Open Recommendations

Secure scanners and verify only authorized employees can enter the Surface Visibility scanner room at the Santa Clarita Processing and Distribution Center.

Verify all drivers are securing trailer cargo and are using wheel chocks at the Santa Clarita Processing and Distribution Center.

Facility leaders ensure staff follow facility policies and maintain a clean environment.

Facility leaders ensure staff develop service-level workflows for the communication of urgent, noncritical test results.

Executive leaders monitor the effectiveness of the patient notification process.

Facility leaders ensure staff follow facility policies and maintain a clean environment.

The under secretary for health require the chief operating officer to direct the Veterans Integrated Service Network directors to fully integrate the core services in accordance with policy to improve operational efficiencies and access for veterans.

The under secretary for health establish a process requiring medical facility directors to coordinate with the Office of Integrated Veteran Care and the clinical contact centers before setting up or maintaining a local phone queue for services the clinical contact center provides.

The under secretary for health require the Office of Integrated Veteran Care to direct the clinical contact center leaders to determine if schedulers are arbitrarily ending calls in the telephone system to remain in after-call work status longer than needed to reduce the number of calls routed to them.

The under secretary for health direct clinical contact center leaders to routinely evaluate and, if needed, address schedulers handle time and availability time to improve performance and reduce inefficiencies.

The under secretary for health direct the Office of Integrated Veteran Care to include schedulers handle time and availability time as part of VA Health Connects annual performance plans to make sure clinical contact centers monitor and address these areas.

The under secretary for health make sure the Office of Integrated Veteran Care and chief operating officer evaluate VA Health Connect staffing for scheduling and, if necessary, reallocate staff so all clinical contact centers provide core services and meet required performance standards for scheduling.

The under secretary for health direct the Office of Integrated Veteran Care to formalize and clarify internal waiver guidance and include examples of the specific evidence that would be required for a clinical contact center not to provide 24-hour services"such as exploring the use of other strategies like routing calls to another service or partnering with other centers to provide coverage.

The under secretary for health ensure the assistant under secretary for health for the Office of Integrated Veteran Care and chief operating officer periodically review the clinical contact center waiver submissions and the planned actions to comply with VA Health Connect requirements.

We recommend the Vice President, Supply Chain, establish a prescribed method for making a forecasted usage determination.

We recommend the Vice President, Supply Chain, establish a process for reorder points to be reviewed and adjusted as necessary, before surplus inventory is transferred.

We recommend the Vice President, Supply Chain, develop and review a report identifying surplus items that were repurchased within a specified period of time to determine if the purchases were appropriate and take actions to address any issues identified.

We recommend the Vice President, Supply Chain, take steps to improve surplus inventory documentation completion.

Determine the scope of the pest control problem within the dry-food storage areas at Federal Correctional Institution Terre Haute and address it.

Until permanent repairs planned by the BOP can be completed at Federal Correctional Institution Terre Haute, assess what steps can be taken to mitigate safety and security risks associated with window disrepair and make temporary repairs to the windows that present the greatest potential safety and security risks at the institution.

After reviewing a draft of this report, the FBI informed the OIG that FBI leadership had recently decided not to make a policy change at this time that would allow non-attorney supervisors to approve certain U.S. person queries. However, FBI indicated that its decision does not remove the option as a possibility in the future. In light of (1) the FBI's query compliance history described in Chapter One, (2) FBI leadership's initial decision immediately after enactment of RISAA to limit approvals of U.S. person queries to attorneys and the improved level of compliance that followed, and (3) the inherently and…

Regardless of whether RISAA's requirement for the Department to review all FBI U.S. person queries remains in place following that provision's sunset on April 20, 2026, because of the limited resources and capabilities of OIA, NSD should continue its current practice of reviewing 100 percent of the FBI's U.S. person queries.

In light of NSD's continuing independent review of all U.S. person queries and OIA's limited resources, OIA should focus its oversight to complement, rather than duplicate, NSD's work. Under such an approach, OIA's continued reviews of all U.S. person queries could be directed to areas not covered by NSD's reviews, or OIA could use sampling or other GAO-endorsed standards and methods to audit a subset of U.S. person queries with the goal of maintaining the multi-level oversight structure that was contemplated by the 2020 Barr Memorandum Regarding FBI Internal Compliance Functions and that we believe appropriate for these activities.

The FBI should maintain records of all requests to the Deputy Director for approval of sensitive queries and the dispositions of such requests, including requests that are not ultimately approved.

Strengthen its RRC contractor performance monitoring practices and procedures to ensure that the BOP adequately assesses contractor performance to the specific requirements of the contract and receives the full scope of services it has contracted with providers to deliver.