DEPARTMENT OF 

VETERANS AFFAIRS

Actions Needed to 

Address Employee 

Misconduct Process 

and Ensure 

Accountability

Report to Congressional Requesters

July 2018

GAO-18-137

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-18-137, a report to 

congressional requesters

July 2018

DEPARTMENT OF VETERANS AFFAIRS

Actions Needed to Address Employee Misconduct 

Process and Ensure Accountability

What GAO Found

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. 

View GAO-18-137. For more information, 

contact Kathy Larin at (202) 512-5045 or 

larink@gao.gov.

Why GAO Did This Study

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 whistleblower 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 whistleblower disclosures from 2010 to 2014.

What GAO Recommends

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). 
Action Proposed in Department of Veterans Affairs (VA) Office of Accountability Review’s 

Legacy Referral Tracking List Compared with Final Action Taken

a

Adverse action.

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. 

Comparison of Adverse Disciplinary Action Taken for Nonanonymous Department of Veterans 

Affairs (VA) Employees Who Reported Wrongdoing and Those Who Did Not, 2010–2014

Employee category Percentage for whom adverse actions were taken

Prior to 

disclosure

Year of 

disclosure

Year after 

disclosure

Individuals who filed a disclosure 2 10 8

Rest of VA 1 1 1

Source: GAO analysis of VA data. | GAO-18-137

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 whistleblowers, such as being denied access to computer equipment necessary to 

complete assignments. 

What GAO Recommends

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.
Page i GAO-18-137 Department of Veterans Affairs

Letter 1

Background 5

Employee Misconduct and Disciplinary Action Data Are Hampered 

by Completeness and Data-Reliability Issues 13

VA Does Not Consistently Adhere to Policies for File Retention 

and Adjudication Documentation Pertaining to Employee 

Misconduct Allegations 25

Investigative Standards Were Not Consistently Followed to 

Ensure That Senior Officials Were Held Accountable 31

VA Has Procedures for Investigating Whistle-Blower Allegations of 

Misconduct, but Investigations Can Lead to Potential Conflicts 

of Interest 45

VA Data and Whistle-Blower Testimony Indicate That Retaliation 

May Be Occurring 51

Conclusions 56

Recommendations for Executive Action 58

Agency Comments and Our Evaluation 60

Appendix I Objectives, Scope, and Methodology 71

Appendix II Department of Veterans Affairs (VA) Data Files and 

Corresponding Data Fields That Are Missing Information 77

Appendix III Department of Veterans Affairs (VA) Data Files and 

Corresponding Data Fields That Lack Standardization 82

Appendix IV Misconduct File Review 86

Appendix V Illustrative Case Examples of Senior-Official Misconduct 

during Calendar Years 2011 through 2014 87

Contents
Page ii GAO-18-137 Department of Veterans Affairs

Appendix VI Comments from the Department of Veterans Affairs 90

Appendix VII Comments from the Department of Veterans Affairs 

Office of Inspector General 97

Appendix VIII GAO Contact and Staff Acknowledgments 103

Tables

Table 1: Disciplinary Actions Associated with Misconduct at the 

Department of Veterans Affairs (VA) 12

Table 2: Overview of the Department of Veterans Affairs (VA) Six 

Information Systems That Collect Misconduct and 

Disciplinary Action Data That Could Potentially Be Shared 15

Table 3: Overview of Six Information Systems That Collect 

Misconduct and Disciplinary Action Data within the 

Department of Veterans Affairs (VA) 18

Table 4: Examples of Missing Data in Fields for Five Department 

of Veterans Affairs (VA) Data Files 21

Table 5: Examples of Missing and Incomplete Documentation 

Requirements in Misconduct Files That Apply to All VA 

Title 5 and Title 38 Permanent Employees from October 

2009 through May 2015 27

Table 6: Six Elements Required for VA Facility and Program

Office Investigations 32

Table 7: Element 1—Independent Review by a Higher-Grade 

Official at VA 33

Table 8: Element 2—VA Review of Allegations 34

Table 9: Element 3—VA Findings Identified as Substantiated or 

Unsubstantiated 34

Table 10: Element 4—VA Corrective Action Taken for 

Substantiated Allegations 35

Table 11: Element 5—Supporting Documentation Provided by VA 

Facility and Program Office 35

Table 12: Element 6—VA Designated Point of Contact 37

Table 13: Timeliness of Responses Received by VA Office of 

Inspector General (OIG) 38

Table 14: VA Separation-of-Duty Violations 44
Page iii GAO-18-137 Department of Veterans Affairs

Table 15: Comparison of Adverse Disciplinary Action Taken for 

Nonanonymous VA Employees Who Reported 

Wrongdoing and Those Who Did Not, 2010–2014 52

Table 16: Comparison of Attrition Rates for VA Employees Who 

Reported Wrongdoing and Those Who Did Not, 

2010–2014 53

Table 17: Missing and Incomplete Documentation in Misconduct 

Files for All VA Title 5 and Title 38 Permanent-Employees 

from October 2009 through May 2015 86

Figures

Figure 1: VA’s Three Major Administrations and Workforce 6

Figure 2: VA’s Process for Addressing Allegations of Misconduct 9

Figure 3: Action Proposed in Department of Veterans Affairs (VA) 

Office of Accountability Review’s Legacy Referral 

Tracking List Compared with Final Action Taken 40

Figure 4: Whistle-Blower Disclosures and Allegations of Employee 

Misconduct Processed at VA, 2010–2014 46
Page iv GAO-18-137 Department of Veterans Affairs

Abbreviations

AIB administrative investigation board

CATS Complaints Automated Tracking System

CSEMO Corporate Senior Executive Management Office

CSRT Client Services Response Team

EEO Equal Employment Opportunity

EHRI Enterprise Human Resources Integration

NARA National Archives and Records Administration

NCA National Cemetery Administration

OAR Office of Accountability Review

OAWP Office of Accountability and Whistleblower Protection

OHRM Office of Human Resource Management

OIG Office of Inspector General

OMI Office of the Medical Inspector

OPM Office of Personnel Management

ORM Office of Resolution Management

ORO Office of Research Oversight

OS&LE Office of Security and Law Enforcement

OSC Office of Special Counsel

PA physician assistant

PAID Personnel and Accounting Integrated Data

POI Person of Interest

PPP prohibited personnel practice

VA Department of Veterans Affairs

VACO Veterans Affairs Central Office

VAPS Veterans Affairs Police System

VBA Veterans Benefits Administration

VHA Veterans Health Administration

VISN Veterans Integrated Service Network

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Page 1 GAO-18-137 Department of Veterans Affairs

441 G St. N.W.

Washington, DC 20548

July 19, 2018

The Honorable Jack Bergman

Chairman

Subcommittee on Oversight and Investigations

Committee on Veterans Affairs

House of Representatives

The Honorable Mike Coffman

House of Representatives

The Honorable Michelle Lujan Grisham

House of Representatives

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.1

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.2

 1

VA defines senior leadership to include members of the Senior Executive Service; 

associate and assistant directors, chiefs of staff, and nurse executives at its medical 

centers; heads of other VA offices such as networks; GS-15 or equivalent positions in the 

Veterans Health Administration (VHA) headquarters; and all other positions centralized to 

the Secretary.

2

For the purposes of this review, employee misconduct is generally job-related or off-duty 

behavior that does not meet expected standards described in laws, regulations, rules, and 

other authoritative policies and guidance. Misconduct may represent an intentional refusal 

to perform or a negligent failure to perform acceptably due to inattention to duty. 

Misconduct categories are delineated in VA Directive 5021, Employee/Management 

Relations, and include, among others, alcohol- and drug-related offenses, relationships 

with contractors, and reprisal against an employee for providing information to the Office 

of Inspector General (OIG), the Office of Special Counsel (OSC), or Equal Employment 

Opportunity (EEO) Investigators. A whistle-blower is a current or former employee who 

reports such wrongdoing. Retaliation is generally defined as employers’ taking or 

threatening to take personnel action against employees for reporting wrongdoing.

Letter
Page 2 GAO-18-137 Department of Veterans Affairs

GAO’s prior related work at VA focused on the use of administrative 

investigation boards (AIB) to conduct investigations of alleged employee 

misconduct.3 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 whistleblower 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, 

 3

GAO, VA Administrative Investigations: Improvements Needed in Collecting and Sharing 

Information, GAO-12-483 (Washington, D.C.: Apr. 30, 2012). 
Page 3 GAO-18-137 Department of Veterans Affairs

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.

4

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).5 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 

 4

VA Directive 5021, Employee/Management Relations (Apr. 15, 2002), governs policy for 

disciplinary and grievance procedures for all VA employees, among other matters.

5

For matters of alleged employee misconduct or potential systemic deficiencies related to 

VA policies or procedures, VA may use an administrative investigation board (AIB) as a 

tool to collect evidence and determine the facts surrounding the matter being investigated. 

These investigations may focus on alleged individual employee misconduct by any VA 

staff member, regardless of level. AIB investigations may be convened throughout VA, 

including its medical centers, networks, and headquarters. 
Page 4 GAO-18-137 Department of Veterans Affairs

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.6

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.7 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.8 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 

 6

VA Directive 0701, Office of Inspector General Hotline Complaint Referrals (Jan. 15, 

2009), provides information and procedures concerning the administration and processing 

of complaints referred to VA offices and facilities by the OIG Hotline Complaint Center.

7

A “protected disclosure” includes any disclosure of information that an employee, former 

employee, or applicant for employment reasonably believes evidences a violation of law, 

rule, or regulation; or gross mismanagement, gross waste of funds, abuse of authority, or 

a substantial and specific danger to public health or safety.

8

These disclosure cases included cases in OSC’s information system that had a 

disposition of “Closed after agency report,” “Closed after informal IG report,” “Closed 

because IG investigated,” and “Referred to Inspector General—No Report.”
Page 5 GAO-18-137 Department of Veterans Affairs

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.9 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.10

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.

 9

VACO is located in Washington, D.C., and provides support to field facilities administered 

by VA’s three major administrations.

10VHA’s coverage area is divided into 18 VISNs that serve as regional systems of care 

that work together to better meet local health-care needs and provide greater access to 

care.

Background
Page 6 GAO-18-137 Department of Veterans Affairs

Figure 1: VA’s Three Major Administrations and Workforce

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 
Page 7 GAO-18-137 Department of Veterans Affairs

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.11

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 

 11Department of Veterans Affairs Accountability and Whistleblower Protection Act of 2017, 

Pub. L. No. 115-41 (2017). This law establishes OAWP within VA and requires that such 

office will be headed by the Assistant Secretary for Accountability and Whistleblower 

Protection, who will not report to the Office of the General Counsel.
Page 8 GAO-18-137 Department of Veterans Affairs

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 lawenforcement 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.
Page 9 GAO-18-137 Department of Veterans Affairs

Figure 2: VA’s Process for Addressing Allegations of Misconduct
Page 10 GAO-18-137 Department of Veterans Affairs

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.12 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.13

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 

 12VA Directive 0701, Office of Inspector General Hotline Complaint Referrals, provides 

information and procedures concerning the administration and processing of complaints 

referred to VA offices and facilities by the OIG Hotline Complaint Center.

13VA does not track misconduct reported to supervisors that does not affect payroll 

department-wide.
Page 11 GAO-18-137 Department of Veterans Affairs

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.14 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 moresevere type of discipline (e.g., removal, suspension more than 14 days, or 

reduction in grade) as described in table 1.15

 14Permanent appointments must go through a competitive hiring process (i.e., written test, 

evaluation of education and experience, or evaluation of other attributes necessary for 

successful performance) before being appointed to a position that is open to all applicants. 

Temporary appointments lasting 1 year or less, with a specific expiration date, are 

typically used to fill a short-term position due to reorganization, abolishment, or completion 

of specific peak workloads and seasonal schedules. Probationary appointments provide 

managers with the opportunity to measure the abilities and fitness of the employee for 

continued employment.

15VA does not consider oral and written counseling of employees to be disciplinary 

actions.
Page 12 GAO-18-137 Department of Veterans Affairs

Table 1: Disciplinary Actions Associated with Misconduct at the Department of Veterans Affairs (VA)

Type of action Definition

Disciplinary action

Admonishment A written statement of censure given to an employee for a minor act of misconduct. An 

admonishment will be in the form of an official letter to the employee describing the 

reasons for the action. A copy of the letter will be removed from the employee’s personnel 

folder and destroyed after 2 years. 

Reprimand A written statement of censure given to an employee for misconduct. A reprimand will be in 

the form of an official letter to the employee describing the reasons for the action. A copy of 

the letter will be removed from the employee’s personnel folder and destroyed after 3 

years. However, in cases of patient abuse, the reprimand may be retained in the personnel 

folder for as long as the individual is employed by VA. 

Suspension, 14 days or fewer The involuntary placement of an employee, for disciplinary reasons, in a nonduty, nonpay 

status for a temporary period.

Adverse action

Suspension, more than 14 days An enforced temporary nonpay status and absence from duty given for serious misconduct, 

or for continued or repeated acts of misconduct of a less-serious nature.

Reduction in grade A reduction in grade or pay imposed for disciplinary reasons where such an action would 

be effective in correcting a situation and thus serve to retain a valuable and trained 

employee.

Removal The involuntary separation of an employee from employment based on serious misconduct 

or repeated acts of misconduct of a less-serious nature.

Source: GAO analysis of Department of Veterans Affairs (VA) information. | GAO-18-137

Note: VA manages suspension or removal of credentials or privileges for health-care personnel 

separately from the disciplinary process outlined in VA Handbook 5021.
Page 13 GAO-18-137 Department of Veterans Affairs

As a federal agency, VA is required to report department-wide information 

on certain disciplinary personnel actions to the Office of Personnel 

Management (OPM).16 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.17

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.18 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 

 16See, 5 C.F.R. § 9.2, Reporting Workforce Information. 

17Pub. L. No. 115-41, § 211, requires the Secretary to report by no later than December 

31, 2017, on, among other things, the outcomes of disciplinary actions carried out by VA 

during the 3-year period prior to June 23, 2017, and the effectiveness of such actions, and 

suggestions for improving the disciplinary procedures and actions of the department.

18GAO, Standards for Internal Control in the Federal Government, GAO-14-704G 

(Washington, D.C.: September 2014). 

Employee Misconduct 

and DisciplinaryAction Data Are 

Hampered by 

Completeness and 

Data-Reliability 

Issues

VA Collects Misconduct 

and Disciplinary-Action 

Data Using Fragmented 

Systems
Page 14 GAO-18-137 Department of Veterans Affairs

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.19 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.

 19For our purposes, an information system is defined as a repository of information that is 

administered by a specific office or administration that contains specific data elements 

pertaining to misconduct or disciplinary actions over a specific time frame. A total of 14 

data files were extracted from these 12 information systems; 3 of the data files were 

extracted from the OAR information system. 
Page 15 GAO-18-137 Department of Veterans Affairs

Table 2: Overview of the Department of Veterans Affairs (VA) Six Information Systems That Collect Misconduct and 

Disciplinary-Action Data That Could Potentially Be Shared

Office

Department-wide information 

system / data file

Type and purpose of information 

system / data file

Office of Human 

Resources Management 

(OHRM)

Personnel and Accounting Integrated Data (PAID) Information system designed to manage time and 

attendance and payroll for all employees; also 

includes disciplinary actions taken that affect pay

Office of Accountability 

Review (OAR)

VA-Wide Adverse Employment Action Database Data file designed to track misconduct and 

disciplinary actions taken against VA employees

Legacy Referral Tracking List Data file designed to track referrals made to OAR, 

including allegations of misconduct related to senior 

officials

Veterans Benefits Administration (VBA) Data file designed to track misconduct and 

disciplinary action taken against VBA employees

Office of Accountability 

and Whistleblower 

Protection (OAWP)

VA-Wide Adverse Employment Action and 

Performance Improvement Plan Database

Data system designed to track misconduct and all 

associated adverse disciplinary actions taken 

against VA employees

Office of Research 

Oversight (ORO)

n/a Tracking spreadsheet specific to formal allegations 

of actual research misconduct

Office of Resolution 

Management (ORM)

Complaints Automated Tracking System (CATS) Information system that tracks Equal Employment 

Opportunity (EEO) discrimination complaints

Office of Security and 

Law Enforcement 

(OS&LE)

VA Police System (VAPS) Information system for tracking allegations of 

misconduct at all VA facilities that involve criminal 

activity related to VA field-facility law enforcement

Source: GAO analysis of Department of Veterans Affairs (VA) information. | GAO-18-137

Note: n/a = No specific information system name.

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).20 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 

 20Standard Form 50 is an official notice of personnel action that is used for current and 

former federal employees. It contains certain employment information useful to the 

applicant or if applying for another federal job.
Page 16 GAO-18-137 Department of Veterans Affairs

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.21 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.

We obtained the following three data files from the OAR Information 

System:

• OAR’s VA-Wide Adverse Employment Action Database is a data file 

designed to track misconduct and disciplinary actions taken against 

VA employees.22 OAR officials stated that human-resource specialists 

report adverse disciplinary actions proposed and decided for 

 21During the course of our review, OHRM officials stated HR Smart was still undergoing 

data migration from PAID and did not offer any new enhancements to the data obtained 

from the PAID information system.

22OAR ceased to exist in 2017, and OAWP inherited the VA-Wide Adverse Employment 

Action Database and underlying processes developed by OAR.

OAR Information System
Page 17 GAO-18-137 Department of Veterans Affairs

employees on a weekly basis. As discussed further below, this data 

file does not have identifiers, which precludes VA from matching 

across other systems to obtain additional information.

• OAR’s Legacy Referral Tracking List is a data file used to track 

referrals, including allegations of misconduct related to senior officials. 

As such, it does not contain information related to alleged misconduct 

by all VA employees. As discussed further below, significant fields 

within this data file contain a large percentage of invalid values, which 

precludes VA from matching to other systems to obtain additional 

information.

• VBA inputs misconduct and disciplinary action information for 

employees into OAR’s information system.23 Thus, the VBA data 

fields significant for matching across information systems contain the 

same formatting and invalid-value issues identified for the OAR 

information system, which precludes VA from matching to other 

systems.

OAWP was established in response to the Department of Veterans Affairs 

Accountability and Whistleblower Protection Act of 2017 in an effort to 

increase accountability of adverse disciplinary actions directed at senior 

officials. The OAWP implemented the VA-Wide Adverse Employment 

Action and Performance Improvement Plan Database to track 

misconduct.24 VA started compiling a list of misconduct and associated 

disciplinary actions taken in January 2017 and publicly releases this 

information on its website. As discussed further below, this information 

system does not have identifiers, which precludes VA from matching to 

other systems to obtain additional information.

ORO’s tracking spreadsheet provides a summary of cases of formal 

allegations of actual research misconduct. The respondent data field, 

which is key for matching across information systems, was well populated 

but required formatting in order to be usable for matching.

 23We analyzed VBA information separately since VBA tracks its own disciplinary actions 

taken for each district, and then inputs those data elements into OAR’s System. 

Additionally, VBA data covered a different period than the data obtained from OAR’s VAWide Adverse Employment Action Database. 

24We analyzed OAWP’s VA-Wide Adverse Employment Action and Performance 

Improvement Plan Database separately since it covered a different period than OAR’s VAWide Adverse Employment Action Database and included improved functionality through 

the addition of data elements for analysis.

OAWP Information System

ORO Information System
Page 18 GAO-18-137 Department of Veterans Affairs

ORM’s Complaints Automated Tracking System is used to track 

discrimination activities at VA. The data are used to produce internal 

reports, as well as the Annual Federal Equal Employment Opportunity 

Statistical Report of Discrimination Complaints. As discussed further 

below, this information system does not have key data elements that 

were defined within and across information systems.

OS&LE’s VA Police System (VAPS) tracks allegations of misconduct that 

involve criminal activity related to VA field-facility law enforcement. As 

discussed further below, significant data fields within this information 

system lacked identifiers, which preclude VA from matching to other 

systems to obtain additional information.

In addition to the six information systems discussed above, we also 

identified six additional information systems that various VA 

administrations and program offices use to collect specific information 

regarding their respective employees’ misconduct and disciplinary actions 

(see table 3).

Table 3: Overview of Six Information Systems That Collect Misconduct and Disciplinary-Action Data within the Department of 

Veterans Affairs (VA)

Office information system Type and purpose of information system

Client Service Response Team (CSRT)—ExecVA Tracking spreadsheet for all allegations received by VA Secretary 

regarding misconduct, patient care, or other wrongdoing

Corporate Senior Executive Management Office (CSEMO) MS Word document used to track misconduct regarding senior officials

National Cemetery Administration (NCA) Tracking spreadsheet for monitoring workload, including misconduct 

and disciplinary actions.

Office of Inspector General (OIG)—Master Case Index Case-management information system designed to collect allegations 

of criminal activity, waste, abuse, and mismanagement received by the 

OIG Hotline Division

Office of Inspector General (OIG)—Senior Management 

Referral System

Information system that tracks allegations of misconduct or gross 

mismanagement by senior VA officials

Office of the Medical Inspector (OMI) Tracking spreadsheet for allegations of whistle-blower disclosures 

related to clinical care

Source: GAO analysis of Department of Veterans Affairs (VA) information. | GAO-18-137

These systems are fragmented and not interoperable (that is, two or more 

information systems are not able to share and transfer information 

electronically), so data from different systems cannot be merged to create 

a department-wide database. Further, each database contains specific 

aspects of misconduct reporting, but none contains all information on 

misconduct and disciplinary actions taken. For example, the OIG’s Master 

ORM Information System

OS&LE Information System
Page 19 GAO-18-137 Department of Veterans Affairs

Case Index contains all allegations of criminal activity, waste, abuse, and 

mismanagement received by the OIG Hotline Division. OIG officials 

stated that this information system compiles information pertaining to

misconduct and relevant to OIG processes, such as allegation and case 

number, but does not track related activity that may take place outside of 

the OIG, such as employee disciplinary actions associated with each 

case.25

The current design of key VA information systems does not provide 

senior officials with ready access to information. For example, the 

department may permit access to the OAWP VA-Wide Adverse 

Employment Action Performance Improvement Plan Database and PAID 

information systems only to staff office points of contact and their 

designated human-resource specialists. Further, extracting misconduct 

data is difficult because these systems are not designed to report on 

misconduct. The process of obtaining usable misconduct data from PAID 

for our analysis took over 2 months from the date of our initial request, 

suggesting that there was not already a process in place to provide this 

information to senior officials on a routine basis.

 25See generally, Inspector General Act of 1978, 5 USCA, App. 3, § 4 (defining duties and 

responsibilities of inspectors general). The OIG can impose disciplinary actions against 

VA OIG employees as the relevant employing entity. The OIG reports its findings to the 

head of the agency (and to the Attorney General when it has reasonable grounds to 

believe a violation of criminal law exists); however, it cannot impose or recommend 

disciplinary action against non-OIG VA employees.
Page 20 GAO-18-137 Department of Veterans Affairs

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.26 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:27

• missing 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 

 26GAO-14-704G.

27A total of 14 data files were extracted from these 12 information systems; 3 of the data 

files were extracted from the OAR information system.

Data-Reliability Issues 

Impair VA’s Ability to 

Systematically Analyze 

Data to Evaluate 

Department-Wide 

Employee Misconduct

Missing Data
Page 21 GAO-18-137 Department of Veterans Affairs

number of data-quality issues.28 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.

Table 4: Examples of Missing Data in Fields for Five Department of Veterans Affairs (VA) Data Files 

Data file and field name

Number of records 

missing data

Percentage of records missing 

data

Office of Accountability Review Legacy Referral Tracking List

Proposed Action 1,210 97

Grade (1) 1,208 97

Disciplinary Action 1,190 96

OAR Action 957 77

POI [Person of Interest] Last Name (1) 632 51

Person of Interest (POI) 588 47

Complainant #1 (First Name) 251 20

Office of Accountability Review VA-Wide Adverse Employment Action Database

Admin Leave 2,959 30

Proposing Official 1,536 16

Settlement 1,375 14

 28We were unable to analyze the Office of the Medical Inspector (OMI) and Office of 

Resolution Management (ORM) data files due to a number of data-quality issues—

including missing values, fields that contained multiple data elements within the same cell, 

and the presence of date ranges rather than discrete dates. Therefore, our discussion 

focuses on the remaining five data files. ORM’s data file did not clearly distinguish among 

different individuals filing complaints, or dates filed for the same individual. On the basis of 

the data provided, we were unable to verify whether this discrepancy was a result of how 

the data was exported.
Page 22 GAO-18-137 Department of Veterans Affairs

Data file and field name

Number of records 

missing data

Percentage of records missing 

data

Office of Accountability Review VA-Wide Adverse Employment Action Database

Deciding Official 1,336 14

Date Proposed 1,052 11

Effective Date 530 5

Action Taken 252 3

Office of Inspector General Master Case Index

Nature of Complaint 480 54

Veterans Benefits Administration

Offense 1 Sustained 720 52

Office of Accountability and Whistleblower Protection VA-Wide Adverse Employment Action and Performance Improvement 

Plan Database

Offense 1 Sustained 754 14

Proposing Official 479 9

Deciding Official 186 3

Source: GAO analysis of Department of Veterans Affairs (VA) information. | GAO-18-137

Note: A full description of field names can be found in app. II.

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 

Lack of Data Definition 

Standardization
Page 23 GAO-18-137 Department of Veterans Affairs

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 VAWide 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 

Lack of Identifiers
Page 24 GAO-18-137 Department of Veterans Affairs

violations.29 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.

 29According to VA officials, VAPS is comprised of multiple tables. Violation Reports 

include parking tickets and other administrative offenses. Incident Reports include moreegregious offenses. For example, if an incident involves a speeding violation and a police 

chase, everything would fall within the Incident Report, but only the speeding violation 

would be recorded as part of the Violation Report.
Page 25 GAO-18-137 Department of Veterans Affairs

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.30 Specifically, VA was unable to provide the files 

for 10 percent (55 of 544) of the files we requested.31 We determined that 

administrations and program offices within VA have various recordretention 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 

 30These files corresponded to 482 individuals involved in 544 adverse disciplinary actions 

from VA facilities and represented each of the Veteran Integrated Service Networks 

(VISN) nationwide.

31We were unable to determine whether 4 of the 55 missing files in our sample of adverse 

action files were outside the file retention period due to the specified range between 4 to 7 

years. We categorized these files as missing since (1) VA did not correctly specify a 

record-retention period of these files due to misinterpretation of the guidance, and (2) we 

did not receive a response from VA when the files were requested that indicated these 

four files were outside of the applicable VA office’s record-retention period.

VA Does Not 

Consistently Adhere 

to Policies for File 

Retention and 

Adjudication 

Documentation 

Pertaining to 

Employee Misconduct 

Allegations
Page 26 GAO-18-137 Department of Veterans Affairs

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 recordretention schedules.32 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.33

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 permanentemployee misconduct case files, table 5 shows the estimated number and 

percentage that deviated from file documentation requirements.34 A list of 

the 22 identified requirements and the percentage of files not in 

compliance can be found in appendix IV.

 32See, National Archives and Records Administration, The General Records Schedules 

Transmittal 29, sec. 2.3, Item 60 (December 2017). 

33With respect to missing files, the probability that files were missing is lower for those 

cases that had a higher sampling weight than for those with a lower sampling weight, 

which is why the estimate is different than what would result from unweighted data. 

34VA has a variety of authorities it uses to hire employees for its facilities. For our 

purposes, Title 5 Employees are those hired under the authorities of Title 5 of the U.S. 

Code and hold positions such as program managers, police officers, and file clerks. Title 

38 employees are hired under VA-specific authorities in Title 38 of the U.S. Code and 

include medical or health-care providers such as physicians, dentists, and registered 

nurses, and are subject to disciplinary and management procedures set out in Title 38. 

Title 38-Hybrid employees are hired under certain Title 38 authorities and include 

positions such as respiratory, occupational, or physical therapists; social workers; and 

pharmacists. For purposes of adverse actions, Title 38-Hybrid employees are subject to 

the same procedures as Title 5 employees.
Page 27 GAO-18-137 Department of Veterans Affairs

Table 5: Examples of Missing and Incomplete Documentation Requirements in Misconduct Files That Apply to All VA Title 5 

and Title 38 Permanent Employees from October 2009 through May 2015

File requirements from VA Handbook 5021 

Estimated files not in 

compliance

Estimated percentage of 

population

Dated, written acknowledgement from the employee that he or she 

received the decision letter in person

5,818 35

Written summary of the employee’s oral reply to proposed disciplinary 

action

4,813 29

Return receipt for certified mail indicating that the decision letter was 

mailed to the employee

3,821 23

Right to representation by an attorney or other representative 3,597 21

Advance notice of proposed action 2,693 16

Statement that the employee will be given a written decision as soon as 

possible after his or her reply has been fully considered

2,561 15

Decision letter provided 2,550 15

Copy of the employee’s written reply 1,765 11

Appeal rights information 1,277 8

Source: GAO analysis of Department of Veterans Affairs (VA) data. | GAO-18-137

Note: Unless otherwise noted, all estimates in the text from this analysis have a margin of error of 

+/-7.4 percentage points or less for a 95 percent confidence interval. Estimates are based on a 

stratified random sample of 544 case files, of which 362 files pertained to permanent Title 5 and Title 

38 employees, from 23,622 relevant VA files.

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.35 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.

 35Unless otherwise noted, estimates related to our generalizable sample have a margin of 

error of +/-7.4 percentage points or less for a 95 percent confidence interval.
Page 28 GAO-18-137 Department of Veterans Affairs

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.36 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 

 36A subsequent update to VA Handbook 5021 (Feb. 19, 2016) pertaining to Title 5 and 

Title 38 hybrid employees requires that a summary of an oral reply heard by a designee 

instead of the deciding official be shared with the employee prior to a final decision being 

made.
Page 29 GAO-18-137 Department of Veterans Affairs

policy governing cases involving disciplinary actions or provided oversight 

of VA’s implementation of record-retention requirements, or that humanresource 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.37 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 recordretention 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.38 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.

 37National Archives and Records Administration, The General Records Schedules 

Transmittal 29. 

38National Archives and Records Administration, Department of Veterans Affairs Records 

Management Program: Records Management Inspection Report (Oct. 7, 2016). 
Page 30 GAO-18-137 Department of Veterans Affairs

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.
Page 31 GAO-18-137 Department of Veterans Affairs

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.

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.39 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.

 39VA Directive 0701, Office of Inspector General Hotline Complaint Referrals, provides 

information and procedures concerning the administration and processing of complaints 

referred to VA offices and facilities by the OIG Hotline Complaint Center.

Investigative 

Standards Were Not 

Consistently Followed 

to Ensure That Senior 

Officials Were Held 

Accountable

VA Facility and ProgramOffice Responses to 

Allegations of Misconduct 

Did Not Consistently 

Follow OIG Policy
Page 32 GAO-18-137 Department of Veterans Affairs

Table 6: Six Elements Required for VA Facility and Program Office Investigations

Element Description

1. Independent review by an official independent of and at a higher grade 

than the accused

2. Specific review of all allegations

3. Findings of each allegation clearly identified as substantiated or 

unsubstantiated

4. Description of any corrective action taken or proposed as a result of a 

substantiated allegation

5. Supporting documentation for the review, such as copies of pertinent 

documents and reports

6. Designation of point of contact for questions

Source: GAO analysis of Department of Veterans Affairs (VA) information. | GAO-18-137

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.40 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.41 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.42 All of the requested files were within the OIG’s 7-year recordretention 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.

 40The OIG was unable to provide a comprehensive data file requested that identified all 

complaints received and reviewed both internally and externally from fiscal years 2010 

through 2014, and related outcomes for each case. 

41See app. V for details on seven selected cases.

42According to the OIG’s record-retention policy, the OIG should keep the investigative 

findings for a minimum of 7 years.
Page 33 GAO-18-137 Department of Veterans Affairs

Table 7: Element 1—Independent Review by a Higher-Grade Official at VA

Reviewed at higher grade Number of cases

Yes 6

No 4

Unknown 11

No file 2

Total 23

Source: GAO analysis of Department of Veterans Affairs (VA) data. | GAO-18-137

Note: Data are from 23 VA Office of Inspector General investigations involving allegations of 

misconduct by a senior official.

Unknown: We were unable to determine the independence of the reviewers, or whether they were of 

a higher grade level than the accused, from the lack of information provided for these cases.

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.
Page 34 GAO-18-137 Department of Veterans Affairs

Table 8: Element 2—VA Review of Allegations

VA responded to allegations Number of cases

Yes 20

No 1

No file 2

Total 23

Source: GAO analysis of Department of Veterans Affairs (VA) data. | GAO-18-137

Note: Data are from 23 VA Office of Inspector General investigations involving allegations of 

misconduct by a senior official.

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.

Table 9: Element 3—VA Findings Identified as Substantiated or Unsubstantiated

VA clearly indicated findings for each allegation Number of cases

Yes 14

No 7

No file 2

Total 23

Source: GAO analysis of Department of Veterans Affairs (VA) data. | GAO-18-137

Note: Data are from 23 VA Office of Inspector General investigations involving allegations of 

misconduct by a senior official.

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 
Page 35 GAO-18-137 Department of Veterans Affairs

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 10: Element 4—VA Corrective Action Taken for Substantiated Allegations

Corrective action taken Number of cases

Yes 4

No 1

Not applicable—no allegations were officially 

substantiated

16

No file 2

Total 23

Source: GAO analysis of Department of Veterans Affairs (VA) data. | GAO-18-137

Note: Data are from 23 VA Office of Inspector General investigations involving allegations of 

misconduct by a senior official.

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.

Table 11: Element 5—Supporting Documentation Provided by VA Facility and 

Program Office

Supporting documentation provided Number of cases

Yes 4

No 17

No file 2

Total 23

Source: GAO analysis of Department of Veterans Affairs (VA) data. | GAO-18-137

Note: Data are from 23 VA Office of Inspector General investigations involving allegations of 

misconduct by a senior official.

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 
Page 36 GAO-18-137 Department of Veterans Affairs

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).
Page 37 GAO-18-137 Department of Veterans Affairs

Table 12: Element 6—VA Designated Point of Contact 

Designated point of contact Number of cases

Yes 15

No 6

No file 2

Total 23

Source: GAO analysis of Department of Veterans Affairs (VA) data. | GAO-18-137

Note: Data are from 23 VA Office of Inspector General investigations involving allegations of 

misconduct by a senior official.

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.
Page 38 GAO-18-137 Department of Veterans Affairs

Table 13: Timeliness of Responses Received by VA Office of Inspector General 

(OIG)

Response received before deadline Number of cases

Yes 14

No 5

Unknowna 2

No file 2

Total 23

Source: GAO analysis of Department of Veterans Affairs (VA) data. | GAO-18-137

Note: Data are from 23 VA OIG investigations involving allegations of misconduct by a senior official.

a

We were unable to determine the timeliness of OIG responses received from the lack of 

documentation provided for these cases.

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 
Page 39 GAO-18-137 Department of Veterans Affairs

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.

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.

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.43 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.44 Of the 5 officials, 2 received the actions that 

 43We were not able to determine the total number of substantiated cases or senior officials 

due to missing information in the 1,245 cases listed in the database.

44Written counseling of employees is not considered disciplinary action, although it may 

be considered when assessing the appropriate penalty for a particular offense.

OAR Data Indicate That 

Senior Officials Involved in 

Substantiated Cases of 

Misconduct May Not 

Always Be Held 

Accountable

Misconduct Substantiated, but 

Proposed Action Not Always 

Taken
Page 40 GAO-18-137 Department of Veterans Affairs

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.

Figure 3: Action Proposed in Department of Veterans Affairs (VA) Office of Accountability Review’s Legacy Referral Tracking 

List Compared with Final Action Taken

a

Adverse action.

For the two officials for whom there was no evidence that disciplinary 

action was taken, we found no evidence within the PAID information 
Page 41 GAO-18-137 Department of Veterans Affairs

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 whistleblower retaliation at the Phoenix VA Health Care System. The 

investigative report documented that allegations were sustained. The 

retaliation included allegations of involuntary reassigning the whistleblower 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.45 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.

 45The investigative report did not specify what disciplinary action should be taken beyond 

“appropriate administrative action.” Disciplinary actions, as defined in VA Handbook 5021, 

include admonishments, reprimands, and suspensions of 14 days or less. Adverse 

actions, as defined in Handbook 5021, include suspensions of more than 14 days, 

reduction in grade, and removal, among others.
Page 42 GAO-18-137 Department of Veterans Affairs

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.

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.46 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 

 46We compared a list of officials who proposed and decided disciplinary actions to the 

PAID information system to determine how many were involved in misconduct that would 

result in disciplinary action at any time during their employment with VA.

Misconduct Substantiated, but 

No Action Recommended

Senior Officials with 

Misconduct Remain in 

Management Positions
Page 43 GAO-18-137 Department of Veterans Affairs

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.47 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.48

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 

 47See, Douglas v. Veterans Administration, 5 MSPR 280 (1981). The Merit Systems 

Protection Board laid out the 12 factors to consider for a federal employee’s discipline 

case, which also include, among others, the potential for the employee’s rehabilitation, 

mitigating circumstances surrounding the offense, and the adequacy and effectiveness of 

alternative sanctions to deter such conduct in the future by the employee or others.

48According to VA Handbook 5021, employees who have continued or repeated acts of 

misconduct can be provided with a more-severe penalty, such as a removal.
Page 44 GAO-18-137 Department of Veterans Affairs

occur below the senior level will be referred to each of the three major VA 

administrations for investigation and resolution. In addition to the VAWide 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 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.49

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.

Table 14: VA Separation-of-Duty Violations

Cases Officials involved

One case 59

Two or more cases 14

Total 73

Source: GAO analysis of Department of Veterans Affairs (VA) data. | GAO-18-137

Note: Data are from the Office of Accountability Review, Office of Accountability and Whistleblower 

Protection, and Veterans Benefits Administration.

 49GAO-14-704G. 

VA Officials Violated 

Separation-of-Duty Policy 

When Taking Disciplinary 

Action against VA Employees
Page 45 GAO-18-137 Department of Veterans Affairs

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.50

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 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.

 50Due to the differences between periods covered among the different data files, we only 

verified whether disciplinary action was taken for separation-of-duty violations found in the 

OAR VA-Wide Adverse Employment Action Database.

VA Has Procedures 

for Investigating 

Whistle-Blower 

Allegations of 

Misconduct, but 

Investigations Can 

Lead to Potential 

Conflicts of Interest
Page 46 GAO-18-137 Department of Veterans Affairs

Figure 4: Whistle-Blower Disclosures and Allegations of Employee Misconduct Processed at VA, 2010–2014
Page 47 GAO-18-137 Department of Veterans Affairs

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.51 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.52

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 2014.53 Of the 

172 disclosures referred, VA referred 53 back to the facility or program 

offices where the complaint originated and 119 to the OIG.54

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 

 51The referral from the OSC is made to the Secretary of Veterans Affairs, and the 

obligation to investigate and report back to the OSC remains with the Secretary under 5 

U.S.C. § 1213. At the time of our review, the VA Executive Secretariat received these 

whistle-blower disclosures that were referred to the Secretary of Veterans Affairs. Under 

the Accountability and Whistleblower Protection Act of 2017, OAWP will receive the 

whistle-blower disclosures initially received by the Secretary of Veterans Affairs and refer 

them to the appropriate investigative entity.

52According to OSC officials, approximately 30 percent of the OSC’s cases involve VA 

employees, and, at one point in late 2014, complaints related to VA employees accounted 

for 75 percent of incoming disclosures and allegations of retaliation.

53A total of 770 disclosures did not move forward due to insufficient evidence or 

withdrawal of disclosure by employee, among other things.

54Of the remaining disclosure cases, 23 were referred to OMI, 27 were referred to facility 

or program offices, 2 were referred to OAR, and 1 was unknown.
Page 48 GAO-18-137 Department of Veterans Affairs

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.

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.55 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 

 55A “protected disclosure” includes any disclosure of information that an employee, former 

employee, or applicant for employment reasonably believes evidences a violation of law, 

rule, or regulation; or gross mismanagement, gross waste of funds, abuse of authority, or 

a substantial and specific danger to public health or safety. 

Disclosures Investigated 

by VA Facility and 

Program Offices
Page 49 GAO-18-137 Department of Veterans Affairs

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 decisionmaking 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 

Disclosures Investigated 

by the VA OIG
Page 50 GAO-18-137 Department of Veterans Affairs

investigation for these cases.56 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.57

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.

 56According to OSC officials, the OSC will not refer a disclosure to the Secretary if the 

OIG has conducted or is already conducting an investigation of that particular complaint.

57GAO-14-704G. 
Page 51 GAO-18-137 Department of Veterans Affairs

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.

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 

VA Data and WhistleBlower 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
Page 52 GAO-18-137 Department of Veterans Affairs

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.

Table 15: Comparison of Adverse Disciplinary Action Taken for Nonanonymous VA 

Employees Who Reported Wrongdoing and Those Who Did Not, 2010–2014

Percent

Percentage for whom adverse actions were taken

Employee category

Prior to 

disclosure

Year of 

disclosure

Year after 

disclosure

Individuals who filed a disclosure 2 10 8

Rest of VA 1 1 1

Source: GAO analysis of Department of Veterans Affairs (VA) data. | GAO-18-137

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.58 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).

 58Comparing mid-year roster information to end-of-year information allowed us to 

generate a rough estimate of the percentage of employees hired in a given year that leave 

VA prior to being counted in an end-of-year roster: approximately 6 percent. This suggests 

that our analysis has the potential to understate the rate of attrition among VA employees 

overall.
Page 53 GAO-18-137 Department of Veterans Affairs

Table 16: Comparison of Attrition Rates for VA Employees Who Reported 

Wrongdoing and Those Who Did Not, 2010–2014

Percent

Employee category Attrition rate (percentage who did not 

appear in subsequent year’s roster)

Individuals who filed a disclosure 66

Rest of VA 9

Source: GAO analysis of Department of Veterans Affairs (VA) data. | GAO-18-137

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.

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).59 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.60 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 

 59A general description of the 14 prohibited personnel practices is as follows: unlawful 

discrimination; requesting or considering background references based on political 

connections or influence; coercion of political activity; obstruction of competition for 

employment; influencing withdrawal of applicants from competition for employment; 

granting unauthorized advantage; nepotism; whistle-blower retaliation; retaliation for 

protected activities, as described in 5 U.S.C. § 2302(b)(9); discrimination based on 

conduct that does not adversely affect job performance; violation of veterans’ preference; 

violation of any law, rule, or regulation implementing or directly related to the merit system 

principles; implementing a nondisclosure agreement that doesn’t allow whistle-blowing; 

and accessing medical records in furtherance of any other prohibited personnel practice. 

605 U.S.C. § 1214.

Testimony of WhistleBlowers Describes 

Retaliation and Lack of 

Understanding of the 

Disclosure Process
Page 54 GAO-18-137 Department of Veterans Affairs

communicating confidential information.61 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.62 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 

 61GAO-14-704G. 

62The Whistleblower Protection Ombudsman provides education about protections for 

current or former employees of VA, VA contractors, or VA grantees who make protected 

disclosures.
Page 55 GAO-18-137 Department of Veterans Affairs

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 whistleblower 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.
Page 56 GAO-18-137 Department of Veterans Affairs

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 

Conclusions
Page 57 GAO-18-137 Department of Veterans Affairs

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 
Page 58 GAO-18-137 Department of Veterans Affairs

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, whistleblowers 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)

Recommendations for 

Executive Action
Page 59 GAO-18-137 Department of Veterans Affairs

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 
Page 60 GAO-18-137 Department of Veterans Affairs

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 

Agency Comments 

and Our Evaluation
Page 61 GAO-18-137 Department of Veterans Affairs

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 misconductrelated 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 recordretention 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 
Page 62 GAO-18-137 Department of Veterans Affairs

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.63 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 

 63The draft recommendation was modified to have the Secretary of Veterans Affairs direct 

OAWP to develop a process. 
Page 63 GAO-18-137 Department of Veterans Affairs

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.64 

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 

 64The draft recommendation was modified to have the Secretary of Veterans Affairs direct 

OAWP to develop a time frame. 
Page 64 GAO-18-137 Department of Veterans Affairs

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.65

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 seniorofficial 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 

 65The draft recommendation was modified to have the Secretary of Veterans Affairs direct 

OAWP to develop a process. 
Page 65 GAO-18-137 Department of Veterans Affairs

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.66 Instead, the OIG 

provided data from the OIG Hotline and Office of Investigations casemanagement systems (subsystems within MCI) that contained a limited 

 66According to the OIG, it did not provide us with comprehensive data due to the (1) 

limitations within the OIG's MCI information system, which did not allow for the easy 

selection of all employee misconduct records; (2) prohibition of the OIG to disclose the 

identity of complainants absent a waiver by the complainant due to the Inspector General 

Act; (3) inability of the OIG to identify allegations of misconduct, unless an investigation 

was conducted and a report was issued, or the complaint was referred to VA for further 

investigation or review; and (4) assertion by the OIG that the number of requested cases 

was too high for the OIG to sort through and redact the requested information in a timely 

fashion.
Page 66 GAO-18-137 Department of Veterans Affairs

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 
Page 67 GAO-18-137 Department of Veterans Affairs

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.
Page 68 GAO-18-137 Department of Veterans Affairs

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. 
Page 69 GAO-18-137 Department of Veterans Affairs

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. 
Page 70 GAO-18-137 Department of Veterans Affairs

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.

Kathy Larin

Director, Forensic Audits and Investigative Service
Appendix I: Objectives, Scope, and 

Methodology

Page 71 GAO-18-137 Department of Veterans Affairs

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.1 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 

 1

For the complete list of the 12 selected information systems with descriptions, see tables 

2 and 3.

Appendix I: Objectives, Scope, and 

Methodology
Appendix I: Objectives, Scope, and 

Methodology

Page 72 GAO-18-137 Department of Veterans Affairs

of the fields contained in the data files.2 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.

3 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. 

 2

We were unable to analyze the Office of the Medical Inspector (OMI) and Office of 

Resolution Management (ORM) data files due to a number of data-quality issues—

including missing values, fields that contained multiple data elements within the same cell, 

and the presence of date ranges rather than discrete dates. 

3

VA Handbook 5021, Employee/Management Relations (Apr. 15, 2002), governs policy 

for disciplinary and grievance procedures for all employees appointed under Title 5 U.S.C. 

and Title 38 U.S.C.
Appendix I: Objectives, Scope, and 

Methodology

Page 73 GAO-18-137 Department of Veterans Affairs

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 datacollection 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.4 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.5

 4

In January 2017, VA established the Office of Accountability and Whistleblower 

Protection (OAWP), intended to provide investigative internal affairs services necessary to 

improve health, benefits, and cemetery needs for veterans. At that time, OAR ceased to 

exist as a separate office and OAWP inherited the active OAR databases, functions, and 

staff.

5

VA Directive 0701, Office of Inspector General Hotline Complaint Referrals (Jan. 15, 

2009), provides information and procedures concerning the administration and processing 

of complaints referred to VA offices and facilities by the OIG Hotline Complaint Center. 
Appendix I: Objectives, Scope, and 

Methodology

Page 74 GAO-18-137 Department of Veterans Affairs

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 
Appendix I: Objectives, Scope, and 

Methodology

Page 75 GAO-18-137 Department of Veterans Affairs

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 whistleblowers 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.6 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 

 6

Employees who left the agency prior to a full year of employment were excluded from our 

analysis. 
Appendix I: Objectives, Scope, and 

Methodology

Page 76 GAO-18-137 Department of Veterans Affairs

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

Page 77 GAO-18-137 Department of Veterans Affairs

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.

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
Appendix II: Department of Veterans Affairs 

(VA) Data Files and Corresponding Data Fields 

That Are Missing Information

Page 78 GAO-18-137 Department of Veterans Affairs

• 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.

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.

Office of 

Accountability Review 

(OAR)—VA-Wide 

Adverse Employment 

Action Database
Appendix II: Department of Veterans Affairs 

(VA) Data Files and Corresponding Data Fields 

That Are Missing Information

Page 79 GAO-18-137 Department of Veterans Affairs

• 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 othercomments 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.

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 

Office of Inspector 

General (OIG)—

Master Case Index
Appendix II: Department of Veterans Affairs 

(VA) Data Files and Corresponding Data Fields 

That Are Missing Information

Page 80 GAO-18-137 Department of Veterans Affairs

entries for administrative action1 taken, but the nature-of-complaint 

fields corresponding to these actions were blank.

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.

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 

 1

Administrative action is a form of corrective action that does not necessarily require 

disciplinary action.

Veterans Benefit 

Administration 

(VBA)—Misconduct 

and Disciplinary 

Action Report

Office of 

Accountability and 

Whistleblower 

Protection (OAWP)—

VA-Wide Adverse 

Employment Action 

and Performance 

Improvement Plan 

Database
Appendix II: Department of Veterans Affairs 

(VA) Data Files and Corresponding Data Fields 

That Are Missing Information

Page 81 GAO-18-137 Department of Veterans Affairs

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

Page 82 GAO-18-137 Department of Veterans Affairs

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 

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

Office of 

Accountability Review 

(OAR)—VA-Wide 

Adverse Employment 

Action Database

Office of Inspector 

General (OIG)—

Master Case Index
Appendix III: Department of Veterans Affairs 

(VA) Data Files and Corresponding Data Fields 

That Lack Standardization

Page 83 GAO-18-137 Department of Veterans Affairs

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, NonEmployee—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.

Veterans Benefit 

Administration (VBA)

National Cemetery 

Administration (NCA)
Appendix III: Department of Veterans Affairs 

(VA) Data Files and Corresponding Data Fields 

That Lack Standardization

Page 84 GAO-18-137 Department of Veterans Affairs

• 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.

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.

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.

Client Service 

Response Team 

(CSRT)—ExecVA

Office of Security and 

Law Enforcement 

(OS&LE)—Veterans 

Affairs Police System 

(VAPS)
Appendix III: Department of Veterans Affairs 

(VA) Data Files and Corresponding Data Fields 

That Lack Standardization

Page 85 GAO-18-137 Department of Veterans Affairs

• 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.”

Office of 

Accountability and 

Whistleblower 

Protection (OAWP)—

VA-Wide Adverse 

Employment Action 

and Performance 

Improvement Plan 

Database
Appendix IV: Misconduct File Review

Page 86 GAO-18-137 Department of Veterans Affairs

Table 17: Missing and Incomplete Documentation in Misconduct Files for All VA Title 5 and Title 38 Permanent-Employees 

from October 2009 through May 2015

File requirements from VA Handbook 5021

Estimated files not in 

compliance

Estimated percentage 

of population

Dated, written acknowledgment from the employee that he or she received the 

decision letter in person

5,818 35

Written summary of the employee’s oral reply to proposed disciplinary action 4,813 29

Return receipt for certified mail indicating that the decision letter was mailed to 

employee

3,821 23

Right to representation by an attorney or other representative 3,597 21

Advance notice of proposed action 2,693 16

Statement that the employee will be given a written decision as soon as possible 

after his or her reply has been fully considered

2,561 15

Decision letter provided 2,550 15

Number of files missing 1,800 10

Copy of the employee’s written reply 1,765 11

Prior disciplinary actions taken into consideration in a separate paragraph 1,575 9

Statement advising the employee that further explanation of appeal rights may be 

obtained by consulting Office of Human Resource Management (OHRM)

1,277 8

Referral of employee to the official who signed the notice or OHRM 953 6

Statement that adverse action will take effect not less than 30 days following 

receipt of notice

633 4

Statement that consideration has been given to all evidence developed 609 4

Statement that full and impartial consideration will be given to the employee’s reply 422 3

Statement that the material relied upon to support the notice will be made available 

upon request

394 2

Identify the decision official 391 2

Written records of referenced counseling 385 2

Informing of employee that he or she will be allowed a specific number of hours of 

official time to review the notice and prepare reply

308 2

Prior counseling mentioned in a separate paragraph 151 1

Statement that the employee has a right to reply orally, or in writing 46 <.5

Effective date for corrective action 32 <.5

Source: GAO analysis of Department of Veterans Affairs (VA) files. | GAO-18-137

Note: Unless otherwise noted, all estimates from this analysis have a margin of error of +/- 7.4 

percentage points or less for a 95 percent confidence interval. Estimates are based on a stratified 

random sample of 544 case files, of which 362 files pertained to permanent Title 5 and Title 38 

employees from 23,622 relevant VA files.

Appendix IV: Misconduct File Review
Appendix V: Illustrative Case Examples of 

Senior-Official Misconduct during Calendar 

Years 2011 through 2014

Page 87 GAO-18-137 Department of Veterans Affairs

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 

Appendix V: Illustrative Case Examples of 

Senior-Official Misconduct during Calendar 

Years 2011 through 2014

Case 1

Case 2

Case 3
Appendix V: Illustrative Case Examples of 

Senior-Official Misconduct during Calendar 

Years 2011 through 2014

Page 88 GAO-18-137 Department of Veterans Affairs

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.

Case 4

Case 5
Appendix V: Illustrative Case Examples of 

Senior-Official Misconduct during Calendar 

Years 2011 through 2014

Page 89 GAO-18-137 Department of Veterans Affairs

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.

Case 6

Case 7
Appendix VI: Comments from the Department 

of Veterans Affairs

Page 90 GAO-18-137 Department of Veterans Affairs

Appendix VI: Comments from the 

Department of Veterans Affairs
Appendix VI: Comments from the Department 

of Veterans Affairs

Page 91 GAO-18-137 Department of Veterans Affairs
Appendix VI: Comments from the Department 

of Veterans Affairs

Page 92 GAO-18-137 Department of Veterans Affairs
Appendix VI: Comments from the Department 

of Veterans Affairs

Page 93 GAO-18-137 Department of Veterans Affairs
Appendix VI: Comments from the Department 

of Veterans Affairs

Page 94 GAO-18-137 Department of Veterans Affairs
Appendix VI: Comments from the Department 

of Veterans Affairs

Page 95 GAO-18-137 Department of Veterans Affairs
Appendix VI: Comments from the Department 

of Veterans Affairs

Page 96 GAO-18-137 Department of Veterans Affairs
Appendix VII: Comments from the Department 

of Veterans Affairs 

Office of Inspector General

Page 97 GAO-18-137 Department of Veterans Affairs

Appendix VII: Comments from the 

Department of Veterans Affairs 

Office of Inspector General
Appendix VII: Comments from the Department 

of Veterans Affairs 

Office of Inspector General

Page 98 GAO-18-137 Department of Veterans Affairs
Appendix VII: Comments from the Department 

of Veterans Affairs 

Office of Inspector General

Page 99 GAO-18-137 Department of Veterans Affairs
Appendix VII: Comments from the Department 

of Veterans Affairs 

Office of Inspector General

Page 100 GAO-18-137 Department of Veterans Affairs
Appendix VII: Comments from the Department 

of Veterans Affairs 

Office of Inspector General

Page 101 GAO-18-137 Department of Veterans Affairs
Appendix VII: Comments from the Department 

of Veterans Affairs 

Office of Inspector General

Page 102 GAO-18-137 Department of Veterans Affairs
Appendix VIII: GAO Contact and 

Staff Acknowledgments

Page 103 GAO-18-137 Department of Veterans Affairs

Kathy Larin, (202) 512-5045 or larink@gao.gov

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.

Appendix VIII: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(101920)
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