Open Recommendations

The Bureau of Diplomatic Security, in coordination with the Office of Crisis Management and Strategy, should review post Emergency Action Plans to ensure that they fully and comprehensively address coordination with nearby posts in crisis-response operations.

Develop, document, and implement a strategy with clear goals, metrics, and priorities to guide efforts for improving customer service to passengers with disabilities. This strategy should also clarify roles and responsibilities, including how the relevant departments should coordinate on accessibility issues.

Strengthen and document a process for collecting, tracking, and resolving all accessibility-related complaints—including defining timelines for resolving them—in accordance with federal regulation.

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 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.

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 keep patient care areas clean and safe.

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 only authorized staff have access to medication storage areas.

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