Open Recommendations

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 facilitys 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.

Facility leaders implement tools to help sensory-impaired veterans navigate the facility.

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

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.

The OIG recommends facility leaders develop and implement a plan to address veterans unanswered phone calls.

The OIG recommends the Associate Director ensures staff identify environment of care trends and establish performance improvement plans with outcome measures to address them.

The OIG recommends the Associate Director ensures the manufacturer satisfies contractual requirements to perform preventive maintenance for beds and stretchers and documents the service.

The OIG recommends the Veterans Integrated Service Network Director works with facility and primary care leaders to address the network call centers effect on primary care team efficiency and workload and reduce the risk of adverse patient safety events.

Revise NHTSA's Special Crash Investigation Procedures Manual to include processes for: a. identifying, and prioritizing crashes to investigate; b. selecting types of crashes for investigation that are likely to produce the most useful results to improve safety and that align with the program's mission; c. assigning crashes to the investigators; d. documenting crashes considered but not selected for investigation; e. adopting an investigation scheduling process that includes tracking and monitoring functions to encourage timeliness and provide early warning of, and document delays in, completing crash investigations; f. establishing realistic timelines and assessing the impact of delays on crash investigation timelines…

Revise the document retention policy and procedure to include a schedule for all supporting evidence for special crash investigations.

Develop, document, and implement a written process to periodically assess and communicate to decisionmakers, stakeholders, and the public how NHTSA's SCI Program investigations are used to identify and influence highway safety improvements.

We recommend that the Chief Financial Officer consider incorporating into policy the requirement that justifications for "other special conveyances," such as car service, include clear and delineable reasoning as to why the selected option meets the FTR's "advantageous to the government" standard.