Open Recommendations

Begin tracking and using other relevant data sources to improve visibility over the quality of the company’s customer service to passengers with disabilities and to inform the strategy it develops.

Formalize a process to regularly train all customer-facing employees and supervisors on interacting with passengers with disabilities in accordance with federal regulation. This should include clarifying the responsibility for enforcing this requirement and which employees and supervisors should receive training.

Establish and document a process to ensure that the company fully considers passengers with disabilities in any efforts to improve the communication of essential travel information.

analysis, develop a proposal of any potential improvement options and submit it to the Executive Leadership Team for consideration.

Since the Supply Chain Buyer Guide is only applicable to the Supply Chain organization, we recommend the Vice President, Supply Chain, develop an agency-wide standard program and process defining the process for evaluating and awarding purchase orders under blanket contracts. The standard program and process should define when (1) the product or service should be competed among multiple vendors before issuing a purchase order and (2) deviations from competition guidelines are acceptable.

The OIG recommends the Director ensures staff have processes to prevent repeat environment of care findings.

The OIG recommends the Veterans Integrated Service Network 1 Director monitors for similar or repeated environment of care findings and ensures facility staff sustain improvements.

The OIG recommends the Veterans Integrated Service Network 1 Director ensures facility leaders identify environment of care trends and establish performance improvement plans with outcome measures to address them.

The OIG recommends the Director ensures staff post biological hazard signs on doors where potentially infectious materials may be present.

The OIG recommends the Director ensures staff keep patient care areas clean and safe.

The OIG recommends the Director ensures only authorized staff have access to medication storage areas.

The OIG recommends the Director ensures staff conduct an inventory of all the facility’s medication storage areas, and the Chief of Pharmacy approves them.

The OIG recommends the Chief of Pharmacy ensures pharmacy staff inspect each approved medication storage area monthly.

The OIG recommends the Director ensures staff monitor temperature and humidity in medication storage areas and track possible deviations, even those that may occur when the areas are closed.

The OIG recommends facility leaders review the local policy to ensure it complies with VHA directives specific to which staff receive notification of critical test results.

The OIG recommends facility leaders implement tools to help sensory-impaired veterans navigate the facility.

The OIG recommends facility leaders ensure the facility has a policy for test result communication that includes methods to monitor the effectiveness of the patient notification process.

The OIG recommends facility leaders ensure staff develop workflows for the communication of test results for each service.

We recommend that the GSA Chief Administrative Services Officer ensure that justifications for other than full and open competition are completed prior to award and publicly posted.

We recommend that the GSA Chief Administrative Services Officer enforce accountability with OAS personnel who did not comply with the FAR, the GSAM, and OIA internal policies in the award of the audited task order.

We recommend that the GSA Chief Administrative Services Officer revise OIA’s Internal Quality Assurance Review policy to reduce delays, and employ a risk-based sampling methodology when selecting contracts for review.

We recommend that the GSA Chief Administrative Services Officer establish an OAS policy to supplement GSA Order ADM 5000.4B, Office of General Counsel Legal Review, to reduce the monetary threshold for legal review commensurate with the monetary values of OIA contracts.

We recommend that BOR immediately suspend the awarding of Inflation Reduction Act funds using miscellaneous obligations.

We recommend that BOR identify and implement additional oversight controls for existing Bucket 2 agreements.

The Chief, Criminal Investigation, should reemphasize body-worn camera policies and procedures to its special agents, specifically highlighting that videos should be timely uploaded into the cloud-based storage platform and reviewed, including those marked for deletion. Also, special agents should be reminded of following pre-operation plans to not deactivate cameras prematurely and maintaining the required documentation certifying completion of training.