue written guidance on how OAWP will verify whether appropriate disciplinary action has been implemented; and

develop procedures to ensure (1) whistle-blower investigations are reviewed by an official independent of and at least one level above the individual involved in the allegation, and (2) VA employees who report wrongdoing are treated fairly and protected against retaliation.

GAO also recommends, among other things, that the VA OIG

revise its policy and require verification of evidence produced in senior-official case referrals.

VA concurred with nine recommendations and partially concurred with five. In response, GAO modified three of the recommendations. The VA OIG concurred with one recommendation and partially concurred with the other. GAO continues to believe that both are warranted.

The Department of Veterans Affairs (VA) provides a wide range of health  services and benefits to 9 million veterans through a nationwide network  of hospitals, outpatient clinics, and other facilities. In 2016, VA accounted  for 18 percent of the executive-branch employee workforce, employing  350,000 federal workers, including approximately 30,000 senior officials.  In that same year, VA employees accounted for about 31 percent of  cases submitted from across the federal government to the Office of  Special Counsel (OSC)—an independent agency where federal  employees can report evidence of waste, fraud, abuse, and retaliation.  These cases pertained to various types of misconduct including gross  mismanagement, waste, fraud, abuse, illegality, and prohibited personnel  practices such as whistle-blower retaliation.

GAO’s prior related work at VA focused on the use of administrative  investigation boards (AIB) to conduct investigations of alleged employee  misconduct. An AIB may be convened by the heads of VA  administrations and staff offices, chief executives of VA facilities, and all  authorities senior to any of these officials. The purpose of an AIB is to  conduct a fact-finding investigation under the standard procedures laid  out in VA Directive 0700, Administrative Investigations, and VA Handbook  0700, Administrative Investigations. We recommended in 2012 that VA  establish a process to collect and analyze aggregate data from these  investigations, and to share data that informed changes to policies and  procedures implemented in response to these investigations. VA  concurred with our recommendations and identified several activities that  the Veterans Health Administration (VHA) uses to share information  about systemic issues in facilities and VHA program offices.

You asked us to review the issue of allegations of VA employee  misconduct. This report reviews the extent to which VA (1) collects  reliable information associated with employee misconduct and disciplinary  actions that are accessible and could be used to analyze misconduct  department-wide; (2) retains documentation that demonstrates VA  adheres to its policies when adjudicating cases of employee misconduct;  (3) ensures allegations of misconduct involving senior officials are  reviewed in accordance with VA investigative standards, and these  officials are held accountable; (4) has procedures to investigate whistle- blower allegations of misconduct; and the extent to which (5) data and  whistle-blower testimony indicate whether retaliation for disclosing  misconduct occurs at VA.

To determine the extent to which VA collects reliable information  associated with employee misconduct and disciplinary actions that are  accessible and could be used to analyze misconduct department-wide,  we analyzed the contents of 12 information systems operated by various  VA components during portions of the period covering October 2009  through July 2017. We obtained data in these 12 information systems  from VA officials who oversee data related to misconduct or disciplinary  actions. We assessed the data and the reliability of each system through  electronic data testing, interviews with knowledgeable agency officials,  and comparison to source documentation for the purposes of identifying  and tracking misconduct cases. As discussed further in this report, the  data were generally not reliable for a department-wide assessment of all  misconduct and disciplinary actions due to the lack of completeness and  compatibility of the data across all information systems. However, we  found the data sufficiently reliable for conducting analysis where fields  were populated and field definition concurrence was obtained by the  program offices.

To determine the extent to which VA retains documentation that  demonstrates VA adheres to its policies when adjudicating cases of  employee misconduct, we selected a generalizable stratified random  sample of 544 misconduct cases from the Office of Human Resource  Management’s (OHRM) Personnel and Accounting Integrated Data  (PAID) information system covering October 2009 through May 2015 from  23,622 misconduct cases. We determined the data to be sufficiently  reliable for analysis of disciplinary actions affecting leave or salary. We  examined evidentiary files associated with these disciplinary actions for  the 489 of 544 cases for which VA was able to locate documentation (90  percent of sampled cases) to determine the extent to which VA’s actions  were consistent with policies contained in VA Directive 5021,  Employee/Management Relations.

To determine the extent to which VA ensures allegations of misconduct  involving senior officials are reviewed in accordance with VA investigative  standards and these officials are held accountable, we obtained data from  the Office of Accountability Review (OAR) Legacy Referral Tracking List  for the period of January 2011 through May 2015. We analyzed the OAR  Legacy Referral Tracking List and reviewed cases involving senior  officials that were referred to program offices for further investigation by  VA’s Office of Inspector General (OIG). As further discussed in the  report, we assessed the data and identified data-quality issues, which  included blank fields within OAR’s information system. However, we  found the data to be sufficiently reliable, for fields that were satisfactorily  populated, for conducting analysis of the investigative process for  referring and reviewing cases of misconduct.

To determine the extent to which VA follows procedures to investigate  whistle-blower allegations of misconduct, we interviewed senior officials  from VA and the OSC responsible for investigating whistle-blower  complaints. We also reviewed the OSC’s procedures for referring  disclosures and VA’s policy for investigating these disclosures once  received at the agency. In addition, we obtained whistle-blower  disclosure data from the OSC covering calendar years 2010 through  2014, where available. To determine the reliability of the data, we  conducted electronic testing and traced data elements to source  documentation. We determined the data to be sufficiently reliable for  determining the universe of disclosure cases involving VA. We selected  the 135 whistle-blower disclosure cases that were reported to the OSC  and indicated an investigation was completed by VA. These cases  represent the universe of VA disclosures and are nongeneralizable to the  entire population of disclosures received by the OSC. We reviewed the  results of OSC’s assessment of investigative documentation developed  by VA for a sample of these whistle-blower disclosure cases. We also  attended a course to assess VA’s training provided to VA employees  conducting investigations.

To determine the extent to which VA data and whistle-blower testimony  indicate whether retaliation for disclosing misconduct occurs at VA, we  selected the same 135 whistle-blower disclosure cases that were  reported to the OSC as indicated above. To estimate the difference in  rates of misconduct and attrition between whistle-blowers and the entire  population, we matched the employees associated with these cases to  employee rosters and adverse disciplinary actions from the PAID system  for the period of fiscal years 2010 through 2014. We also interviewed  representatives from different whistle-blower advocacy groups, and  individuals who disclosed wrongdoing or retaliation at VA who were  referred to us by one advocacy group.

To address all objectives, we interviewed senior officials from VA’s major  components responsible for investigating and adjudicating cases of  employee misconduct. We also reviewed standard operating procedures,  policy statements, and guidance for staff charged with investigating and  adjudicating allegations of employee misconduct. Further details about  our scope and methodology can be found in appendix I.

We conducted this performance audit from January 2015 to May 2018 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.

VA comprises a Veterans Affairs Central Office (VACO) and over 1,000  facilities and offices throughout the nation, as well as the U.S. territories  and the Philippines. As shown in figure 1, VA’s three major  administrations are the Veterans Health Administration (VHA), Veterans  Benefits Administration (VBA), and National Cemetery Administration  (NCA). The largest of the administrations, in terms of workforce, is VHA  and its associated Veterans Integrated Service Networks (VISN). VHA is  estimated to employ about 316,800 employees in 2017, followed by the  VBA and NCA with about 22,700 and 1,850 employees, respectively.  The remaining 15,000 employees are in various staff offices. VA’s budget  request for fiscal year 2018 of $186.4 billion includes $82.1 billion in  discretionary resources and $104.3 billion in mandatory funding.

The following offices are involved in addressing misconduct at VA.

Office of Human Resource Management (OHRM): OHRM develops  policies with regard to performance management and assesses the  effectiveness of department-wide human-resource programs and policies.

Office of Accountability Review (OAR): OAR was established in 2014  within VA’s Office of General Counsel and was intended to ensure  leadership accountability for improprieties related to patient scheduling  and access to care, whistle-blower retaliation, and related disciplinary  matters that affect public trust in VA.

Office of Inspector General (OIG): The VA OIG provides oversight  through independent audits, inspections, and investigations to prevent  and detect criminal activity, waste, abuse, and mismanagement in VA  programs and operations.

Office of Accountability and Whistleblower Protection (OAWP): As  required by the Department of Veterans Affairs Accountability and  Whistleblower Protection Act of 2017, OAWP will take on the  responsibility of, among other things, receiving whistle-blower  complaints.

Corporate Senior Executive Management Office (CSEMO): CSEMO  supports the entire life-cycle management of VA’s senior executives by  developing policy and providing corporate-level personnel services, such  as training and coaching to VA’s senior executive workforce.

Client Services Response Team (CSRT): CSRT serves to centralize  and streamline internal processes to improve VHA’s overall  responsiveness to concerns of veterans, employees, and other internal  and external stakeholders. This office works closely with VA and VHA  program offices and facilities to review, research, and respond to inquiries  sent to the Office of the Under Secretary for Health, Office of the  Secretary, and other concerns received via program offices within VACO,  which lack a formalized response process.

National Cemetery Administration (NCA): NCA honors veterans and  their families with final resting places in national shrines that  commemorate their service. NCA’s Office of Management oversees and  administers all human-resource management, including activities  associated with labor and employee relations.

Office of the Medical Inspector (OMI): OMI is responsible for assessing  the quality of VA health care through investigations of VA facilities  nationwide, which include employee whistle-blower allegations referred to  VA by the OSC; veteran complaints referred by the OIG, Congress, or  other stakeholders; and site-specific internal reviews directed by the  Office of the Under Secretary for Health.

Office of Research Oversight (ORO): ORO promotes the responsible  conduct of research, serves as the primary VHA office in advising the  Office of the Under Secretary for Health on matters of research  compliance, and is to provide oversight of compliance with VA and other  federal requirements related to research misconduct.

Office of Resolution Management (ORM): ORM provides Equal  Employment Opportunity (EEO) discrimination complaint processing  services to VA employees, applicants for employment, and former  employees, which include counseling, investigation, and final agency  procedural decisions.

Office of Security and Law Enforcement (OS&LE): OS&LE develops  policies, procedures, and standards that govern VA’s infrastructure law- enforcement program. The Law Enforcement Oversight and Criminal  Investigations Division is responsible for conducting investigations of  serious incidents of misconduct.

Veterans Benefits Administration (VBA): VBA provides benefits and  services to veterans, their families and survivors. VBA’s Office of  Management directs and oversees nationwide human-resources activities  and supports ORM in processing EEO complaints filed by employees and  applicants who allege employment discrimination.

The process for addressing employee misconduct involves various  components within VA that are responsible for investigating and  adjudicating allegations, as shown in figure 2.

Receipt of Allegation: The OIG receives allegations of criminal activity  and employee misconduct from VA employees, the OSC, members of  Congress, the public, or other stakeholders. The allegations received by  the OIG are initially routed to the OIG Hotline Division. The OIG also  receives other types of allegations outside the scope of this review, such  as issues pertaining to VA employee benefits and contracts. In addition to  reporting allegations of employee misconduct to the OIG, VA employees  may also report allegations of misconduct directly to their supervisors.

Review and Referral of Allegation: Due to the substantial number of  allegations received through the OIG Hotline Division, the OIG exercises  a “right of first refusal” on misconduct cases, which allows it to take no  further action, refer the case to program offices within VA for review and  response, or open an investigation. For example, the OIG can either  decide to (1) take no further action on matters not within the OIG’s  jurisdiction or too vague to warrant further review; (2) refer allegations  that warrant some action to the OMI, OAR, or VA facilities or program  offices within each administration to conduct an independent review of the  allegations; or (3) open cases for further review for serious allegations of  criminal activity, fraud, waste, abuse, and mismanagement. Cases  opened by the OIG typically involve misconduct by senior officials, or  matters relating to the quality of care provided by licensed professionals.  In contrast, the OIG typically refers allegations to VA facility or program  offices for matters where the OIG does not have sufficient resources to  open an internal case. The OIG generally does not review matters that  are addressed in other legal or administrative forums, such as allegations  of discrimination or whistle-blower retaliation.

Notice to Employee Once Allegations Are Substantiated: The type of  appointment an employee holds determines whether an employee is to  be provided advance notice of planned disciplinary action once  misconduct is substantiated at the conclusion of an investigation.  Employees holding a permanent appointment are entitled to receive a  notice of proposed action that states the specific charges for which the  proposed disciplinary action is based and informs the employee of his or  her right to review the material that is relied upon to support the reasons for the action. Employees in the competitive service serving in a  permanent appointment (who have completed their probationary period)  are treated differently than those who are still in their probationary period  or serving under temporary appointments. An employee serving a  probationary period or under a temporary appointment does not receive a  notice of proposed action and may be immediately terminated because  his or her work performance or conduct fails to demonstrate fitness or  qualifications for continued employment. Temporary employees are  terminated by notifying employees in writing as to why they are being  separated and the effective date of the action.

Disciplinary Action: VA Handbook 5021, Employee/Management  Relations, governs policy for disciplinary and grievance procedures for all  employees. Supervisory staff or appropriate higher-level officials use the  results from investigations to help determine whether any disciplinary  actions are warranted and, if so, the type and severity of each action.  Other VA staff, such as human-resources and general-counsel staff may  also provide guidance to management in determining appropriate  disciplinary actions. After determining the facts in a case, VA may employ  either disciplinary or adverse action. Adverse action involves a more- severe type of discipline (e.g., removal, suspension more than 14 days, or  reduction in grade) as described in table 1.

Employee Misconduct and Disciplinary- Action Data Are Hampered by Completeness and Data-Reliability Issues VA Collects Misconduct and Disciplinary-Action Data Using Fragmented Systems

As a federal agency, VA is required to report department-wide information  on certain disciplinary personnel actions to the Office of Personnel  Management (OPM). OPM’s Enterprise Human Resources Integration  (EHRI) system currently collects, integrates, and publishes data for  executive-branch employees on a biweekly basis. This system provides  federal workforce data to other government systems and the public. To  adhere to this reporting requirement, VA provides information on certain  disciplinary actions such as terminations and removals to OPM. The  Department of Veterans Affairs Accountability and Whistleblower  Protection Act of 2017 also requires the Secretary to provide a report on  the disciplinary procedures and actions of the department to Congress.

To understand the depth and breadth of misconduct and related issues in  a large entity, such as VA, comprehensive and reliable information is  needed. Standards for Internal Control in the Federal Government states  that an information system represents the life cycle of information used  for the entity’s operational processes that enables the entity to obtain,  store, and process quality information. Therefore, management should  design the entity’s information system to obtain and process information  to meet each operational process’s information requirements and to  respond to the entity’s objectives and risks, such as the ability to  systematically analyze misconduct department-wide to identify trends and  make management decisions regarding misconduct. A deficiency exists  when (1) a control necessary to meet an objective is missing or (2) an  existing control is not properly designed, so that even if the control  operates as designed, the objective would not be met.

We identified 12 fragmented information systems that VA has used, or  continues to use, to collect employee misconduct and disciplinary  actions. Although VA has made efforts to develop repositories to collect  information pertaining to misconduct and disciplinary action, none of the  12 information systems contain complete information. Six of these  systems collect partial misconduct and disciplinary action information and  contain fields that could potentially be shared with other systems to obtain  additional information, while the other six systems are intended for  internal office use only, each containing their own unique fields and  values tailored to the needs of that particular office, which are not shared.  Therefore, the number of eligible fields for each information system was  also limited to those not specifically designated for internal use. On the  basis of our review, the 12 information systems are not currently able to  communicate, or interoperate, with one another to provide a complete  picture of misconduct and disciplinary actions across VA.

Table 2 provides an overview of VA’s six information systems and  associated data files that collect partial misconduct and disciplinary-action  data that could potentially be shared with other systems.

According to OHRM officials, VA’s information system for recording  adverse disciplinary actions—the Personnel and Accounting Integrated  Data (PAID) system—was not designed to track all misconduct cases. In  addition, OHRM stated that the 53-year-old PAID system was developed  primarily to track payroll actions for all employees and is the system of  record that holds department-wide personnel information that is reported  to OPM’s EHRI system. It contains information about adverse disciplinary  actions that affect employee leave or salary, or result in a Notification of  Personnel Action Form (Standard Form 50). However, PAID does not  track comprehensive information on instances of misconduct such as the  offense, or the date of occurrence, and it does not include instances of  other types of disciplinary actions, such as admonishments or reprimands  that would not affect leave or salary, or result in a Standard Form 50.

OHRM officials stated VA implemented a system called HR Smart in June  2016 that is intended to replace PAID, but the agency does not plan to  upgrade the functionality of the new system to enable reliable collection of  misconduct information. According to OHRM, HR Smart includes the  same personnel-processing functions as PAID but will allow for tracking  data changes and transaction history over time. However, as with the  PAID system, adverse disciplinary actions involving leave and salary will  be tracked, but other actions, such as reprimands and admonishments,  will not. It also will not track information related to the offense that  prompted the disciplinary action.

While the HR Smart system has the capability to include modules to  enhance performance features, such as the ability to track misconduct,  according to OHRM officials VA does not currently have plans to  implement these modules. As a result, the HR Smart system will not have  the capability to track all employee misconduct department-wide and will  not improve VA management’s visibility over the depth and breadth of  misconduct so that it can systematically understand misconduct  department-wide.

VA has five additional information systems for tracking complaints or  allegations of misconduct and disciplinary actions, but, similar to the  agency’s PAID information system, each of these information systems  contains a subset of the information that would be needed to understand  all misconduct department-wide.

Data-Reliability Issues Impair VA’s Ability to Systematically Analyze Data to Evaluate Department-Wide Employee Misconduct

According to Standards for Internal Control in the Federal Government,  systems should include relevant data from reliable internal sources that  are reasonably free from error and faithfully represent what they purport  to represent. Additionally, management is advised to process data into  quality information that is appropriate, current, complete, accurate,  accessible, and provided on a timely basis. Management should also  evaluate processed information, make revisions when necessary so that  the information is quality information, and use the information to make  informed decisions.

Additionally, according to Standards for Internal Control in the Federal  Government, management should design the entity’s information system  and related control activities to achieve objectives and respond to risks.  The standards add that the information system design should consider  defined information requirements for each of the entity’s operational  processes. Defined information requirements allow management to obtain  relevant data from reliable internal and external sources. In order to  achieve complete and accurate data, internal controls are needed, among  other things, to ensure that fields are not left blank, data elements are  clearly defined and standardized, and common data elements are  included across data systems to allow for interoperability and  aggregation.

Our analysis of VA’s 14 data files identified the following three categories  that reduced the reliability of the data:  lack of data standardization, and  lack of identifiers.

We found that 7 data files we reviewed contained a majority of data within  fields, but 5 data files were missing a significant amount of data within  certain fields. We were unable to analyze the remaining two files due to a  number of data-quality issues. Among the fields that were missing data  were several that would be useful for analyzing misconduct, including  complainant name, proposed action, and person of interest, as shown in  table 4. For example, we found that in the OAR Legacy Referral Tracking  List, 97 percent of the entries for the Proposed Action field (1,210 of  1,245) and 96 percent for the Disciplinary Action field (1,190 of 1,245)  were blank. If available, comparison of the proposed and disciplinary  action-taken fields would allow VA to assess whether actions are  consistently implemented department-wide. However, the high  percentages of blank values in multiple fields impair VA’s ability to  conduct a comprehensive analysis of misconduct to identify and address  trends.

See appendix II for a further listing of the five data files and the  corresponding fields that were missing data.

In addition, we found that several data files had options such as “not  applicable” or “no” for certain fields so that the field would not be left  blank, but these options were not consistently used. For example, the  Complainant Name field within the Legacy Referral Tracking List was  blank for some entries and not applicable (N/A) for others. Accordingly,  we did not know whether data were intentionally omitted or not entered by  mistake. In addition, the Offense Sustained field found within the VA-Wide  Adverse Employment Action and Performance Improvement Plan  Database was blank for some entries and either a yes or no for others.

Eight of the 14 data files we reviewed did not have key data elements that  were defined within and across information systems. In other words, the  data files contained entries that described similar information in different  ways. For example:

The Complaints Automated Tracking System (CATS) Employment  data were not mutually exclusive, or independent of one another. For  example, this field includes two distinct categories of information:  employment status, such as full time or part time; or hiring authority,  such as Title 5 or Title 38. This method of storing information resulted  in undercounting each of the separate values due to the system’s  inability to account for expected overlap. For instance, an employee  could be both a full-time and Title 5 employee and the field only tracks  one or the other. ORM officials stated that this field has since been  modified to capture more options to account for the overlap.

The NCA data file’s Action Proposed/Decided/Taken data were  tracked in a single field and updated with the most-recent action,  rather than capturing proposed actions, decided actions, and actions  taken in separate fields.

We also identified standardization issues with the newly updated VA- Wide Adverse Employment Action and Performance Improvement Plan  Database. For example, we found 15 different variations of Registered  Nurse, such as “Registered Nurse,” “Staff RN,” and “RN” position names.  In addition, we found 28 alternate values that identified Diagnostic  Radiologic Technologists (e.g., Diagnostic Radiologic Technologist,  Diagnostic Radiological Technologist, and Radiologic Technologist).

See appendix III for a description of the fields that did not have  standardization within the eight data files.

We determined that 5 out of the 14 data files did not have identifiers that  would allow comparisons of information across systems. Identifiers are  important because they reference one unique individual or case, which  makes it possible to analyze historical data pertaining to all records with  the same identifier and analyze trends in employee misconduct over time.  For example:

The OAR VA-Wide Adverse Employment Action Database and the  VBA data files had a combined total of 4,487 closed cases of  misconduct that received adverse corrective action during the  combined period of November 2013 through December 2016. We  found that these two data files did not contain unique identifiers for  complainants or accused individuals for a given case. OAR officials  stated that this system does not contain Personal Identifying  Information since its purpose is to track proposed and taken adverse  actions. If more-specific information is needed, OAR staff coordinate  with the human-resource point of contact. Although OAR may obtain  additional information, this information is not entered into the OAR  VA-Wide Adverse Employment Action Database, which would assist  with conducting analysis.

VAPS tracks misconduct in two separate subsystems, one of which  tracks traffic violations and other administrative offenses, and one of  which also tracks more-egregious offenses such as criminal  violations. These subsystems also do not have unique identifiers  that would allow data matching between the two subsystems, which  could impede the analysis of this information. Even with both files,  there is no ready way to capture the complete number of individuals  with misconduct in both files due to the lack of a shared identifier.

The newly updated VA-Wide Adverse Employment Action and  Performance Improvement Plan Database does not contain unique  identifiers, such as employee identification number, name of the  complainant or accused, or other linking variables, to allow for the  analysis of historical trends or comparison of information among other  information systems.

The data-quality issues described above are due in part to most of VA  information systems not having data dictionaries, field definitions, or other  documented guidance and procedures on data entry and automated edit  checks to control for erroneous entries and blank fields. Absent guidance  and procedures, VA lacks assurance that employees will enter complete  and accurate information in the various data systems. Further, the lack of  unique identifiers such as employee identification number, case number,  or other linking variables for each of the records does not allow for  analysis of historical trends or comparison of information among different  information systems. Consequently, this precludes VA from determining  the frequency and nature of allegations by specified category, or  identifying trends, thus impeding senior officials’ ability to analyze  misconduct department-wide and develop corrective actions.

VA Does Not Consistently Adhere to Policies for File Retention and Adjudication Documentation Pertaining to Employee Misconduct Allegations

VA Directive 5021, Employee/Management Relations, governs policy for  disciplinary procedures for all employees and outlines the provisions for  the adjudication of each disciplinary action and associated file  documentation requirements. Specifically, files must be established  before a notice of proposed adverse action is issued to the employee to  document that the adjudication procedures were followed. The file must  contain all available evidence upon which the notice of proposed action is  based and that supports the reasons in that notice. In addition, each file  should contain specific documentation related to the adjudication of  employee misconduct.

VA Handbook 5021 states that disciplinary actions and associated  adjudication procedures for all VA employees appointed under Title 5 are  governed by three basic principles: (1) an employee shall be informed in  writing honestly and specifically why the action is being brought against  him or her; (2) an employee shall be given a reasonable opportunity to  present his or her side of the case; and (3) the employee and  representative shall have assurance of freedom from restraint,  interference, coercion, discrimination, or reprisal in discussing, preparing,  and presenting a defense.

Our review of a generalizable sample of 544 misconduct case files (from  a universe of 23,622 files) associated with disciplinary actions that affect  pay from October 2009 through May 2015 revealed that VA officials did  not consistently adhere to VA’s policy for retaining files containing  evidence of misconduct. Specifically, VA was unable to provide the files  for 10 percent (55 of 544) of the files we requested. We determined that  administrations and program offices within VA have various record- retention schedules. Offices that have not established a record-retention  schedule refer to the general records schedule developed by the National  Archives and Records Administration (NARA). However, we found that  some offices are misinterpreting OPM and NARA guidance and specify  the record retention period for adverse action files as a range between 4  to 7 years rather than selecting a specific number of years in their record- retention schedules. All of the files were within VA’s record-retention  range specified during the time of our review. The files that were  unaccounted for were dispersed throughout most of the VISNs, but one  VISN was not able to account for 19 of the missing files in our sample.

On the basis of our weighted analysis of the generalizable sample, we  estimate that VA would not be able to account for approximately 1,800  files in the full population that were within the record-retention period  specified.

In addition, VA officials did not consistently adhere to VA’s policy for  documenting that procedures were followed in the adjudication of  misconduct cases. We identified 22 out of 36 file requirements where VA  was not able to consistently demonstrate compliance with VA policy due  to the lack of documentation contained in files, based on our  generalizable sample. Specific to both Title 5 and Title 38 permanent- employee misconduct case files, table 5 shows the estimated number and  percentage that deviated from file documentation requirements. A list of  the 22 identified requirements and the percentage of files not in  compliance can be found in appendix IV.

As table 5 indicates, Title 5 and Title 38 permanent employee files did not  always contain documentation that employees were informed of the  reason the action was brought against them. For example, on the basis of  our generalizable sample, we estimate that the advance notice of  proposed action, which includes a statement of the specific alleged  misconduct upon which the proposed action is based, was not included in  16 percent of the files department-wide. A final decision letter, which  contains a statement of the decision official’s determination regarding  which charges, if any, in the advance notice were sustained, was not  included for an estimated 15 percent of all files. Further, an estimated 35  percent of all files did not include a written acknowledgement from the  employees that they received the final decision letter in person, and an  estimated 23 percent of all files did not include the required return receipt  for certified mail indicating that the decision letter was mailed to the  employee.

In addition, Title 5 and Title 38 permanent employee files did not always  contain documentation that employees were provided a reasonable  opportunity to present their side of the case. Our review found that  permanent-employee disciplinary files did not adhere to basic principles  outlined in VA Handbook 5021 and lacked evidence to demonstrate that  employees were adequately informed regarding their rights during the  adjudication procedure. Specifically, our generalizable sample found that  an estimated 21 percent of all files did not include statements regarding  the employee’s rights to due process, such as his or her entitlement to be  represented by an attorney or other representative. In addition, an  estimated 8 percent of all files did not mention that more information  regarding appeal rights could be obtained by consulting Human  Resources Management offices. For files where the employee provided  an oral reply in response to proposed disciplinary action, an estimated 29  percent of files did not include the required written summary, which is to  be signed by the official hearing the oral reply. Where a written reply  was submitted, an estimated 11 percent of files did not include a copy of  the employee’s written reply.

Further, VA officials did not consistently adhere to VA’s best practices  specific to Title 5 permanent employees only. We found that in a majority  of these files (an estimated 72 percent) the proposal letters did not  include a statement that assured the employee he or she had freedom  from restraint, discrimination, or reprisal in discussing, preparing, and  presenting a defense. VA Handbook 5021, Employee/Management  Relations, also states that Title 5 employees should provide their written  responses through supervisory channels to the decision official. We  estimate that a total of 6,819 files (47 percent) of Title 5 permanent  employee files did not provide their written reply through supervisory  channels to the decision official.

Although OHRM is responsible for assessing the effectiveness of  department-wide human resource programs and policies of VA Handbook  5021, according to OHRM officials, each facility is responsible for  oversight of implementing policies and guidelines pertaining to how  disciplinary actions are processed. We found no evidence that OHRM has  assessed whether documentation exists that demonstrates adherence to  policy governing cases involving disciplinary actions or provided oversight  of VA’s implementation of record-retention requirements, or that human- resource personnel adhere to basic principles outlined in policy to ensure  employees are informed of their rights during the adjudication process.

The resulting lack of oversight to HR policies increases the risk that  employees will not be adequately informed of their rights during the  adjudication process. Accordingly, employees may not (1) be provided  with information on why an action is being brought against them, (2) be  provided with a reasonable opportunity to present their case, and (3) be  adequately protected from potential reprisal in preparing their defense.

Regarding retention of records, according to NARA, disciplinary and  adverse action case files should be destroyed no sooner than 4 years but  no later than 7 years after the case is closed. According to OPM, to  implement this authority, each agency must select one fixed retention  period between 4 and 7 years and publish the retention in the agency’s  records disposition manual.

We determined that some offices are misinterpreting OPM and NARA  guidance by not selecting a specific number of years in their record- retention schedules. For example, three of the six policy record-retention  schedules we reviewed did not establish a specific number of years for  record retention. Specifically, record-retention policies for the Office of  Information and Technology, VACO staff offices, and VBA specified the  record-retention period for adverse action files as a range between 4 to 7  years rather than selecting a fixed retention period. For example, we  found that the Records Control Schedule pertinent to VACO was dated  June 30, 1967, without references to new or revised items since 1969.

Our results are consistent with an October 2016 inspection conducted by  NARA. The inspection report contained 16 findings and 19  recommendations for improvement of the records-management program  at VA. Among the findings and recommendations were the following.

Finding: The VA records management program has not ensured  that the VACO maintains a current Records Management  Handbook and a current Records Control Schedule, which  together establish program objectives, responsibilities, and  authorities for the creation, maintenance, and disposition of  agency records.

Recommendation: The Department Records Office must update  and maintain the VACO handbook and the Records Control  Schedule for Central Office Staff Offices and the Offices of the  Assistant Secretaries to include specific Records Management  roles and responsibilities for all VACO staff and to include  mandates for implementation of records management policies and  procedures in accordance with Federal statutes and regulations.

Finding: The VA Departmental Records Management program  does not conduct regular records management evaluations within  VACO and the Offices of the Secretary and Assistant Secretaries  or monitor the oversight activities of the Administrations.

Recommendation: The VA Departmental Records Management  program, working with the Administrations, VACO, and Enterprise  Risk Management, must establish effective Records Management  evaluation programs to monitor VA compliance with Federal  regulations.

Recommendation: The VA Departmental Records Management  program, working with the Senior Agency Official for Records  Management, must establish effective Records Management  evaluation programs to monitor the records management  practices within the Office of the Secretary and Assistant  Secretaries to ensure compliance with Federal regulations.

Finding: VACO Staff Offices and the Offices of the Assistant  Secretaries are not routinely conducting records inventories.

Recommendation: VACO Staff Offices and the Offices of the  Assistant Secretaries, with support from the Department Records  Management program, must conduct inventories of existing  electronic and non-electronic records to identify scheduled,  unscheduled, and vital records.

In response to NARA findings, VA is to submit a plan of corrective action  that specifies how the agency will address each inspection report  recommendation, including a timeline for completion and proposed  progress reporting dates.

VA does not have a method in place to evaluate the implementation of  records-management practices outside of those being conducted by VHA  and VBA. Accordingly, VA has not been conducting records-management  oversight with any uniformity department-wide. Further, VA’s use of  multiple retention periods for adverse action files, and in some cases the  lack of adherence to OPM and NARA guidance in defining a specific  retention period for these files, results in inconsistent retention of these  files across VA.

Investigative Standards Were Not Consistently Followed to Ensure That Senior Officials Were Held Accountable VA Facility and Program- Office Responses to Allegations of Misconduct Did Not Consistently Follow OIG Policy

The OIG receives allegations of employee misconduct from VA  employees, the OSC, members of Congress, the public, and other  stakeholders. When the OIG receives allegations it can either take no  further action, open an investigation, or refer the case to facility or  program offices within VA for review and response. For cases referred to  facility or program offices, the OIG has developed a policy for VA facilities  and program offices to use when investigating allegations of  misconduct. This policy includes six elements that VA facility and  program officials are to incorporate in their investigations, as shown in  table 6. According to OIG officials, if the reviewing employees have  concerns about the adequacy of the response provided, the OIG can  either ask for additional information to supplement the response or open  an internal case. Departmental heads (Under Secretaries for Health,  Benefits, and Memorial Affairs, Assistant Secretaries, and other key  officials) are responsible for ensuring that referrals are properly reviewed,  documented, and answered within specified time frames.

Our review of the 23 OIG cases of alleged misconduct between calendar  years 2011 and 2014 involving senior officials found that VA facility and  program offices did not consistently follow policies and procedures  established by the OIG for investigating such allegations. In several  instances, VA facility and program offices did not include one or more of  the six elements required in their investigative response to allegations of  misconduct. In addition, our review of the 23 cases found instances in  which VA facility and program offices did not include sufficient  documentation for their findings, or provide a timely response to the OIG.  The OIG was not able to produce the documentation provided by the  facility or program office that was used to close 2 of the 23 cases in our  review. All of the requested files were within the OIG’s 7-year record- retention period during the time of our review.

As shown in table 7, we identified four cases that did not contain evidence  of an independent review by an official separate from and at a higher pay  grade than the accused.

In three of the four cases that were not reviewed by an independent  official at a higher grade, the review was performed by the medical center  director, who was one of the accused named in the allegation. For  example, in one case involving alleged time-and-attendance abuse by a  physician, the medical center director, who was also named in the  allegation as having received a similar complaint against the physician 2  years earlier, reviewed the allegations made against the physician and  himself. The documentation provided showed that the medical center  director conducted the investigation of allegations and found the  allegations were not substantiated and no corrective actions were  implemented. In all four cases, both the independence and higher-grade  criteria were not followed when the accused senior officials investigated  allegations against themselves.

As shown in table 8, we generally found that VA facility and program  offices reviewed each allegation contained in the original referrals,  although in one case the reviewer did not respond directly to all  allegations.

As shown in table 9, VA facility and program offices clearly indicated their  findings for each allegation in 14 of the 21 cases of misconduct involving  senior officials for which files could be located, as well as their  assessment of whether the allegations were substantiated or  unsubstantiated. However, we identified seven cases in which VA  discussed its findings but did not provide a clear indication of whether all  allegations were substantiated or unsubstantiated.

Responses lacking a clear statement of substantiation may be more  difficult for subsequent reviewers, including OIG and OAR investigators,  to track and perform follow-up where necessary. For example, in one  case involving 11 allegations, no statement of substantiation was  provided, but VA’s response included seven recommendations, three of  which involved disciplinary action. We did not find evidence in the case  file that follow-up was performed by the OIG personnel to clarify this  discrepancy, and the case was closed.

As shown in table 10, most allegations involving senior officials (16 of 21  cases for which files could be found) were not formally substantiated and  did not require a recommendation for corrective action based on OIG  case-referral criteria. Specifically, the criteria require a description of  corrective actions taken or proposed as a result of substantiated  allegations, but make no mention of allegations that were not  substantiated as part of VA’s response. For one substantiated allegation,  however, we found no evidence of a recommendation for corrective  action.

Table 11 shows that 17 cases from VA facility and program offices did not  provide the supporting documentation they used to reach their  conclusions about the OIG case referrals.

In 17 cases, including one case reviewed by an AIB panel, VA referenced  documents reviewed but did not attach any of the supporting evidence.  OIG case-referral criteria state that VA facility or program offices must  provide supporting documentation used in their review, such as copies of  pertinent documents. However, the criteria do not specify whether copies  of all documentation reviewed must be included in the file. Supporting  documentation, which must be provided according to OIG policy, will vary  depending on the circumstances of the case, but those used to support  the findings and recommendations should be included.

For example, we reviewed one case where pertinent documents were  referenced to support the allegation, but documents supporting the  findings and recommendation were not included. The case contained  allegations involving false patient wait-time documentation and abuse of  authority. Specifically, a medical center director instructed staff to review  patient wait times between follow-up appointments in order to meet VA’s  14-day timeliness metric. The investigation revealed that VA staff had  changed several hundred veteran appointment wait times. The  investigation concluded that the false documentation allegation was  substantiated, but attributed the cause to the staff not understanding how  to enter a follow-up appointment date into the system. However, there  was no documentation in the files to support (1) that the medical center  director had not abused his authority by instructing staff to review wait  times greater than 14 days to determine how they could be reduced, and  (2) findings for the conclusion that the original wait times were entered in  error.

Absent supporting documentation, it is difficult for the OIG to determine  whether enough evidence was gathered before closing alleged cases of  misconduct that were found to be unsubstantiated or closing  substantiated cases of misconduct that required further action. VA  Directive 0701 states that copies of voluminous transcripts of interviews,  the entire claims folder, and medical charts are not necessary. However,  VA Directive 0701 further states that such materials should be available if  the OIG subsequently requests them within the record-retention period.  Case examples of allegations reviewed, and subsequently closed, by the  VA OIG based on its evaluation of evidence provided by facility and  program offices in response to allegations of misconduct can be found in  appendix V.

As shown in table 12, VA facilities’ or program offices’ response letters,  which were sent to the OIG, included a point of contact for further  questions in 15 of the 21 OIG case referrals involving senior officials,  including the individual’s name and a means of contact (phone or e-mail).

In 2 of the 15 cases where a point of contact was provided, the contact  was also one of the accused in the allegation. Although that is not  technically a violation of OIG criteria, it likely presents a conflict of interest  in regard to independent reviewers obtaining objective case information.  In six other cases, no contact was listed, although the letter was signed  by the reviewer. If a specific point of contact is not identified, including  position title, it may be assumed erroneously by employees involved in  the case, or following up on the case, that the default contact is the  reviewer, who may not be the appropriate point of contact, and may or  may not be able to provide objective case information.

OIG guidelines state that VA facilities and program offices assigned  Hotline case referrals are responsible for reporting written findings to the  Hotline Division within 60 days, unless an extension is requested. Our  review of the 21 cases found instances in which VA facility or program  offices did not always provide a timely response to the OIG. Table 13  shows five instances in which VA facility or program offices submitted a  response after the deadline requested by the OIG. One response was not  reported timely after an extension was provided by the OIG.

In one of the five cases involving allegations of abuse of authority by a VA  medical center director, the reviewer requested an extension, which is  permitted by OIG policy, but still missed the revised deadline. The five  case files did not contain any information regarding any follow-up actions  taken in response to delays.

According to OIG officials, when a case has been referred to a program  office for investigation, the OIG reviews the program office’s response for  completeness and sufficiency before closing the case. However, there is  no requirement for the OIG to ensure that the responses contain the six  elements listed in VA Directive 0701 and confirm that case referral  allegations have been addressed. Consequently, the lack of verification  could have contributed to insufficient evidence that does not meet the  requirements outlined by the OIG.

Additionally, VA facility and program offices have not consistently  adhered to VA Directive 0701 policy and do not always provide  supporting documentation for their findings and recommendations, or  always provide a timely response when reporting findings to the OIG’s  Hotline division. Inconsistent adherence to the reporting standards  provided by the OIG to VA facilities and program offices for investigating  and resolving misconduct case referrals from the OIG Hotline impedes  VA’s ability to ensure that misconduct cases are being handled  appropriately.

According to OIG officials, the OIG has taken steps to enhance the review  of case responses. Specifically, OIG officials stated that in April 2018 the  OIG implemented a new Enterprise Management System to reduce  reliance on certain manual processes. According to OIG officials, Hotline  analysts will now have more time to review their work and perform other  quality-assurance activities. In implementing this new system, it will be  important for the OIG to consider how the system can assist in ensuring  requirements are met and responses are received timely.

OAR Data Indicate That Senior Officials Involved in Substantiated Cases of Misconduct May Not Always Be Held Accountable

Our review of VA’s information systems that track misconduct involving  senior officials department-wide indicates that they may not always be  held accountable for misconduct. Specifically, (1) misconduct was  sometimes substantiated, but the proposed disciplinary action was not  taken; (2) misconduct was sometimes substantiated, but no disciplinary  action was recommended; (3) previous penalties did not have the  corrective effect for officials found to have engaged in repeated acts of  misconduct and who have remained in VA management positions; and  (4) senior officials violated separation-of-duty policy when taking  disciplinary action.

VA Handbook 5021 allows the deciding official to determine the  appropriate disciplinary action if one or more allegations are  substantiated. However, the disciplinary action may not be more severe  than what had been proposed.

Misconduct Substantiated, but Proposed Action Not Always Taken

In several cases, misconduct was substantiated, but the proposed action  was not always taken. Our review of the OAR Legacy Referral Tracking  List identified 17 officials between calendar year 2011 through May 2015  with substantiated misconduct where action was proposed. However, in  some of these cases, the officials were given a lesser penalty than the  one proposed, while in other cases there is no evidence that action was  taken. As shown in figure 3, we found that for 12 of the 17 officials with  substantiated misconduct, an adverse disciplinary action (removal) was  proposed. Of those 12 officials, 3 were removed, 2 received a  suspension, 4 received a reprimand or admonishment, 2 were allowed to  resign or retire before receiving disciplinary action, and we found no  evidence of disciplinary action for the remaining individual. For the other 5  officials, actions such as counseling, admonishment, suspension, or  reprimand were proposed. Of the 5 officials, 2 received the actions that were proposed, 1 received a lesser penalty than what had been  proposed, 1 was allowed to retire before receiving action, and we found  no evidence of the proposed action for the remaining individual.

For the two officials for whom there was no evidence that disciplinary  action was taken, we found no evidence within the PAID information  system or personnel files that these officials received the action proposed  in the OAR Legacy Referral Tracking List. Counseling was proposed for  one official, and removal from the position for the other official. OAR did  not provide us with evidence that the officials had received the action  proposed.

We also reviewed an additional 15 cases that involved a fact-finding or an  AIB. Our review of these cases found that 11 out of 23 officials were  associated with instances of substantiated misconduct and proposed  action was recommended. For 4 of the 23 officials where the proposed  action field was populated, the information within the OAR Legacy  Referral Tracking List reflected the action recommended. The applicable  data fields for the remaining 19 officials within the OAR Legacy Referral  Tracking List were not in agreement with the action recommended, or  blank. This review also identified two officials with substantiated  misconduct where OAR did not provide evidence that the disciplinary  action proposed was taken:

Two officials were involved in a case concerning alleged whistle- blower retaliation at the Phoenix VA Health Care System. The  investigative report documented that allegations were sustained. The  retaliation included allegations of involuntary reassigning the whistle- blower to another position, placement of the whistle-blower on  administrative leave, and lowered performance pay ratings following  disclosures regarding poor patient care and nursing triage errors.  Appropriate administrative action for persons identified as having  engaged in retaliation was recommended. We did not find any  evidence in the PAID system that these two officials involved in  retaliation received disciplinary action. OAR provided documentation  to show that no action was taken against one official, and was unable  to provide documentation to show that the disciplinary action had  been taken for the other. The official who received no action received  approximately $11,500 in performance pay during a 2-year period  following the allegations.

Misconduct Substantiated, but No Action Recommended

OAR’s quality-review process for investigative reports does not ensure  that reports with findings of substantiated misconduct include  recommendations for action. Our review of OAR’s Legacy Referral  Tracking List identified 70 out of 1,245 closed cases involving officials  where misconduct was either substantiated, or partially substantiated, but  no disciplinary action was recommended. One case involved three  allegations of poor dental care provided to patients by three different  senior officials. One physician cut underneath a patient’s tongue with the  bur of a hand-piece drill (substantiated), another administered medication  the patient was allergic to (partially substantiated), and the final senior  official extracted the wrong tooth (substantiated). We did not find any  evidence in the PAID system that these senior officials received  disciplinary action. Further, OAR did not provide documentation to show  that any disciplinary action had been proposed or taken. The physician  that cut underneath a patient’s tongue received performance pay totaling  $15,000 approximately 6 days after the investigation had concluded that  misconduct was substantiated. As of March 2018, two of these senior  officials received performance pay, and appear to still be employed at VA.

While an investigation was conducted that substantiated (or partially  substantiated) the allegations, there is an increased risk that some  substantiated misconduct will go unaddressed if there is no  recommendation for corrective action.

Senior Officials with Misconduct Remain in Management Positions

Our review of OAR’s Legacy Referral Tracking List indicated that some  officials who had been disciplined for misconduct remained in positions  where they were responsible for proposing or deciding disciplinary action  for other employees. We identified 15 officials in the OAR VA-Wide  Adverse Employment Action Database who received disciplinary action  between 14 days to 1 year prior to proposing disciplinary action for  another employee. Most of the 15 officials (12 officials) had received a  suspension.

We also found that five officials in the OAR Legacy Referral Tracking List  had received prior disciplinary actions for offenses unrelated to the new  OAR allegations. A prior history of disciplinary actions indicates that some  officials may be repeat offenders for whom the previous penalties did not  have the desired corrective effect. For example, 4 out of 5 officials were suspended for a different offense prior to being the subject of a new  allegation. One of the four officials was suspended less than 2 months  prior to being the subject of a new allegation, while another received a  suspension before, and again approximately 7 months following, the OAR  allegation. According to VA Handbook 5021, the deciding official must  use the “Douglas” factors, which include the employee’s past disciplinary  record, to determine a reasonable penalty. One of the five VA officials  was eventually removed approximately 6 months after the new OAR  allegation.

In analyzing cases involving senior management, we noted that the OAR  Legacy Referral Tracking List often did not accurately reflect the  disciplinary action that was decided based on the results of the  investigation. In numerous instances for the OAR Legacy Referral  Tracking List, the applicable data fields indicating the proposed and final  disciplinary action were blank. In these cases where the disciplinary fields  were populated, the data usually did not agree. Specifically, for 32 out of  the 40 records we reviewed where misconduct was substantiated, the  final disciplinary action taken did not reflect the information within the  OAR Legacy Referral Tracking List. When disciplinary actions are taken  in response to findings of misconduct but are not entered within an  appropriate information system, or are inaccurately recorded, it is more  difficult to (1) monitor whether disciplinary actions have been  implemented, and (2) ensure information relevant to management for  making decisions is available. Further, without a prior record of  misconduct or disciplinary action, senior officials who are repeat offenders  may not receive the appropriate penalty required.

Pursuant to the Department of Veterans Affairs Accountability and  Whistleblower Protection Act of 2017, OAWP will now be responsible for  receiving, reviewing, and investigating allegations of misconduct,  retaliation, or poor performance involving senior officials. According to  OAWP officials, their office investigates allegations of misconduct at the  senior level only. OAWP officials also stated that misconduct issues that  occur below the senior level will be referred to each of the three major VA  administrations for investigation and resolution. In addition to the VA- Wide Adverse Employment Action and Performance Improvement Plan  Database, OAWP officials stated that it has implemented two additional  information systems that are used concurrently to capture case  information. OAWP officials stated that they are currently working with VA  Information Technology to assess options for other case-management  systems that could consolidate these three information systems into one  comprehensive system.

VA Officials Violated Separation-of-Duty Policy When Taking Disciplinary Action against VA Employees

VA Handbook 5021, Employee/Management Relations, states that the  decision on a proposed major adverse action will be made by an official  who is in a higher position than the official who proposed the action,  unless the action is proposed by the Secretary. Standards for Internal  Control in the Federal Government states that management should divide  or segregate duties among different people.

Our review of the OAR VA-Wide Adverse Employment Action Database,  OAWP VA-Wide Adverse Employment Action and Performance  Improvement Plan Database, and VBA data file identified examples  where VA officials did not follow separation-of-duty requirements. As  shown in table 14, 73 (out of an estimated 7,886) VA officials acted as  both the proposing and deciding official in cases involving removals for  employees found to have engaged in misconduct.

Fourteen VA officials acted as both the proposing and deciding official in  two or more cases. One of these 14 officials acted as both the proposing  and deciding official for seven different removal cases. Further, our  review of 29 VA officials found that none received disciplinary action for  violating separation-of-duty policy.

The systemic lack of adherence to VA’s separation-of-duty policy is  reflective of a lack of controls that would allow such activity to occur.  Focusing on ensuring such controls are implemented would help ensure  that VA decreases the risk of abuse when officials act as both proposing  and deciding officials.

VA Has Procedures for Investigating Whistle-Blower Allegations of Misconduct, but Investigations Can Lead to Potential Conflicts of Interest

VA has procedures in place to ensure that allegations of misconduct are  investigated, but these procedures allow VA program offices or facilities  where a whistle-blower has reported misconduct to conduct the  investigation. According to VA officials, investigations that are deemed  necessary are occasionally ordered directly from the head of the facility or  VA leadership, which takes the lead on an investigation into the  allegation. Alternatively, an OIG official stated if allegations of misconduct  are received by the OIG, the OIG has the option of investigating the  allegation or exercising a “right of first refusal” whereby it refers  allegations of misconduct to VA facilities or program offices where the  allegation originated to complete an independent review and provide a  response to the OIG.

As shown in figure 4, the majority of contacts the OIG received (127,265  out of 133,435) from calendar years 2010 through 2014 were not  investigated due to several reasons, such as insufficient evidence or lack  of jurisdiction. Of those contacts that were investigated, the majority  (4,208 of 6,170 investigated contacts) were not investigated by the OIG  but rather were referred to facility or program offices for investigation.

Whistle-blowers also have the option of reporting alleged misconduct  outside VA by filing a disclosure with the OSC, and may do so if they  believe there has not been a resolution to their complaint internally. If the  OSC determines that there is substantial likelihood of wrongdoing, it may  refer the disclosure back to the Secretary of Veterans Affairs for further  investigation. According to OSC officials, as a general policy, the OSC  will not refer a disclosure to the Secretary if the OIG is already conducting  an investigation of that particular complaint and defers to the OIG to  finalize the investigation. According to OIG officials, the OIG may, in turn,  exercise its “right of first refusal” when cases are referred from the OSC.  Consequently, this process can result in a disclosure that was originally  made to the OSC being referred back to the facility or program office  where the allegation originated.

As shown in figure 4, the OSC referred 172 of 942 disclosures (18  percent) filed by VA employees back to the Secretary of Veterans Affairs  for further investigation from calendar years 2010 through 2014. Of the  172 disclosures referred, VA referred 53 back to the facility or program  offices where the complaint originated and 119 to the OIG.

The independence of officials conducting or reviewing the results is  paramount to the integrity of the process both in deed and appearance.  According to VA Directive 0700, the decision whether to conduct an  investigation should not be made by an official who may be a subject of  the investigation, or who appears to have a personal stake or bias in the  matter to be investigated. Moreover, according to OIG policy,  investigations referred to VA offices must be reviewed by an official  independent of and at least one level above the individual involved in the  allegation.

VA does not have oversight measures to ensure that all referred  allegations of misconduct are investigated by an entity outside the control  of the facility or program office involved in the misconduct, to ensure  independence. VA OIG officials acknowledged that there have been  concerns about referring cases back to the chain of command because  the OIG is unsure where cases go once they are referred. The  investigation of allegations of misconduct by the program office or facility  where the complaint originated may present the appearance of a conflict  of interest in which managers and staff at facilities may investigate  themselves or other allegations where they may have a personal stake or  bias in the matter to be investigated. Consequently, there may be an  increased risk that the results of the investigation are minimized, not  handled adequately, or questioned by the OSC or the individual who  made the original allegation.

Disclosures Investigated by VA Facility and Program Offices

According to VA Directive 0700, significant incidents occurring, and  issues arising, within VA facilities or offices shall be reported and  investigated as necessary to meet the informational and decision-making  needs of VA. Primary responsibility in this regard rests with the chief  executives of the facility or staff office involved, and with their supervisors  in VA and its administrations. According to an OIG official, VA (the  Secretary or a delegate) sends disclosures received from the OSC to the  OIG, which may then refer to VA facility or program offices for further  review and investigation. According to OSC officials, for cases that are  referred to a program office, the OSC requires that the Secretary or  delegate provide a report that outlines its conclusions and findings. This  reporting is not required for disclosures where an ongoing OIG  investigation is already under way.

According to OSC officials, for each disclosure, the OSC is to review the  report for statutory sufficiency and determine whether the findings of the  agency head appear reasonable. The OSC is to send its final  determination, report, and any comments made by the whistle-blower to  the President and responsible congressional oversight committees.

The OSC has raised concerns in its reports to the President about  investigations conducted by VA program offices and facilities. Of the 172  whistle-blower disclosures referred by the OSC between calendar years  2010 through 2014, the Secretary of Veterans Affairs referred 53 to  facility and program offices. Our review of these 53 OSC reports found  that the OSC had concerns about the conclusions VA reached in 21 (40  percent) of the 53 disclosure cases. For example, the OSC found that the  conclusions in some VA reports were unreasonable because VA  reached its conclusion without interviewing the witness, provided shifting explanations that strained credibility and did not  provide evidence of an unbiased investigation,  ignored whistle-blower concerns by refusing to investigate allegations,  and  refused to acknowledge the impact on the health and safety of  veterans seeking care after confirming problems in these areas.

For disclosure cases that were referred from the OIG to facility and  program offices during the 2010–2014 time frame of our review, the OIG  acknowledged that these concerns arose because of a lack of  communication between the department and the OIG regarding the scope  of the review. At the time of our review, VA did not have a procedure in  place to ensure the conclusions reached for investigations involving OSC  disclosure cases are reasonable and meet the informational and decision- making needs of VA whereby all allegations are addressed. More  recently, the OIG has started to communicate the scope of its reviews  that involve matters referred by the OSC to the Office of the Secretary. In  implementing this new process, it will be important for the Office of the  Secretary to ensure that any allegations outside the purview of the OIG’s  investigation are fully addressed by a departmental entity in accordance  with OSC requirements.

As shown in figure 4, of the 172 disclosure cases referred to VA by the  OSC, a total of 119 cases were referred to the OIG. The OIG had  conducted, or was already conducting, an investigation of the particular  allegations for all 119 disclosures. Since these 119 disclosure cases were  already under investigation by the OIG, the OSC deferred to the OIG’s  investigation for these cases. A total of 37 of these 119 disclosure cases  that were referred to the VA OIG were submitted to the OSC  anonymously. Therefore, we were unable to conduct a review of these  investigations because there was no information available to identify the  individuals involved.

According to Standards for Internal Control in the Federal Government,  management’s ability to make informed decisions is affected by the  quality of information. Accordingly, the information should be appropriate,  timely, current, accurate, and accessible. The oversight body oversees  management’s design, implementation, and operation of the entity’s  organizational structure so that the processes necessary to enable the  oversight body to fulfill its responsibilities exist and are operating  effectively.

Our review of the remaining 82 disclosure cases determined that the OIG  does not have procedures in place to track cases that were referred from  the OSC for further investigation. According to OIG officials, the OIG’s  information system did not have a method in place to ensure that OSC  case numbers are linked to the OIG investigative case number and final  report. Consequently, the OIG was unable to produce the investigative  documentation for these 82 disclosures. According to OIG officials, OSC  case numbers and associated Hotline numbers are currently tracked in a  spreadsheet until the implementation of a new system.

The inability to locate investigative documentation prevents a third party  from verifying whether the OIG examined the disclosures, whether any  recommendations were addressed, or whether appropriate disciplinary  action was taken for these cases. In addition, because the OSC defers to  the OIG’s investigation for allegations that were already conducted, or  being conducted, the OSC and individuals that made the allegations do  not have documentation to demonstrate that the allegations were  addressed. This information, or lack of it, has direct influence on  management’s ability to make sound decisions relating to investigative  matters.

Pursuant to the Department of Veterans Affairs Accountability and  Whistleblower Protection Act of 2017, OAWP will be responsible for  recording, tracking, reviewing, and confirming implementation of  recommendations from audits and investigations involving whistle-blower  disclosures, including the imposition of disciplinary actions and other  corrective actions contained in such recommendations. According to  OAWP officials, the whistle-blower disclosure process will be similar to  the current process when cases are referred to facility and program  offices for investigation. OAWP will follow up on any open points with the  level of leadership that is most appropriate in each case, such as the  medical center or VISN director. Case details will be tracked through the  three active databases that are being used concurrently.

OAWP is currently working to develop an internal process that will bring  the investigative communities together. For instance, OAWP would like to  monitor cases that are referred to VA facility and program offices, but it  does not currently have documented criteria to guide the process.  According to OAWP officials, OAWP is finalizing new policies in the form  of a policy manual and handbook. However, these officials were unable to  provide a time frame for completion of the published guidance.

VA Data and Whistle- Blower Testimony Indicate That Retaliation May Be Occurring

Individuals Who Reported Wrongdoing Are More Likely to Receive Disciplinary Action and Leave the Agency Than Their Peers

Our analysis of VA data shows that individuals who filed a disclosure of  misconduct with the OSC received disciplinary action, and left the  agency, at a higher rate than the peer average for the rest of VA. We  identified 135 disclosure cases that were received by the OSC between  calendar years 2010 and 2014 and were alleging misconduct. Of the 135  disclosures, a total of 129 employees made a total of 130 disclosures  nonanonymously. We compared the 129 employees who made  nonanonymous disclosures to the PAID information system using the  complainants’ information.

As shown in table 15, on average approximately 1 percent of all  employees in the VA roster received an adverse action in any given fiscal  year. For the 129 nonanonymous whistle-blowers, we found that  approximately 2 percent received an adverse action in the fiscal year prior  to their disclosure, while 10 percent had received an adverse action in the  fiscal year of their disclosure, and 8 percent received an adverse action in  the year subsequent to this disclosure. While the fact that nonanonymous  whistle-blowers faced higher rates of adverse action subsequent to their  disclosure than the VA population as a whole is consistent with a pattern  of retaliation for nonanonymous whistle-blowers, it is only an indication  that retaliation could be occurring.

Our analysis also showed that among employees who could be matched  to the PAID end-of-year roster, attrition rates were higher for those  individuals who filed a nonanonymous disclosure with the OSC. On  average, approximately 9 percent of all VA employees on the end-of-year  roster in one fiscal year were not on the subsequent year’s roster. In  contrast, 66 percent of the 129 nonanonymous whistle-blowers did not  appear in the subsequent year’s roster. Attrition rates were higher among  employees who had filed a disclosure than among their peers who had  not filed disclosures, for all fiscal years in our review (see table 16).

Our analysis did not confirm the reasons for disciplinary action or attrition  involving any of the 129 employees who made nonanonymous  disclosures to the OSC. According to VA officials, employees who have a  history of poor performance or conduct may be more likely to file a  disclosure with the OSC or allege misconduct, which could explain some  of the disparities between whistle-blowers and other employees.  However, we also could not rule out instances where retaliation by senior  officials may have occurred after misconduct was disclosed.

Testimony of Whistle- Blowers Describes Retaliation and Lack of Understanding of the Disclosure Process

The Civil Service Reform Act of 1978, as amended, states, among other  things, that federal personnel management should be free from prohibited  personnel practices (PPP). The law also authorizes the OSC to  investigate allegations involving PPP that include reprisals against  employees for the lawful disclosure of certain information pertaining to  individuals who engage in such conduct or other wrongdoing. According  to Standards for Internal Control in the Federal Government, laws and  regulations may require entities to establish separate lines of  communication, such as whistle-blower and ethics hotlines, for  communicating confidential information. Management informs  employees of these separate reporting lines, how they operate, and how  they are used, and how the information will remain confidential. Reporting  lines are defined at all levels of the organization and provide methods of  communication that can flow down, across, up, and around the structure.

Our interviews with six VA whistle-blowers who claim to have been  retaliated against provided anecdotal evidence that retaliation may be  occurring. Whistle-blowers we spoke to alleged that managers in their  chain of command took a number of actions that were not traceable to  retaliate against the whistle-blowers after they reported misconduct.  These alleged actions included being reassigned to other duty locations  or denied access to computer equipment necessary to complete  assignments, and socially isolating these individuals from their peers,  among other things.

Whistle-blowers we spoke to also expressed concerns regarding the lack  of guidance available to employees about how to file a disclosure through  VA and the OSC. Whistle-blowers stated that employees are not provided  adequate information on how to document or file a claim of misconduct or  retaliation. Employees can file disclosures regarding misconduct and  complaints of retaliation through multiple reporting lines. As mentioned  previously, however, the OSC will generally not refer to the Secretary  under its statutory process a disclosure if the OIG has conducted or is  already conducting an investigation of that particular complaint. Thus,  whistle-blowers may limit their chance of having an independent, non-VA  entity oversee their complaint if they file a complaint with the OIG first.

The Department of Veterans Affairs Accountability and Whistleblower  Protection Act of 2017 requires the Secretary, in coordination with the  Whistleblower Protection Ombudsman, to provide training regarding  whistle-blower disclosures to each employee of VA. This information  shall include, among other items, an explanation of each method  established by law in which an employee may file a whistle-blower  disclosure, an explanation that the employee may not be prosecuted or  reprisal taken against him or her for disclosing information, and language  that is required to be included in all nondisclosure policies, forms, and  agreements. The Secretary shall also publish a website and display the  rights of an employee making a whistle-blower disclosure.

In August 2017, VA began providing additional information on its website  for potential whistle-blowers who wish to report criminal or other activity to  the OIG. The information provided focuses on reporting misconduct to the  OIG and provides other lines of reporting established by law in which an  employee may file a whistle-blower disclosure, such as directly to an  immediate supervisor or the OSC. In addition, the information provided  explains the process after misconduct is reported through the OIG  Hotline, but does not clarify the process for referred disclosure cases  received from the OSC. As mentioned previously, OIG officials stated that  a disclosure made to the OSC or the OIG can be referred back to the  facility or program office where the allegation originated, which may  compromise confidentiality.

Consequently, employees may not be aware that their information may be  shared among the OSC, the OIG, OAWP, or VA facility and program  offices when a disclosure is made to the OSC. Adequately  communicating the investigative process to employees may alter their  decision to report wrongdoing. Without a clear understanding of the lines  for reporting misconduct and how they operate, whistle-blowers may be  uncertain as to their options for reporting misconduct, which increases the  risk that they may not report workplace misconduct.

According to OSC, it has learned through its cases that OAWP has a  practice of allowing VA employees, who are the subject of the allegations  brought forward by whistle-blowers to review or participate in  investigations, or both, which could make the whistle-blower feel  uncomfortable or intimidated. This practice has led to confusion regarding  the role and responsibilities of OAWP personnel. OAWP’s use of VA  employees that are employed at the facility under investigation in the  review of allegations creates the possibility of a conflict of interest or an  appearance of a conflict of interest. For example, in a case OSC  described in its comments on a draft of our report, an OAWP  representative who was also associated with the human-resource office  at the VISN that oversees the whistle-blower’s facility, placed the whistle- blower under oath and questioned her about issues unrelated to the  referred allegations. OSC has since sought clarification of OAWP’s role  and the OAWP employee’s possible connection to the VISN.

While VA collects data on some types of disciplinary actions, it is limited  in its ability to use those data because it does not collect all misconduct  and associated disciplinary-action data through a single information  system, or multiple interoperable systems. Absent a process to collect  such data department-wide, VA does not have the ability to analyze and  report data systematically. In addition, the data currently collected are not  always reliable or useful. The inclusion of appropriate documented  guidance and standardized field definitions would help to ensure VA  collects reliable misconduct and associated disciplinary-action data. With  high-quality information that is accurate and comprehensive, VA  management would be better positioned to make knowledgeable  decisions regarding the extent of misconduct occurring and how it was  addressed, department-wide.

VA has not ensured that program and facility human-resources personnel  adhere to policy governing documentation contained within evidence files  to support conclusions reached. In addition, VA often had no record of the  evidence involved with the adjudication of these actions and could not  verify whether these individuals received reasonable and fair due  process. The absence of documentation in some files also raises the  possibility that VA may not always be in compliance with its procedures  for governing the adjudication of alleged employee misconduct.  Additionally, ensuring that human-resources personnel adequately inform  employees of their rights during the adjudication process would provide  them with a reasonable opportunity to present their case when preparing  their defense. VA also does not consistently adhere to OPM and NARA  guidance in defining a specific retention period for adverse action files.  This results in an inconsistent retention of these files across VA which  complicates department-wide analysis.

VA’s inconsistent adherence to the standards provided by the OIG to  facilities and program offices for investigating and resolving misconduct  cases increases the risk that misconduct case are not being handled  appropriately. Additionally, the lack of verification of responses received  to ensure documentation supports findings and recommendations has  contributed to evidence that does not always meet the requirements  outlined by the OIG. Finally, timely responses are not consistently  provided when facility and program offices report findings to the OIG’s  Hotline Division.

OAR did not monitor whether substantiated instances of misconduct  involving senior officials received disciplinary action. OAR’s Legacy  Referral Tracking List also did not accurately reflect the disciplinary action  that was decided based on the results of the investigation. When  disciplinary actions are taken, in response to findings of misconduct, but  are not entered within an appropriate information system, or are  inaccurately recorded, it is more difficult to monitor whether disciplinary  actions have been implemented in substantiated instances of misconduct  involving senior officials. As demonstrated, this may result in no action  being taken for substantiated misconduct or the previous penalties not  having the corrective effect for repeat offenders. There is also an  increased risk that substantiated misconduct will go unaddressed if there  is no recommendation for corrective action. Further, VA also does not  have internal controls to ensure adherence to proper separation-of-duty  standards involving the removal of an employee. Such controls would  minimize the risk of abuse when officials act as both proposing and  deciding officials.

In addition, VA does not have oversight measures to ensure that all  allegations of misconduct referred by the OIG to facility and program  offices are investigated by an entity outside the control of the facility or  program office involved in the misconduct. The investigation of allegations  of misconduct by the program office or facility where the complaint  originated may present the appearance of a conflict of interest in which  managers and staff at facilities may investigate themselves or other  allegations where they may have a personal stake or bias in the matter to  be investigated. Therefore, the risk that the results of the investigation are  minimized, or not handled adequately, is increased. VA’s newly  developed process to communicate the scope of its reviews that involve  matters referred by the OSC to the Office of the Secretary will be  important to ensure any allegations outside the purview of the OIG’s  investigation are fully addressed by a departmental entity in accordance  with OSC requirements.

Further, the OIG’s inability to locate investigative documentation prevents  a third party from verifying whether the OIG examined the disclosures,  whether any recommendations were addressed, or whether appropriate  disciplinary action was taken for these cases. This lack of information has  direct influence on management’s ability to make sound decisions relating  to investigative matters. According to OIG officials, a spreadsheet is being  used for tracking case numbers associated with disclosures, but plans to  implement a process within the new system.

Nonanonymous whistle-blowers faced higher rates of adverse action  subsequent to their disclosure than the VA population as a whole. In  addition, these individuals also had attrition rates higher than their peers  who had not filed a disclosure. The disparities between whistle-blowers  and other employees may be an indication that retaliation by senior  officials may have occurred after misconduct was disclosed. Although VA  has started to provide additional information for potential whistle-blowers  who wish to report criminal or other activity to the OIG, VA does not have  a process to inform employees of how their information may be shared  between organizations when misconduct is reported. Without a clear  understanding of how the lines for reporting misconduct operate, whistle- blowers may be uncertain as to their options for reporting misconduct,  increasing the risk that they may not report workplace misconduct.

We are making the following 16 recommendations to VA.

The Secretary of Veterans Affairs should develop and implement  guidance to collect complete and reliable misconduct and associated  disciplinary-action data department-wide, whether through a single  information system, or multiple interoperable systems. Such guidance  should include direction and procedures on addressing blank data fields,  lack of personnel identifiers, and standardization among fields, and on  accessibility. (Recommendation 1)

The Secretary of Veterans Affairs should direct applicable facility and  program offices to adhere to VA’s policies regarding employee  misconduct adjudication documentation. (Recommendation 2)

The Secretary of Veterans Affairs should direct the Office of Human  Resource Management (OHRM) to routinely assess the extent to which  misconduct-related files and documents are retained consistently with  VA’s applicable documentation requirements. (Recommendation 3)

The Secretary of Veterans Affairs should direct OHRM to assess whether  human-resources personnel adhere to basic principles outlined in VA  Handbook 5021 when informing employees of their rights during the  adjudication process for alleged misconduct. (Recommendation 4)

The Secretary of Veterans Affairs should adhere to OPM and NARA  guidance and establish a specific record-retention period for adverse  action files. In doing so, the Secretary should direct applicable  administration, facility, and program offices that have developed their own  record-retention schedules to then adhere to the newly established  record-retention period. (Recommendation 5)

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)

The Secretary of Veterans Affairs should direct the Office of  Accountability and Whistleblower Protection (OAWP) to review responses  submitted by facility or program offices to ensure evidence produced in  senior-official case referrals demonstrates that the six elements required  in VA Directive 0701 have been addressed. (Recommendation 7)

The Secretary of Veterans Affairs should direct OAWP to issue written  guidance on how OAWP will verify whether appropriate disciplinary action  has been implemented for all substantiated misconduct by senior officials.  (Recommendation 8)

The Secretary of Veterans Affairs should direct OAWP to develop a  process to ensure disciplinary actions proposed in response to findings of  misconduct are recorded within appropriate information systems to  maintain their relevance and value to management for making decisions  and take steps to monitor whether the disciplinary actions are  implemented. (Recommendation 9)

The Secretary of Veterans Affairs should direct OAWP to issue written  guidance on how OAWP will review the disposition of accountability  actions for all substantiated misconduct cases involving senior officials  resulting from investigations. (Recommendation 10)

The Secretary of Veterans Affairs should implement internal controls to  ensure that proper adherence to separation-of-duty standards involving  the removal of an employee are consistent with policy. (Recommendation  11)

The Secretary of Veterans Affairs should develop oversight measures to  ensure all investigations referred to facility and program offices are  consistent with policy and reviewed by an official independent of and at  least one level above the individual involved in the allegation. To ensure  independence, referred allegations of misconduct should be investigated  by an entity outside the control of the facility or program office involved in  the misconduct. (Recommendation 12)

The VA Inspector General, in consultation with the Assistant Secretary of  OAWP, should develop a process to ensure that OSC case numbers are  linked to the investigative case number and final report.  (Recommendation 13)

The Secretary of Veterans Affairs should direct OAWP to develop a time  frame for the completion of published guidance that would develop an  internal process to monitor cases referred to facility and program offices.  (Recommendation 14)

The Secretary of Veterans Affairs should ensure that employees who  report wrongdoing are treated fairly and protected against retaliation.  (Recommendation 15)

The Secretary of Veterans Affairs should direct OAWP to develop a  process to inform employees of how reporting lines operate, how they are  used, and how the information may be shared between the OSC, the  OIG, OAWP, or VA facility and program offices when misconduct is  reported. (Recommendation 16)

We provided a draft of this report to the Department of Veterans Affairs  (VA), VA Office of Inspector General (OIG), and the Office of Special  Counsel (OSC) for review and comment. In its comments, VA concurred  with nine of our recommendations and partially concurred with five (see  app. VI for a copy of VA’s letter). Regarding our recommendations to the  Inspector General, the OIG concurred with one recommendation and  partially concurred with the other. The OIG also provided comments on  our findings (see app. VII for a copy of the OIG’s letter). We received  technical comments by e-mail from OSC’s Principal Deputy Special  Counsel, which we incorporated in the report as appropriate.

Regarding VA’s comments, in its response to our first recommendation  that the Secretary develop and implement guidance to collect complete  and reliable misconduct and associated disciplinary-action data  department-wide, VA concurred and outlined steps it plans to take to  address our recommendations. These steps include the creation of new  policies to address blank data fields, lack of personnel identifiers, lack of  standardization among fields, and accessibility issues related to  misconduct and associated disciplinary-action data department-wide. The  target date for system implementation, dependent on approved funding  and acquisition-related requirements, is January 1, 2020.

On our second recommendation, that the Secretary direct applicable  facility and program offices to adhere to VA’s policies regarding  employee-misconduct adjudication documentation, VA concurred. It  stated that a memorandum will be distributed to reiterate facility and  program-office requirements to adhere to VA Handbook 5021,  Employee/Management Relations, no later than October 1, 2018.

VA also concurred with our third recommendation, that the Secretary  direct the Office of Human Resource Management (OHRM) to routinely  assess the extent to which misconduct-related files and documents are  retained. According to VA, OHRM will assess, during periodic Oversight  and Effectiveness Service reviews, the extent to which misconduct- related files and documents are retained. The first assessment is to be  incorporated into the fiscal year 2019 Oversight and Effectiveness  Service schedule no later than November 1, 2018.

VA concurred with our fourth recommendation, that the Secretary direct  OHRM to assess whether human-resources personnel adhere to basic  principles outlined in VA Handbook 5021. VA stated that OHRM will  assess, during periodic Oversight and Effectiveness Service reviews,  whether human-resources and administration personnel adhere to basic  principles outlined in VA Handbook 5021. The first assessment is to be  incorporated into the fiscal year 2019 Oversight and Effectiveness  schedule no later than November 1, 2018.

In its response to our fifth recommendation, that the Secretary adhere to  Office of Personnel Management (OPM) and National Archives and  Records Administration (NARA) guidance and establish a specific record- retention period for adverse-action files, VA concurred and indicated that  the Human Resources and Administration Assistant Secretary will  establish VA guidance regarding the retention period for adverse-action  files. In addition, the Human Resources and Administration Assistant  Secretary is to advise applicable administration, facility, and program  offices that have developed their own record-retention schedules to  adhere to the newly established directive. According to VA, the directive  will be established no later than November 1, 2018.

VA partially concurred with our seventh recommendation, that the  Secretary direct departmental heads to review responses submitted by  facility or program offices to ensure evidence produced in senior-official  case referrals demonstrates that the six elements required in VA Directive  0701 have been addressed. VA stated that the process described in our  report pertaining to OIG findings or results will be changed to require all  such reports to be submitted to OAWP. VA also indicated that it expects  to publish new guidance by October 1, 2018, that will require the Office of  Accountability and Whistleblower Protection (OAWP) to review responses  and recommendations from facilities or program offices. Given VA’s  comments, we have revised our draft recommendation to have the  Secretary direct OAWP, not the department heads, to ensure evidence  demonstrates that the six elements have been addressed.

VA also partially concurred with our eighth recommendation, that the  Assistant Secretary of OAWP review all substantiated misconduct by  senior officials to verify whether disciplinary action has been  implemented. VA stated that all substantiated misconduct by senior  leaders in VA is handled by OAWP from intake, through investigation,  working with the proposing and deciding officials. VA also stated that it  expects to publish written guidance by October 1, 2018, that will clarify  how OAWP will work with the appropriate servicing personnel office to  ensure that the recommended disciplinary actions decided are  implemented for substantiated misconduct involving senior officials. Given  VA’s comments, we have revised our draft recommendation to have the  Secretary of Veterans Affairs direct OAWP to issue written guidance on  how OAWP will verify that appropriate disciplinary action has been  implemented for all substantiated misconduct by senior officials.

VA partially concurred with our ninth recommendation, that the Assistant  Secretary of OAWP develop a process to ensure disciplinary actions  proposed are recorded within appropriate information systems. VA  stated that the VA-wide discipline tracking system currently used by  OAWP will eventually be phased out. It added that once the Human  Resources Information System (HRSmart) is capable of capturing and  recording similar data, it will be used for this purpose. Accordingly, we  have not revised our draft recommendation.

VA partially concurred with our 10th recommendation, that the Assistant  Secretary of OAWP assess all misconduct cases involving senior officials  to ensure investigative reports with findings of substantiated misconduct  include recommendations for action. According to VA, OAWP has  instituted several processes since our review. VA plans to issue written  guidance that outlines the process for the review and disposition of  appropriate accountability actions for allegations of misconduct by senior  officials by October 1, 2018. Given VA’s comments, we have revised our  draft recommendation to have the Secretary of Veterans Affairs direct  OAWP to issue written guidance on how OAWP will review the disposition  of accountability actions for all substantiated misconduct cases involving  senior officials resulting from investigations.

In its response to our 11th recommendation, that the Secretary implement  internal controls to ensure that separation-of-duty standards involving the  removal of an employee are consistent with policy, VA concurred. It  stated that it will also establish and distribute internal controls to ensure  that separation-of-duty standards involving the removal of an employee  are consistent with policy no later than November 1, 2018.

VA partially concurred with our 12th recommendation, that the Secretary  take steps to ensure independence of referred allegations of misconduct  by requiring that investigations be conducted outside the control of the  facility or program office involved in the misconduct. VA stated that  OAWP is responsible for recording, tracking, reviewing, and confirming  the implementation of recommendations from audits and investigations.  However, VA did not address how it will ensure the independence of the  entity responsible for conducting an investigation. As we discuss in our  report, during the review OAWP officials stated that the process of  referring cases of misconduct back to facilities and program offices where  the misconduct occurred will continue. Accordingly, we have not revised  our draft recommendation and believe implementation of it will help  ensure independence.

VA concurred with our 14th recommendation, that the Assistant Secretary  of OAWP develop a time frame for the completion of published guidance  for the development of an internal process to monitor cases referred to  facility and program offices. VA provided an expected date of October 1,  2018, for publishing the internal VA guidance, with the subsequent  Directive and Handbook to be published as rapidly as staff coordination  permits.

In its response to our 15th recommendation, that the Secretary ensure  that employees who report wrongdoing are treated fairly and protected  against retaliation, VA concurred. It stated that OAWP and OSC have  developed a functional process to ensure whistle-blower protections are  implemented, but did not indicate what the process entails. The VA  Secretary has also delegated authority to the Executive Director, OAWP,  to put individual personnel actions on hold if the actions appear motivated  by whistle-blower retaliation. VA added that OAWP has also hired two  whistle-blower program specialists specifically to increase awareness of  whistle-blower protections and work with individuals that disclose  employee wrongdoing to ensure individuals are treated fairly and  protected from retaliation for their disclosures.

VA concurred with our 16th recommendation, that the Assistant Secretary  of OAWP develop a process to inform employees of how reporting lines  operate. VA stated that it will provide whistle-blower training to all  employees on a biennial basis, which will include the reporting lines for  disclosures of wrongdoing, the manner in which disclosures flow once  they are made, how information is shared among the whistle-blower  entities, and what protections exists for those who disclose wrongdoing.

Regarding our recommendations to the Inspector General, the OIG  partially concurred with our sixth recommendation, to 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. The OIG indicated that VA Directive  0701 is currently being updated to require a written or electronic signature  from the person preparing the responses as an attestation that the  specific requirements of the directive were met. The OIG also indicated in  its letter that the OIG’s Hotline staff carefully review the case response  but Hotline staff are not required to request an updated response from VA  to address matters not necessary to the resolution to the referral. The  OIG asserted that requesting an update would detract from the resources  for other important VA activities. On page 4 of the OIG’s letter, the OIG  states that Hotline analysts are allowed to exercise some discretion in  accepting responses that may include minor departures from the six  elements.

We continue to believe that, in order to have a complete response to a  referral, all six elements required by the directive should be addressed. In  addition, Directive 0701 does not allow for the use of professional  judgement to decide which elements to include or not to include in a  response. While we agree that requiring a written or electronic signature  from the person preparing the responses as an attestation will help  ensure that the specific requirements of the directive were met, we  maintain that not requiring Hotline analysts to review responses to ensure  that all elements of the directive are addressed is inconsistent with the  intent of the directive.

In its response to our 13th recommendation, that the OIG develop a  process to ensure that an OSC case number is linked to the investigative  case number and the final report, the OIG concurred. It stated that it will  engage with the Executive Director of OAWP to develop a process to  ensure that OSC case numbers are linked to OIG and OAWP  investigative case numbers, as appropriate, and linked to any final report  of investigation.

In addition to its response to recommendations, the VA OIG also raised a  number of concerns with our findings. Page 1 of its letter summarizes  some of these concerns and then provides more detail on each concern  raised, starting on page 2. Our responses to each of these detailed  concerns are provided below.

The OIG stated that our report does not focus on the most important  cases, but focuses primarily on case referrals regarding senior officials  that were not handled by the OIG because the allegations were lower risk  or because of resource constraints. In addition, the OIG stated that GAO  risks presenting a skewed picture of the OIG’s oversight work. We  disagree with this characterization of our findings. We requested that the  OIG provide us with data from the OIG’s Master Case Index (MCI)  information system that would allow us to select a sample of cases, in  accordance with the scope of our review. The OIG was unable to provide  the requested information due to several reasons. Instead, the OIG  provided data from the OIG Hotline and Office of Investigations case- management systems (subsystems within MCI) that contained a limited  number of fields for analysis and 23 cases pertaining to SES misconduct  that were referred to VA for investigation during GAO’s period of review.  Therefore, as we discuss in the report, we were only able to review the 23  senior-official misconduct cases included in our report because the OIG  was only able to provide related documentation for these cases. The OIG  stated that we only reviewed a sample of just 23 case referrals from fiscal  years 2011 through 2014. As described, we reviewed all 23 senior-official  misconduct cases that were referred to VA for investigation that the OIG  was able to provide us, not a sample.

The OIG stated that our report inaccurately states that the extracts  received from the MCI information system contained missing information.  We disagree with this characterization of our findings. Our review  included a comprehensive assessment of the reliability of the OIG’s data.  To conduct this assessment, we requested an explanation of each data  field to clarify when fields are normally populated and how they are used.  Our findings are consistent with the information provided in response to  this request. For example, the OIG’s response to our data-reliability  assessment stated that the data field used to identify the type of  allegations being investigated should never be blank. However, we found  that field to be blank in some cases in the data that were provided to us,  though the OIG asserted that the MCI information system is a relational  database where each case may be associated with multiple allegations  and codes. In response to the OIG’s comments on our report, we  requested supporting documentation to demonstrate that the fields  analyzed during our period of review did not contain missing data. The  OIG provided the MCI information system user’s manual that contains  detailed procedures for accessing and entering data into the MCI  information system, and a compilation of various internal documents.  However, the documentation did not provide evidence of the  completeness of data entered into the MCI information system as part of  quality-assurance reviews performed by the OIG or other designated  entity. Absent evidence of data-quality reviews aimed at assessing the  accuracy and completeness of data contained in the MCI information  system, we did not change the conclusions based on our previous  analysis.

The OIG stated that our report provides incomplete information regarding  sampled cases and mischaracterized one of the OIG’s case referrals in  the body of the report. We disagree with this characterization of our  findings. Specifically, the OIG said that we inaccurately stated that a  medical center director conducted the investigation into his own alleged  misconduct and found no allegations were substantiated. The synopsis  included in our report clearly articulates that the medical center director  was named in the allegation for having received a similar complaint  involving time and attendance abuse by a physician. The medical center  director, who provided the response to the OIG, was implicated in the  allegation as having not addressed a similar time and attendance  complaint regarding the same physician 2 years earlier. The OIG did not  provide any supporting documentation to demonstrate that the alleged  time and attendance abuse allegations against the physician were not  substantiated.

The OIG stated that our report inaccurately stated that the medical center  director conducted his own investigation of himself and found no  allegations were substantiated. We disagree. In response to the OIG’s  comments on our report, we requested that the OIG provide additional  support used to determine that the medical center director did not  investigate the allegation in which he was named. The additional case  documentation provided by the OIG further reaffirmed our assessment  that the medical center director performed his own investigation and  found no allegations were substantiated. Additional documentation  provided by the OIG indicated that the OIG referred the case to the  Veterans Integrated Service Network (VISN) for a response. However,  documentation we examined during the course of our audit, and the  documentation provided in response to our draft report, indicates that the  medical center director performed the investigation of the allegations and  then the results were routed through the VISN back to the OIG. The OIG  stated that routing the response through the VISN should address our  concerns of independence. This process does not address our concerns  regarding independence because VA Directive 0701 states that all  responses to Hotline case referrals must contain evidence of an  independent review by an official separate from and at a higher grade  than the subject / alleged wrongdoer. In this case, the name of the  medical center director who signed the facility response provided to the  OIG was the same individual named in the allegations.

The OIG stated that the report does not provide a balanced presentation  of the rigor with which the OIG reviews all incoming Hotline contacts and  case responses. We disagree with this characterization of our findings. As  described above, the OIG was unable to provide comprehensive data to  select a sample of OIG audits, evaluations, and inspections for review  due to the limitations cited. We focused on misconduct involving senior  officials consistently with the scope of our review and thoroughly reviewed  all 23 senior-official misconduct cases that were referred to VA for  investigation, which were the only cases that the OIG was able to provide.

The OIG stated that the description for one of the cases included in  appendix V of the draft report was incomplete because we misunderstood  the OIG’s process. We disagree with this characterization. In response to  the OIG’s comments on our report, we requested additional supporting  documentation. The documentation provided reaffirmed our assessment  that another medical center director performed his own investigation and  found no allegations were substantiated. Similar to the case described  above, the medical center director completed his own investigation and  then routed the response through the VISN back to the OIG. In contrast to  the previous case, however, the Hotline Workgroup reviewed the  response to the OIG and found it to be insufficient. Specifically, the OIG  noted that the medical center director who provided the response was the  subject of the complaint, despite the response being directed to the VISN,  and requested clarification. The VISN informed the OIG that it is not its  policy for the complainant to have any involvement in the review and data  submission on a case in which the complainant is involved. The VISN  stated that while this did obviously occur in this instance, it has taken  steps to ensure it does not occur in the future. The supporting evidence  provided for the case included in appendix V also contradicts the OIG’s  previous assertion that the routing of a response through the entity with  oversight (VISN) over the medical center director should have addressed  GAO’s concerns of independence.

The OIG stated our report provides a misrepresentation of the OIG’s  failure to follow internal policies for department responses. We disagree.  According to OIG statements on page 4 of the OIG’s letter, Hotline  analysts are allowed to exercise some discretion in accepting responses  that may include minor departures from the six elements required in VA  Directive 0701. We continue to believe that in order to have a complete  response to a referral, all six elements required by the directive should be  addressed. On the basis of our review, the OIG does not have an  effective method to ensure that cases referred to VA are reviewed in  accordance with VA Directive 0701. Out of the 23 cases we reviewed,  only 4 included sufficient documentation needed to support VA’s findings,  and we could not identify a case that contained all six elements required  in VA Directive 0701. This suggests that the current OIG review process  is not adequately resolving case referrals, as asserted by the OIG’s  response. In addition, VA Directive 0701 does not currently include a  provision that would allow Hotline analysts to deviate from the six  required elements. As stated in our report, the OSC also raised concerns  regarding 40 percent of disclosure cases that were referred to VA facility  and program offices.

The OIG stated that much of the information in the draft report is dated  and ignores system updates, specifically several key Hotline-related  process improvements since 2014. Although our review began in 2015,  we disagree with this characterization of our findings. In our report, we  included relevant improvements to demonstrate where the OIG was able  to provide support for those improvements. For example, our report  discusses: (1) a new process for communicating the scope of reviews that  involve matters referred by the OSC to the Office of the Secretary, (2) a  description on the VA website of the process for employees who wish to  report criminal or other activity to the OIG, (3) a new Enterprise  Management System, and (4) a new process for receiving whistle-blower  disclosures by the Secretary. In response to the OIG’s comments on our  report, we requested additional documentation for any systems, practices,  or personnel changes that have been implemented since 2011, including  improvements to Hotline-related processes since 2014 that were not  included in our report. In response, the OIG provided a copy of the OIG’s  organizational chart (current as of Apr. 23, 2018), described the oversight  responsibilities of each OIG component, and summarized the pertinent  staff positions within each component. On the basis of this  documentation, we identified a new office (the Office of Special Reviews),  a promotion, staff reassignments, and numerous vacancies during our  review period. However, the OIG did not provide evidence of any  measures to improve the MCI information system, case-referral  processes, or relevant staff roles that were not already included in our  report.

As described above, the OIG was unable to provide comprehensive data  to select a sample of OIG audits, evaluations, and inspections for our  initial review due to the limitations cited. In response to the OIG’s  comments on our report, we requested documentation related to any  significant changes that have been made to the MCI information system  that allows the OIG to identify all allegations of misconduct for export and  analysis. The OIG provided additional information regarding overall  departmental achievements that are highlighted in the OIG’s Semiannual  Report to Congress, and other products from its website published  between fiscal years 2011 through 2018. We recognize the OIG’s broader  administrative and oversight work described in the published reports.  However, this information does not address changes specifically made to  the MCI information system that would enable the OIG to analyze cases  pertaining to alleged misconduct by senior officials that we requested.

We are sending copies of this report to the appropriate congressional  committees, the Secretary of Veterans Affairs, and other interested  parties. In addition, the report will be available at no charge on the GAO  website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact  me at (202) 512-5045 or larink@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report.

Appendix I: Objectives, Scope, and Methodology

Our objectives were to determine the extent to which the Department of  Veterans Affairs (VA) (1) collects reliable information associated with  employee misconduct and disciplinary actions that is accessible and  could be used to analyze misconduct department-wide; (2) retains  documentation that demonstrates VA adheres to its policies when  adjudicating cases of employee misconduct; (3) ensures allegations of  misconduct involving senior officials are reviewed in accordance with VA  investigative standards, and these officials are held accountable; (4) has  procedures to investigate whistle-blower allegations of misconduct; and  the extent to which (5) data and whistle-blower testimony indicate  whether retaliation for disclosing misconduct occurs at VA.

For the first objective, we obtained VA employee misconduct data from 12  information systems operated by various VA components covering  October 2009 through July 2017, where available. To determine the  reliability of VA’s misconduct data, we analyzed the contents of the 12  information systems operated by various offices across VA. These data  encompass each of the three major administrations that constitute VA— the National Cemetery Administration (NCA), Veterans Benefits  Administration (VBA), and Veterans Health Administration (VHA). We  selected the information systems based on our discussions with VA  officials and staff that oversee the data and, hence, identified databases  capable of collecting information pertaining to either employee  misconduct or disciplinary actions. Data fields were selected based on  whether they would provide beneficial information to better understand  the disciplinary process.

VA’s Personnel and Accounting Integrated Data (PAID) system, which  was developed to track payroll actions, contains information about  adverse disciplinary actions that affect employee salary department-wide.  We obtained an extract of all adverse disciplinary actions from the PAID  system.

We assessed the reliability of each system for the purposes of identifying  and tracking misconduct cases. To do this, we performed electronic tests  on 12 information systems to determine the completeness and accuracy  of the fields contained in the data files. We also submitted to the  overseeing offices for all 12 information systems general data-quality  questions regarding the purpose of the data, their structure, definitions  and values for certain fields, automated and manual data-quality checks  to ensure the accuracy of the data, and limitations. As discussed further,  the data were generally not reliable for a department-wide assessment of  all misconduct and disciplinary actions due to the lack of completeness  and compatibility of the data across all information systems. VA staff  could not confirm whether some of the missing data we identified were  artifacts of the database extraction process VA used to assemble the data  files we used in our review. Despite challenges with aspects of the data,  we found the data sufficiently reliable for conducting analysis where fields  were populated and field definition concurrence was obtained by program  offices.

For the second objective, we selected a generalizable stratified random  sample of 544 misconduct cases from October 2009 through May 2015.  Where available, we reviewed the employees’ disciplinary-action files and  Electronic Official Personnel Folders to determine the extent to which  VA’s actions were consistent with disciplinary policy outlined in VA  Handbook 5021, Employee/Management Relations. These data  encompass each of the three major administrations that constitute VA— NCA, VBA, and VHA. We determined the data to be sufficiently reliable  for analysis of disciplinary actions affecting salary that resulted from  misconduct that was not reported to supervisors directly from employees.  Accordingly, our sample only includes misconduct cases that resulted in a  change in salary or were reported to departmental organizations within  the 12 information systems selected.

We developed a data-collection instrument to document the results of our  case reviews. We revised our data-collection instrument to address  issues found during the course of our analysis, and developed a  companion document that outlined the decision rules for reviewing cases.

We also designated two primary reviewers to ensure the decision rules  were consistently applied across all cases.

Our review of laws and regulations revealed that disciplinary rules  sometimes vary depending on whether employees fall under Title 5, Title  38, or hybrid Title 5 and Title 38 hiring authority. To minimize confusion  associated with these differences, we incorporated criteria into our data- collection instrument. In addition, we were unable to obtain complete case  information for 25 percent of the cases. For these cases, we obtained  direct access to the Office of Personnel Management’s (OPM) Electronic  Official Personnel Folders system to attempt to recover some of the  missing information. Ultimately, we were unable to complete our review  for 10 percent of cases in our sample because of missing files.

In addition to reporting missing case information, we used our  generalizable analysis results to project VA-wide figures for several data  elements that were not in compliance with VA policy. Unless otherwise  noted, estimates in this report have a margin of error of +/-7.4 percentage  points or less for a 95 percent confidence interval.

For the third objective, we analyzed data from the Office of Accountability  Review (OAR) Legacy Referral Tracking List and VA Office of Inspector  General (OIG) case-referral and investigative case-management  systems, and we selected cases for in-depth review. We selected these  two systems based on discussions with VA officials who were  knowledgeable with databases that have the capacity to track misconduct  information pertaining to senior officials. The OAR Legacy Referral  Tracking List comprises referrals from January 2011 through May 2015.  The OIG provided 23 case-referral files involving senior officials from  calendar years 2011 through 2014. As part of our review of the OIG case  files, we evaluated specific data elements contained in VA’s response  documents using VA policy for referring and reviewing misconduct  cases.

We assessed the reliability of the OAR Legacy Referral Tracking List and  OIG case-management systems for the purposes of identifying and  tracking misconduct cases. To do this, we performed electronic tests on  each database to determine the completeness and accuracy of the fields  contained in the data files, including senior-official indicators. Where  feasible, we opted to match individual datasets to PAID to determine  whether disciplinary actions were administered as prescribed. We also  submitted to OAR and the OIG general data-quality questions regarding  the purpose of the data, their structure, definitions and values for certain  fields, automated and manual data-quality checks to ensure the accuracy  of the data, and limitations. On the basis of this information, we found the  OAR data to be sufficiently reliable for conducting analysis where fields  were sufficiently populated.

For the OAR data, we matched the persons of interest to adverse-action  files from PAID to determine whether adverse disciplinary actions were  administered as prescribed during the available time frame (January 2011  through May 2015). We also obtained VA’s response documents for the  23 case-referral files provided by the OIG to evaluate whether VA was  adhering to its own policy for referring and reviewing misconduct cases.

Through our OAR Legacy Referral Tracking List analysis, we identified  illustrative case examples of misconduct involving senior officials. Further,  based on our evaluation of the 23 OIG case referrals using VA’s referral  policy, we developed several illustrative case examples.

For the fourth objective, we interviewed senior officials from VA and the  OSC responsible for investigating whistle-blower complaints. We obtained  the OSC’s procedures for referring disclosure complaints and VA’s policy  for investigating these complaints once received at the agency. In  addition, we obtained whistle-blower disclosure data from the Office of  Special Counsel (OSC) covering calendar years 2010 through 2014. To  determine the reliability of the data, we conducted electronic testing and  traced data elements to source documentation. We determined the data  to be sufficiently reliable to identify the total number of cases that were  investigated by the OIG, or referred to facility and program offices. We  also observed a course to assess VA’s training provided to VA employees  conducting investigations.

We identified 135 OSC disclosure cases for analysis based on two  criteria: (1) they contained at least partial complainant information (i.e.,  the allegations were not anonymously reported or could be identified with  supplemental information) and (2) they contained an indicator that the  case had been closed by the OSC pending an ongoing investigation by  VA or the OIG. These cases represent the universe of VA disclosures  accepted by the OSC. Of the 135 disclosure cases referred to VA, 53  cases were referred to VA facility and program offices for further  investigation. The remaining 82 disclosure cases indicated that they were  investigated by the OIG. We reviewed the results of OSC’s assessment of  investigative documentation developed by VA for these whistle-blower  disclosure cases.

For the fifth objective, we analyzed the 135 whistle-blower disclosure  cases obtained from the OSC. These cases represent the universe of VA  disclosures accepted by the OSC from calendar years 2010 through  2014, which were investigated by VA. We obtained an extract of year-end  rosters from the PAID system as of September for fiscal years 2010  through 2014, with a final extract through May 30, 2015. Finally, we  interviewed representatives from whistle-blower advocacy groups, as well  as established whistle-blowers who disclosed wrongdoing or retaliation at  VA and who were referred to us by one advocacy group.

Of the 135 disclosures received by the OSC, a total of 129 employees  made a total of 130 disclosures nonanonymously. For these 130  disclosure cases, we reviewed OSC and OIG investigative reports, as  well as PAID roster files, to gather additional information to perform  analysis of potential retaliation. We also interviewed six individual whistle- blowers with formal disclosure cases accepted by the OSC, indicating  that the OSC had previously reviewed the case and determined that it  contained sufficient evidence and merit to warrant further investigation.

Our analysis of potential retaliation comprised two parts. First, we  compared the 129 employees associated with the selected OSC cases to  the PAID rosters using the complainants’ information to determine  whether employees associated with the selected OSC cases were more  likely to leave the agency. We identified the overall count and proportion  (across years) of roster-matched employees who made a disclosure  between fiscal years 2010 through 2014 but were not employed at VA the  following fiscal year. Second, to determine whether employees  associated with the selected OSC cases were more likely to receive  disciplinary action, we also calculated the yearly totals and proportion of  roster-matched employees identified above for whom a record existed in  the PAID disciplinary action information system. We did this by comparing  the proportion of employees who received one or more disciplinary  actions in the year prior to the appearance in the roster, in the same fiscal  year as the roster, and in the subsequent fiscal year. We also completed  this analysis utilizing the PAID roster file to determine the yearly  proportion of all VA employees who left the agency. On the basis of the  results of our analysis, we reported by fiscal year the percentage of  whistle-blowers that received disciplinary action or left VA at a higher rate  than the overall VA population following a disclosure.

To address all objectives, we interviewed senior officials from VA’s major  components responsible for investigating and adjudicating cases of  employee misconduct. We also reviewed standard operating procedures,  policy statements, and guidance for staff charged with investigating and  adjudicating allegations of employee misconduct.

We conducted this performance audit from January 2015 to May 2018 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.

Appendix II: Department of Veterans Affairs (VA) Data Files and Corresponding Data Fields That Are Missing Information

Office of Accountability Review (OAR)—Legacy Referral Tracking List

This data file is designed to track referrals made to OAR, including  allegations of misconduct related to senior officials. Through our analysis  of this spreadsheet, we identified 11 fields out of 92 that were missing  information that could be used to analyze misconduct.

Complainant #1 (First Name) (20 percent of 1,245 blank)— According to OAR, this field is populated when there is a known  complainant for a matter. Some matters referred to OAR may be  anonymously disclosed and not contain complainant information. This  file also contains a case-origin field that specifies whether a case was  anonymous. Our review of both the complainant and case-origin field  indicated that only 11 percent of the complaints were generated from  an anonymous source, and the remaining records should have  included a complainant name.

Disciplinary Action (96 percent of 1,245 blank)—This field should  be populated to indicate whether a disciplinary action was taken after  the completion of an investigation.

Grade (97 percent of 1,245 blank)—According to OAR, this field  should be populated with the grade of the Person of Interest (POI), if  known. Our review of this field indicated that 97 percent were blank,  therefore we were unable to analyze the variation in grade level for  officials who were the subject of complaints.

OAR Action (77 percent of 1,245 blank)—According to OAR, this  field should be populated as an internal reference to describe what  stage in the administrative process the matter was in when received.  The lack of information did not allow for analysis of the types of  actions taken for each case.

Person of Interest (POI) (47 percent of 1,245 blank)—This field  specifies the first and last name of the Department of Veterans Affairs  (VA) employee who is the subject of an allegation.

POI (Person of Interest) Last Name 1–5 (51 to 99 percent of 1,245  blank)—This field specifies the last name of VA employee who is the  subject of an allegation. There are a total of five person-of-interest  (POI) fields for each matter. According to OAR, blank POI fields occur  when the case has fewer than five POIs or the POI was not specified  in the matter referred. Our review of the five POI fields indicated that  more than half of the records did not contain at least one POI because  no individual was specified. The lack of information did not allow for  further investigation of senior-level officials involved in misconduct.

Proposed Action (97 percent of 1,245 blank)—According to OAR,  this field should be populated to notify OAR staff if any disciplinary  action was proposed. Our review of this field indicated that 97 percent  were blank, suggesting that very few high-level officials received  corrective action, or the field was not consistently completed for each  record. Due to the large share of blank values, the data posed  limitations when analyzing how many senior officials received  corrective action as a result of a complaint.

Office of Accountability Review (OAR)—VA-Wide Adverse Employment Action Database

This data file is designed to track misconduct and disciplinary actions  taken against VA employees. Through our analysis of this spreadsheet,  we identified 9 fields out of 21 that were missing information that could be  used to analyze misconduct.

Action Taken (3 percent of 9,851 blank)—According to OAR, this  field should be populated with the action that the deciding official  takes, with the exception of pending actions. If there is a pending  action, this field will remain blank. Our review of the action-taken field  found three records that were annotated as a “pending decision”  within this field, which indicates that there is an option for entering  information into this field when there is an action pending and the field  should never be blank.

Admin Leave (30 percent of 9,851 blank)—According to OAR, this  field should be populated if an employee is placed on administrative  leave while an adverse action is pending. If an employee is not placed  on administrative leave, the field may be left blank. Our review of the  admin-leave field found that about 66 percent of the records were  annotated as “no” within this field, which indicates that there is an  option for entering information into this field when an employee was  not placed on administrative leave.

Date Proposed (11 percent of 9,851 blank)—According to OAR, this  field is used when an adverse action is proposed for an employee.  There are some actions that are not proposed, such as probationary  terminations or admonishments that may be taken without being  proposed, and therefore result in this field being blank. Our analysis  found that about 95 percent of these records containing blank  proposed date fields also had an entry in the proposed adverse-action  field, which contained such entries as removals, suspensions, and  demotions that require a proposed date.

Deciding Official (14 percent of 9,851 blank)—According to OAR,  this field should be populated with the name of the official who issued  the action taken.

Effective Date (5 percent of 9,851 blank)—According to OAR, this  field should be populated with the date of the action taken. Some  entries will not have an effective date if an entry is pending decision.  Also, if no action is taken, the decision was counseling, or the  proposed action was rescinded, this field may not have an effective  date. Our review found that about 14 percent of the cases that  included adverse actions, such as a suspension, removal,  reassignment, or demotion, and that should have included a date of  action, were blank.

Offense 2 and 3 (79 and 95 percent of 9,851 blank)—According to  OAR, this field tracks the second- and third-most-significant charge  against the employee when applicable.

Proposing Official (16 percent of 9,851 blank)—According to OAR,  this field should be populated with the name of the official who makes  the proposed adverse action. Instances where a proposing official has  left the agency at the time of entry and could not be found in the  lookup feature that relies on the e-mail global address list may  produce blank fields. Also, disciplinary actions that were taken without  proposal would not have a proposing official. In these instances, the  human-resources specialists who enter the actions are instructed to  include the name in the other-comments box. Our review of these  records indicated that a majority of records lacking an entry in the  proposing official field also lacked an annotation in the other- comments field to accurately identify the proposing official.

Settlement (14 percent of 9,851 blank)—According to OAR, this  field tracks whether a settlement agreement occurred.

Office of Inspector General (OIG)— Master Case Index

This data file is designed to collect allegations of criminal activity, waste,  abuse, and mismanagement received by the OIG Hotline Division.  Through our analysis of this information system, we identified one field  out of seven that was missing information that could be used to analyze  misconduct.

Nature of Complaint (54 percent of 896 blank)—According to the  OIG, this field should contain a brief description of the issue that most  closely matches the allegation. Each case can have more than one  nature of complaint and corresponding administrative action, if any.  OIG officials stated that this field identifies the type of allegations  being investigated and should never be blank. Our review of these  cases found that over half of the cases involving the OIG contained  entries for administrative action taken, but the nature-of-complaint  fields corresponding to these actions were blank.

Veterans Benefit Administration (VBA)—Misconduct and Disciplinary Action Report

This data file is designed to track misconduct and disciplinary action  taken against VBA employees. Through our analysis of this spreadsheet,  we identified 3 fields out of 20 that were missing information that could be  used to analyze misconduct.

Alleged Offense 2 and 3 (92 and 99 percent of 1,375 blank)— According to VBA officials, this field should be populated if an  individual is charged with multiple offenses, or has additional offenses  in the same reporting period. In most instances, there is typically only  one offense at the time of reporting.

Sustained (52 percent of 1,375 blank)—According to VBA, this field  should be populated if an offense is sustained at the time of reporting.

Office of Accountability and Whistleblower Protection (OAWP)— VA-Wide Adverse Employment Action and Performance Improvement Plan Database

This data file is designed to track all allegations of misconduct and  associated disciplinary actions taken against VA employees. Through our  analysis of this spreadsheet, we identified 8 fields out of 34 that were  missing information that could be used to analyze misconduct.

Deciding Official (3 percent of 5,571 blank)—According to OAWP,  this field should be populated with the name of the official who makes  the decision for adverse action.

Detail Position (89 percent of 5,571 blank)—According to OAWP,  this field should be populated with the position an employee was  detailed to if removed from official position.

Offense 2 and 3 (69 and 91 percent of 5,571 blank)—According to  OAWP, this field tracks the most-significant charges against the  employee. If there are fewer than three charges, these fields are left  blank.

Offense 1 Sustained (14 percent of 5,571 blank)—According to  OAWP, this field should be populated if an individual’s first offense  has been sustained.

Offense 2 and 3 Sustained (73 and 91 percent of 5,571 blank)— According to OAWP, these fields should be populated if an  individual’s second and third offenses have been sustained. The  majority of cases only involve one offense.

Proposing Official (9 percent of 5,571 blank)—According to OAWP,  this field should be populated with the name of the official who makes  the proposed adverse action.

Appendix III: Department of Veterans Affairs (VA) Data Files and Corresponding Data Fields That Lack Standardization

Office of Resolution Management (ORM)—Complaints Automated Tracking System

This data file tracks Equal Employment Opportunity (EEO) discrimination  complaints. Through our analysis of this information system, we identified  1 field out of 66 that did not have standardization that could be useful to  analyze misconduct.

Employment—We found that the values for this field were not  mutually exclusive, or independent of one another. For example, this  field includes two distinct categories of information: employment  status, such as full time or part time; and hiring authority, such as Title  5 or Title 38. This method of storing information resulted in  undercounting each of the separate values due to the system’s failure  to account for expected overlap. For instance, an employee could be  both a full-time and Title 5 employee and the field only tracks one or  the other. ORM officials stated that this field has since been modified  to capture more options to account for the overlap.

This data file is designed to track misconduct and disciplinary actions  taken against Department of Veterans Affairs (VA) employees. Through  our analysis of this spreadsheet, we identified 1 field out of 21 that did not  have standardization that could be useful to analyze misconduct.

Position—We found the VA-Wide Adverse Employment Action  Database contained variations within this field, such as multiple  values for the “Cemetery Caretaker” position name. According to  OAR, this field is a free-text field, and the office conducts manual  searches to review and analyze position titles when needed. Our  review found that the different variations in position titles made it  difficult to successfully determine the frequency and nature of  allegations by position.

This is an information system designed to collect allegations of criminal  activity, waste, abuse, and mismanagement received by the OIG Hotline  Division. Through our analysis of this data file, we identified 1 field out of  7 that did not have standardization that could be useful to analyze  misconduct.

Nature of Complaint—Our review of the Master Case Index file  found variations of similar values in this field. For example, this field  contained 21 different claim types pertaining to similar types of fraud,  which made it difficult to assess the frequency and nature of claims  entered into the system. OIG officials stated that they do not attempt  to account for these variations or assess the frequency of use  because they are assigned based on a “best match” to the allegations  of the case.

This data file is designed to track misconduct and disciplinary action  taken against VBA employees. Through our analysis of this spreadsheet,  we identified 1 field out of 20 that did not have standardization that could  be useful to analyze misconduct.

Position—Our review found some duplication and overlapping values  among this field. For example, the position title for “service  representative” contained 21 similar categories with numerous  variations in spelling (i.e., Veteran Service Representative vs.  Veterans Service Representative, and Rating Veteran Service  Representative vs. Rating Veterans Service Representative). We  were unable to verify the number of distinct positions due to the lack  of standardization within this field.

This data file is a tracking spreadsheet for monitoring misconduct and  disciplinary action workload. Through our analysis of this spreadsheet, we  identified 5 fields out of 12 that did not have standardization that could be  useful to analyze misconduct.

Action Proposed/Decided/Taken—We were unable to analyze this  data field because the action taken was tracked in one single field and  updated with the most-recent action, rather than each distinct action  being entered in a separate field. Consequently, we were not able to  distinguish those cases where corrective action may have been taken,  to verify whether the corrective action had been implemented.

Current Status—We were unable to analyze this data field because it  was not a standardized field. For example, we were unable to  determine the total number of cases that were closed, open, or  pending due to the variations in the data field (e.g., Open, open, open  – pending, open-pending).

Full Name of Employee, Grievant, Appellant, Complainant, Non- Employee—We were unable to distinguish whether the individual  filing a complaint was an employee, grievant, appellant, complainant,  or nonemployee because the information entered into this single field  only provided the employee’s full name and did not provide a  distinction as to which category the record was assigned, as indicated  by the field name.

NCA Facility—We were unable to analyze this data field because it  was not a standardized field. For example, we were unable to run  demographic information on the different facilities involved because  this field contained erroneous information. Examples of erroneous  information included the name of the Memorial Service Network in  one case, and the region, rather than the facility name, in another.

Supervisor Name—We were unable to analyze this data field  because it was not a standardized field. For example, we were unable  to determine the total number of supervisors that were associated with  each case due to the variations in the names entered within this field,  which included misspelled first or last names, addition/omission of  middle initials, or no first name.

Client Service Response Team (CSRT)—ExecVA

This data file is a tracking spreadsheet for all allegations received by the  VA Secretary regarding misconduct, patient care, or other wrongdoing.  Through our analysis of this spreadsheet, we identified 1 field out of 9 that  did not have standardization that could be useful to analyze misconduct.

Subject—Our review of this tracking spreadsheet found over 380  different possible categories that could be assigned to one record.  These categories contained a significant number of variations. For  example, we found 38 different categories that contained possible  EEO-related issues such as “EEO/Whistleblower,” “Potential EEO,”  and “EEO Violations.” We were unable to distinguish the different  subject categories for this field due to the lack of standardization.  CSRT officials stated that ExecVA reports contain only data  corresponding to specific search criteria.

Office of Security and Law Enforcement (OS&LE)—Veterans Affairs Police System (VAPS)

This is an information system for tracking allegations of misconduct at all  VA facilities that include violation of law and misdemeanors. Through our  analysis of this data file, we identified 3 fields out of 29 that did not have  standardization that could be useful to analyze misconduct.

Classification—We found that this field contained at least three  different variations of assault categories (i.e., assault, assault-other,  and assault-aggravated). VAPS officials stated that this field is  determined and entered by the user.

Crime Type—We found this field contained at least five different  variations of alcohol-consumption categories, such as “entering  premises under the influence” and “alcohol – under the influence.”  VAPS officials stated that this field is determined and entered by the  user.

Final Disposition—We found this field contained at least two  different variations of charge type (i.e., charged, charged – Issued  Ticket), six different variations of open type (for example,  open/referred to Court, open/cvb), and two different variations of  closed type (i.e., closed, case closed). VAPS officials stated that this  field is determined and entered by the user.

This data file is designed to track all allegations of misconduct and  associated disciplinary actions taken against VA employees. Through our  analysis of this spreadsheet, we identified 1 field out of 34 that did not  have standardization that could be useful to analyze misconduct.

Position Title—We found this field contained at least 15 different  variations of Registered Nurse, such as “Registered Nurse,” “Staff  RN,” and “RN.”

Appendix V: Illustrative Case Examples of Senior-Official Misconduct during Calendar Years 2011 through 2014

Allegations surrounding inadequate staffing, patient care, and safety at a  Department of Veterans Affairs (VA) emergency room were investigated  by the medical center director of the facility. The medical center director  found that the inadequate patient care and safety issue was  unsubstantiated based on a review of patient safety incidents for the last  6 months. The medical center director did not provide a copy of her report  review to support this conclusion. She also indicated that an external  consultant was hired to assess staffing issues, and found generally that  improvements could be made for staffing to address surge capacity. The  director stated the medical center was in the process of implementing the  recommendations made by the consultant, but her response did not  discuss the specific improvements planned or include the external  consultant’s report.

A fact-finding was performed by a panel comprised of VA Connecticut  Healthcare System officials in response to alleged violations of law, gross  mismanagement, and waste of funds that included the improper billing of  services for a Las Vegas conference and paying contracts through a VA  nonprofit corporation to handle such expenditures. The allegations  specifically requested a cost-benefit analysis for the conference location.  The response received from the program office stated that an outside  accounting firm performs an annual financial audit of the VA nonprofit  corporation and found no material issues. Neither a copy of the annual  financial audit nor a cost-benefit analysis was provided in the response as  support. Additionally, the response did not address allegations regarding  the status of several essential positions vacated over the prior 3 years.

Allegations involved time-and-attendance abuse by a physician who was  accused of not responding to calls from peers or coming into the clinic, in  favor of his private practice. According to the complainant, physician  assistants (PA) examine the physician’s patients at the clinic for him. The  medical center director, who was also named in the allegation as having  received a similar complaint against the physician 2 years earlier,  reviewed the case against the physician and himself. The medical center  director’s response claimed that the location indicated in the allegation  was not a private practice, but rather a location where the physician  reviews medical records and sometimes serves as an expert witness. He  did not provide evidence to support his claim. The medical center director  also stated that he had not received any reports against the physician for  missed calls or clinics and that PAs are expected to participate in these  activities. However, he did not provide the physician’s work log, or the PA  position descriptions showing that they are allowed to perform these  functions autonomously. Finally, the medical center director claimed he  did not recall the allegation made against the physician 2 years prior and  neither formally substantiated nor disproved the current allegations  against the physician. No recommendations were made.

The medical center director was accused of hiring an unqualified  individual to a Quality Manager position due to their romantic relationship.  The response received from the human-resources consultant noted that it  was unusual to find a Nurse II manager with only an associate’s degree,  but was not illegal, and the employee was qualified based on prior  experience. Concerns were also raised concerning the medical center  director’s use of over $400 in government funds to “soundproof” the  Quality Manager’s office, including having panels attached to one wall  and the hollow office door replaced with a solid door. The Chief of  Engineering Services was interviewed regarding the request and stated it  was an odd request, and the first time he was asked to soundproof an  administrative employee’s office. The response provided by the program  office did not address why the director used government funds to  soundproof the Quality Manager’s office. The response provided also did  not address whether recommendations that the Quality Manager’s  retention allowance be reviewed for compliance and that she be  counseled for appropriate office dress code were implemented.

The medical center director was alleged to have misrepresented a plan to  track and provide mental-health services to veterans in non-VA hospitals  and created a hostile work environment against African-American  veterans and employees. The medical center director investigated the  allegations against himself and provided a response that was eventually  submitted late to the OIG. His response indicated that a review was  completed and all allegations were unsubstantiated. Several documents  provided with his response showed that only 12 contacts were made to  veterans with mental-health care needs during the requested 24-month  period, the percentage of patients experiencing wait times greater than 14  days before receiving mental-health services averaged 18 percent, and  two veteran suicides occurred. The medical center director did not  address allegations of creating a hostile work environment for African  American veterans and employees.

The medical center director improperly reannounced a vacancy in order  to hire an individual with whom he allegedly had a close personal  relationship to an Assistant Director position. He also requested the  master key to the facility be issued to her against regulations. The  allegation involving the master key was substantiated, but the Deputy  Under Secretary who conducted the investigation stated that while there  was no record of the key being returned, the key was returned and the  general engineer brought the facility into compliance with VA regulations.  Nonetheless, the Deputy Under Secretary found that a master key was  issued in violation of policy, but no recommendations were made to the  medical center director for corrective action.

Allegations involved false patient wait-time documentation and abuse of  authority. Specifically, a medical center director instructed staff to falsify  patient wait times between follow-up appointments in order to meet VA’s  14-day timeliness metric. The investigation concluded that the false  documentation allegation was substantiated, but attributed the cause to  staff not understanding how to enter a follow-up appointment date into the  system. It was also concluded that the correction of several hundred  dates in the system improved the performance of the department for the  national wait-time metric. However, no documentation was provided to (1)  prove the medical center director had not abused his authority by  instructing staff to review wait times greater than 14 days to determine  how they could be reduced, and (2) support the conclusion that the  original wait times were entered in error.

Appendix VI: Comments from the Department of Veterans Affairs

Appendix VII: Comments from the Department of Veterans Affairs Office of Inspector General

Appendix VIII: GAO Contact and Staff Acknowledgments

In addition to the contact above, Dave Bruno (Assistant Director), Erica  Varner (Analyst in Charge), Hiwotte Amare, Chris Cronin, Carrie  Davidson, Ranya Elias, Colin Fallon, Mitch Karpman, Grant Mallie, Anna  Maria Ortiz, Sabrina Streagle, Reed Van Beveren, and April Van Cleef  made key contributions to this report.

Employee misconduct at VA's medical facilities can have serious consequences for veterans. We looked at how VA deals with employee misconduct and found several opportunities for improvement. For example:

VA doesn't always maintain required files and documents for adjudication, suggesting that employees may not have received due process.

VA officials found guilty of misconduct sometimes received a lesser punishment than recommended or no punishment.

Whistleblowers were 10 times more likely than their peers to receive disciplinary action within a year of reporting misconduct.

We made recommendations to address these and other issues we found.