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Inspector General Open Recommendations

07/22/2021 - Federal Housing Finance Agency FHFA Lacked Documentation of its Validation of Data Used to Produce the Third Quarter 2020 Seasonally Adjusted, Expanded-Data FHFA HPI and Failed to Timely Review its Information Quality Guidelines [Report Details] Audit - Open Recommendations

07/22/2021 - Department of Veterans Affairs Contracted Residence Programs Need Stronger Monitoring to Ensure Veterans Experiencing Homelessness Receive Services [Report Details] Audit - Open Recommendations

01
Establish control mechanisms at the Veterans Integrated Service Network and Contracted Residential Services program levels to ensure Contracted Residential Services staff at medical facilities comply with Veterans Health Administration Handbook 1162.09 requirements for monitoring and documentation.
02
Direct Network Contracting Offices to establish controls to verify contracting officers meet with contracting officer’s representatives on at least a quarterly basis to evaluate contractor performance and document the meetings.
03
Direct Network Contracting Offices for all Contracted Residential Services contracts to ensure contracting officers include quality assurance surveillance plans and promptly issue letters of delegation to staff who have been nominated to be contracting officer’s representatives.
04
Update Veterans Health Administration Handbook 1162.09 to incorporate unannounced site visits to the extent possible during annual inspections and quarterly evaluations.
05
Update Veterans Health Administration Handbook 1162.09 to include guidance on paying for veteran absences and make certain these requirements are reflected in contracts and surveillance plans.

07/22/2021 - Department of Homeland Security CBP Needs to Strengthen Its Oversight and Policy to Better Care for Migrants Needing Medical Attention [Report Details] Audit - Open Recommendations

1
We recommend the Acting Commissioner of U.S. Customs and Border Protection periodically assess and document requirements to review and update related policies and procedures to: 1. clearly define at-risk populations; 2. establish set times for frequency of welfare checks; 3. ensure completion of medical assessments for all juveniles; and 4 ensure rescreening of migrants after detainment exceeds guidelines.
2
We recommend the U.S. Customs and Border Protection Chief Medical Officer continue to collaborate with U.S. Border Patrol and Office of Field Operations to strengthen oversight and quality assurance plans through the CBP Self-Inspections Program, to review and assess medical screening, welfare checks, and the recording of supporting documentation.
3
We recommend the Acting Commissioner of U.S. Customs and Border Protection develop training and require U.S. Border Patrol agents and Office of Field Operations officers to attend the training, which should include: 1. updates and changes to policies and procedures when revised; and 2. recurrent medical training requirements to identify common signs and symptoms of persons in a medical emergency in order to initiate lifesaving measures and activation of Emergency Medical Services.

07/22/2021 - Department of Homeland Security Review of the February 16, 2020 Childbirth at the Chula Vista Border Patrol Station [Report Details] Inspection / Evaluation - Open Recommendations

1
We recommend the Chief, U.S. Border Patrol provide guidance to Border Patrol personnel about creating custody logs for newborn U.S. citizens held in Border Patrol custody.
2
We recommend the Commissioner, Customs and Border Protection Develop formal guidance with comprehensive processes for documenting childbirths that occur in custody.
3
We recommend the Commissioner, Customs and Border Protection implement standard practices to expedite the release of U.S. citizen newborns in custody following detainee childbirths.
4
We recommend the Commissioner, Customs and Border Protection develop written protocols for CBP personnel at hospital and healthcare facilities to defer, absent exigent circumstances, to hospitals and other local health-care providers to provide interpreter services for in custody, limited-English proficiency individuals when discussing medical information

07/21/2021 - Department of Veterans Affairs Audiology Leaders’ Deficiencies Responding to Poor Care and Monitoring Performance at the Eastern Oklahoma VA Health Care System in Muskogee [Report Details] Inspection / Evaluation - Open Recommendations

01
The Eastern Oklahoma VA Health Care System Director confirms the Chief of Staff, the Service Chief, and the Supervisory Audiologist have processes in place to ensure patients affected by the audiologist’s poor care are identified and receive clinically-indicated follow-up.
02
The Eastern Oklahoma VA Health Care System Director evaluates processes, including annual competencies, used to ensure audiology leaders’ compliance with the Veterans Health Administration’s adverse event disclosure requirements, and takes action as indicated.
03
The Eastern Oklahoma VA Health Care System Director requires the Chief of Staff, the Service Chief, and the Supervisory Audiologist to complete clinical disclosures, as appropriate, for patients identified as being affected by the audiologist’s poor care.
04
The Eastern Oklahoma VA Health Care System Director initiates the process to determine whether a large scale disclosure is required, in accordance with the Veterans Health Administration policy.
05
The Eastern Oklahoma VA Health Care System Director evaluates processes, including annual competencies, used to ensure audiology leaders’ compliance with the Veterans Health Administration’s patient safety reporting requirements, and takes action as indicated.
06
The Eastern Oklahoma VA Health Care System Director directs the Chief of Staff, the Service Chief, and the Supervisory Audiologist to notify the Patient Safety Manager of adverse events identified through the review of patients impacted by the audiologist’s poor care.
07
The Eastern Oklahoma VA Health Care System Director ensures the Supervisory Audiologist verifies and documents annual competency assessments for audiologists in compliance with facility policy.

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