Open Recommendations

We recommend that the Health Resources and Services Administration require the six hospices identified in our report as having used PRF payments for unallowable expenditures, totaling $8,306,519, to return the PRF payments to the Federal Government or ensure that the hospices properly replace the unallowable expenditures with allowable unreimbursed lost revenues or eligible expenses, if applicable.

We recommend that the Health Resources and Services Administration work with the hospice identified in our report as having used $3,967,025 of its PRF payments for potentially unallowable expenditures to determine what amounts should have been allocated and require the hospice to return unallowable amounts to the Federal Government or ensure that the hospice properly replaces these unallowable expenditures with unreimbursed lost revenues or eligible expenses, if applicable.

(U) Rec. 1: The DoD OIG recommended that the Secretary of Defense, in coordination with the Secretary of the Navy, designate a single point of command or leadership for Defense Fuel Support Point Joint Base Pearl Harbor-Hickam operations, maintenance, safety, and environmental protection.

(U) Rec. 2.a: The DoD OIG recommended that the Secretary of Defense direct the Secretary of the Navy and the Director of the Defense Logistics Agency to perform a review of leak detection systems at Navy Defense Fuel Support Points, including an analysis of leak detection effectiveness and reliability.

(U) Rec. 2.b: The DoD OIG recommended that the Secretary of Defense direct the Secretary of the Navy and the Director of the Defense Logistics Agency to implement corrective actions based on the review that will ensure effective leak detection at Navy Defense Fuel Support Points.

(U) Rec. 3: The DoD OIG recommended that the Secretary of Defense direct the Under Secretary of Defense for Acquisition and Sustainment to update the DoD Manual 4140.25 series to address the deficiencies discussed in this report.

(U) Rec. 4.a: The DoD OIG recommended that the Secretary of the Navy designate an entity to be responsible for ensuring that all laws, policies, and agreements made in response to the fuel incident at Defense Fuel Support Point Joint Base Pearl Harbor-Hickam are implemented, and that appropriate action is taken with regard to recommendations made in prior oversight and command investigation reports. Specifically, implement the requirements of the 2015 Administrative Order on Consent and 2023 Administrative Consent Order related to Defense Fuel Support Point Joint Base Pearl Harbor-Hickam.

(U) Rec. 4.b: The DoD OIG recommended that the Secretary of the Navy designate an entity to be responsible for ensuring that all laws, policies, and agreements made in response to the fuel incident at Defense Fuel Support Point Joint Base Pearl Harbor-Hickam are implemented, and that appropriate action is taken with regard to recommendations made in prior oversight and command investigation reports. Specifically, Implement the recommendations of the U.S. Environmental Protection Agency Region 9 compliance evaluation inspections for Oil Pollution Prevention regulations.

(U) Rec. 4.d: The DoD OIG recommended that the Secretary of the Navy designate an entity to be responsible for ensuring that all laws, policies, and agreements made in response to the fuel incident at Defense Fuel Support Point Joint Base Pearl Harbor-Hickam are implemented, and that appropriate action is taken with regard to recommendations made in prior oversight and command investigation reports. Specifically, implement the recommendations of the Vice Chief of Naval Operations command investigation related to Defense Fuel Support Point Joint Base Pearl Harbor-Hickam.

(U) Rec. 5.a: The DoD OIG recommended that the Secretary of the Navy direct a comprehensive review of the operation and maintenance programs at Defense Fuel Support Point Joint Base Pearl Harbor-Hickam. This review should include a review of: authorities; reporting chain of command; operational procedures; process control; change management; records management; maintenance planning, tracking, and support programs, such as supply and tool control; staffing levels and skill sets; training; and safety.

(U) Rec. 5.b: The DoD OIG recommended that the Secretary of the Navy direct implementation of corrective actions based on the review that will ensure safe operations at Defense Fuel Support Point Joint Base Pearl Harbor-Hickam.

(U) Rec. 6.a: The DoD OIG recommended that the Secretary of the Navy direct a comprehensive review of the operational safety programs at Joint Base Pearl Harbor-Hickam. This review should include a review of authorities, reporting chain of command, policies, and safety office staffing levels at the Joint Base Pearl Harbor-Hickam, including safety oversight of tenant commands.

(U) Rec. 6.b: The DoD OIG recommended that the Secretary of the Navy direct implementation of corrective actions based on the review that will ensure safe operations at Joint Base Pearl Harbor-Hickam, including tenant commands.

(U) Rec. 7: The DoD OIG recommended that the Secretary of the Navy direct the Commander, Navy Region Hawaii, in coordination with the Director of the Defense Logistics Agency, to update the oil and hazardous substance incident response plans to address the deficiencies discussed in this report and implement the updated oil and hazardous substance incident response plans, including training and exercises.

(U) Rec. 8: The DoD OIG recommended that the Secretary of the Navy direct the Commander, Naval Supply Systems Command to develop and implement a standard operating procedure for causative research and post?incident investigations and reporting for oil or hazardous substance incidents at Navy Defense Fuel Support Points.

(U) Rec. 9: The DoD OIG recommended that the Secretary of the Navy initiate a review of the P?1551 Military Construction project to determine whether any Federal law, acquisition regulation, or contracting requirements were violated or funds were wasted and take appropriate action.

(U) Rec. 1.a: The DoD OIG recommended that the Secretary of the Navy designate an entity to be responsible for ensuring that all laws, policies, and agreements made in response to the 2021 drinking water contamination incident at the Joint Base Pearl Harbor-Hickam Community Water System are implemented, and that appropriate action is taken with regard to recommendations made in prior oversight reports and command investigation reports. Specifically, implement the requirements of the 2015 Administrative Order on Consent and the 2023 Administrative Consent Order related to the Joint Base Pearl Harbor-Hickam Community Water System.

(U) Rec. 1.b: The DoD OIG recommended that the Secretary of the Navy designate an entity to be responsible for ensuring that all laws, policies, and agreements made in response to the 2021 drinking water contamination incident at the Joint Base Pearl Harbor-Hickam Community Water System are implemented, and that appropriate action is taken with regard to recommendations made in prior oversight reports and command investigation reports. Specifically, implement the requirements put forth in the FY 2024 National Defense Authorization Act.

(U) Rec. 1.c: The DoD OIG recommended that the Secretary of the Navy designate an entity to be responsible for ensuring that all laws, policies, and agreements made in response to the 2021 drinking water contamination incident at the Joint Base Pearl Harbor-Hickam Community Water System are implemented, and that appropriate action is taken with regard to recommendations made in prior oversight reports and command investigation reports. Specifically, implement the recommendations of the U.S. Environmental Protection Agency Safe Drinking Water Act Investigation.

(U) Rec. 1.d: The DoD OIG recommended that the Secretary of the Navy designate an entity to be responsible for ensuring that all laws, policies, and agreements made in response to the 2021 drinking water contamination incident at the Joint Base Pearl Harbor-Hickam Community Water System are implemented, and that appropriate action is taken with regard to recommendations made in prior oversight reports and command investigation reports. Specifically, implement the recommendations of the Agency for Toxic Substances and Disease Registry.

(U) Rec. 1.e: The DoD OIG recommended that the Secretary of the Navy designate an entity to be responsible for ensuring that all laws, policies, and agreements made an response to the 2021 drinking water contamination incident at the Joint Base Pearl Harbor-Hickam Community Water System are implemented, and that appropriate action is taken with regard to recommendations made in prior oversight reports and command investigation reports. Specifically, implement the recommendations of the Vice Chief of Naval Operations command investigation related to the Joint Base Pearl Harbor-Hickam Community Water System.

(U) Rec. 1.f: The DoD OIG recommended that the Secretary of the Navy designate an entity to be responsible for ensuring that all laws, policies, and agreements made in response to the 2021 drinking water contamination incident at the Joint Base Pearl Harbor-Hickam Community Water System are implemented, and that appropriate action is taken with regard to recommendations made in prior oversight reports and command investigation reports. Specifically, implement the recommendations of the Naval Facilities Engineering Systems Command command investigation.

(U) Rec. 1.g: The DoD OIG recommended that the Secretary of the Navy designate an entity to be responsible for ensuring that all laws, policies, and agreements made in response to the 2021 drinking water contamination incident at the Joint Base Pearl Harbor-Hickam Community Water System are implemented, and that appropriate action is taken with regard to recommendations made in prior oversight reports and command investigation reports. Specifically, implement the requirements of Commander, Navy Installation Command Instruction 5090.7.

(U) Rec. 2.a: The DoD OIG recommended that the Secretary of the Navy revise Operations Navy Manual 5090.1. Specifically, include the roles, responsibilities, and training requirements for the Operator in Responsible Charge for Treatment and Distribution.

(U) Rec. 2.b: The DoD OIG recommended that the Secretary of the Navy revise Operations Navy Manual 5090.1. Specifically, align requirements of Operations Navy Manual 5090.1 with Commander, Navy Installation Command Instruction 5090.7. Specifically, clarify conflicting requirements for roles and responsibilities, including for the preparation and publication of public notices and contingency plans for alternate drinking water supplies during a drinking water emergency.