Open Recommendations

Ensure Healing Action establishes and implements grant financial management policies and procedures to help ensure adequate administration of federal grant funds and that all relevant personnel are aware of these policies and procedures. In particular, these policies should cover, at a minimum: (1) improving internal controls over its debit card access; (2) complying with DOJ Grants Financial Guide consultant requirements, including prior approval and justification for exceeding the established daily or hourly consultant rate and adequate time and effort reports as well as ensuring its staff understand and adhere to the policies and procedures; (3) allocating costs properly to awards…

Ensure Healing Action reminds staff of its policy to obtain bids for consultant services, when necessary.

Remedy the $2,548 in unsupported expenditures related to staff cell phones, monthly bus passes, staff continuing education, and case management software costs.

Establish a process to take future projects’ constructability into account when assessing track outage and force account needs.

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.

Ensure the root cause of Orion heat shield char liberation is well understood prior to launch of the Artemis II mission.

Conduct analysis of Orion separation bolts using updated models that account for char loss, design modifications, and operational changes to Orion prior to launch of the Artemis II mission.

Require EGS conduct additional verification and validation for launch imagery equipment prior to launch attempts should launch conditions change.

Reexamine procedures to better ensure recovery of Orion jettisoned hardware for the Artemis II mission.

Develop a corrective action plan to mitigate or prevent the recurrence of uninterpretable Orion telemetry data for the Artemis II mission.

Establish a course of action and timeline for individual Artemis system design changes before beginning integrated system assembly stacking operations.

The VA New Mexico Health Care System Director ensures Sterile Processing Service has a formal process in place to sustain daily quality assurance reviews and monitors compliance.

The VA New Mexico Health Care System Director ensures Sterile Processing Service leaders demonstrate clear communication of Sterile Processing Service staff roles and responsibilities in accordance with Veterans Health Administration High Reliability Organization principles and values.

The VA New Mexico Health Care System Director ensures the facility’s Sterile Processing Service identifies and resolves high-level disinfection documentation errors as they occur, prior to use of associated reusable medical devices on patients.

The VA New Mexico Health Care System Director ensures Sterile Processing Service has a process to communicate all instances when high-level disinfection documentation cannot be located to the associated clinical services when the reusable medical devices was used in patient care.

Complete Privacy policy

We recommend the Vice President and Chief Information and Digital Officer, Technology and Innovation, implement the planned project to upgrade software and hardware to supported versions.

We recommend the Vice President and Chief Information and Digital Officer, Technology and Innovation, take action to remediate both instances of insecure protocols in use where technically and operationally possible.

The Executive Director ensures staff store reusable medical equipment in temperature- and humidity-controlled storage locations.

Re-evaluate the OSTEM performance goals to ensure they are distinct and well correlated with outcomes.

Develop a procedure to ensure OSTEM tracks and reports funding for all Agency STEM engagement activities.

Re-evaluate jurisdictions eligible for EPSCoR funds to ensure effective and equitable distribution of Agency funds.

Require all NASA organizations capture STEM engagement activities in STEM Gateway.

The Commissioner, SB/SE Division, and Chief, Criminal Investigation, should identify opportunities to partner with the EPA to use the agency’s expertise and data when selecting, conducting examinations and investigations involving taxpayers that claimed biofuel tax credits and revise the MOU as needed.

The Under Secretary for Health, Veterans Integrated Service Network directors, and facility leaders ensure staff enter data into the local cancer registry database in a timely manner.