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Inspector General Open Recommendations
05/02/2024
-
Department of Veterans Affairs
Delays in Community Care Consult Processing and Scheduling at the Martinsburg VA Medical Center in West Virginia
[Report Details]
Review
-
Open Recommendations
04
Ensure that the performance plan of the chief of community care has standards related to the metrics for community care.
03
Continue to increase specialty provider availability in VA and the community for veterans assigned to the Martinsburg VA medical facility.
02
Conduct a strategic business evaluation of the community care department’s workflow processes to determine if there are alternatives that could improve consult processing and scheduling efficiency and timeliness.
05/02/2024
-
Amtrak (National Railroad Passenger Corporation)
Major Programs: Portal North Bridge Project is Progressing, but Opportunities Exist to Improve Company Oversight and Reduce Risk
[Report Details]
Audit
-
Open Recommendations
3
Establish a process to identify the company’s unique information requirements related to its role on future capital projects and communicate these requirements to its partners.
2
Assess where information-sharing expectations between the company and NJ Transit may continue to differ on the Portal North Bridge project and determine a course of action to remedy them, including amending the agreement if necessary.
1
Establish a process to take future projects’ constructability into account when assessing track outage and force account needs.
05/02/2024
-
Department of Veterans Affairs
Comprehensive Healthcare Inspection of the VA Maryland Health Care System in Baltimore
[Report Details]
Inspection / Evaluation
-
Open Recommendations
05
The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in all ambulatory care settings.
04
The Assistant Director ensures staff document VA police response times for panic alarm testing in the inpatient mental health unit.
01
The Chief of Staff ensures service chiefs recommend continued privileges for licensed independent practitioners based on Ongoing Professional Practice Evaluation activities, and the Medical Executive Committee recommends them based on evaluation results.
05/01/2024
-
General Services Administration
Audit of PBS National Capital Region’s Asbestos Management in Building 40 of the St. Elizabeths West Campus
[Report Details]
Audit
-
Open Recommendations
3
We recommend that the PBS NCR Regional Commissioner take the actions listed below to improve asbestos management in Building 40: develop and maintain an accurate, current, and comprehensive ACM inventory; upon completion of the ACM inventory, assess hazards arising from the ACM in the building and implement appropriate actions to mitigate or eliminate those hazards; ensure all required asbestos records are maintained in the Inventory Reporting Information System; enforce the asbestos management requirements established in the Building 40 operations and maintenance contract; update, enforce, and administer the Building 40 asbestos management plan; and notify tenants of ACM inventory annually.
2
We recommend that the PBS NCR Regional Commissioner comprehensively train PBS NCR management and staff so that they have a clear understanding of PBS’s asbestos management policy and their roles and responsibilities for effectively and safely managing ACM in GSA-owned facilities.
1
We recommend that the PBS NCR Regional Commissioner conduct a comprehensive assessment of PBS NCR’s asbestos management program and implement internal controls to ensure adherence to federal regulations and PBS asbestos management policy.
05/01/2024
-
Department of Veterans Affairs
Comprehensive Healthcare Inspection of the Harry S. Truman Memorial Veterans' Hospital in Columbia, Missouri
[Report Details]
Inspection / Evaluation
-
Open Recommendations
07
The Chief of Staff ensures clinical staff notify the suicide prevention team when patients report suicidal behaviors during the Comprehensive Suicide Risk Evaluation.
06
The Chief of Staff ensures suicide prevention coordinators conduct, track, and report a minimum of five suicide prevention outreach activities each month.
05
The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation the same calendar day, when logistically feasible and clinically appropriate, for all ambulatory care patients with a positive suicide risk screen.
04
The Medical Center Director ensures staff follow the manufacturer’s recommendations for testing over-the-door alarms on mental health inpatient unit sleeping room doors.
03
The Chief of Staff ensures service chiefs include service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.
02
The Chief of Staff ensures the Clinical Executive Board reviews professional practice evaluation data for licensed independent practitioners.
01
The Chief of Staff ensures service chiefs regularly complete Ongoing Professional Practice Evaluations for licensed independent practitioners.
05/01/2024
-
National Aeronautics and Space Administration
NASA's Readiness for the Artemis II Crewed Mission to Lunar Orbit
[Report Details]
Audit
-
Open Recommendations
6
Establish a course of action and timeline for individual Artemis system design changes before beginning integrated system assembly stacking operations.
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