Open Recommendations

Executive leaders ensure facility staff keep clean and dirty equipment and supplies separated in storage areas and ensure staff can access medical equipment when needed.

Executive leaders ensure facility staff use video monitors for patient safety purposes only and limit them to staff directly involved in the patients care.

Veterans Integrated Service Network leaders ensure facility executive leaders provide effective oversight of the environment of care program.

Executive leaders ensure quality management staff implement a system-wide process to monitor the effectiveness of patient notification of all urgent, noncritical test results.

Determine whether any administrative action should be taken with respect to the conduct of the medical facility director and the chief of staff of the Omaha VA Medical Center.

Direct the medical facility director to educate and train those involved with consults on the process, including how to customize the clinically indicated date to reflect the date of care agreed to by the provider and the veteran. The training should be mandatory, its contents should comply with national policy, and its frequency should be determined by the medical facility director.

Assess the actions the medical facility has taken to review the consults that were potentially affected by the 29-day default in the clinically indicated date field and ensure veterans received the care they needed.

At a minimum, conduct annual reviews of cost and volume inputs for the PostalPro Undeliverable-as-Addressed data model to verify they are accurate and up-to-date.

Collaborate with the National Customer Support Center to identify primary customers of PostalPro Undeliverable-as-Addressed data, evaluate the impact of inaccuracies on customers, and make necessary corrections.

Identify, address, and monitor delivery unit supervisors and carriers not following Undeliverable Marketing Mail policy.

Determine the frequency in which supervisors perform and document reviews of carrier handling and disposal of Undeliverable Marketing Mail, and implement accordingly.

Identify, address, and monitor delivery units with elevated rates of No Record Mail to achieve the nationwide target.

Determine the frequency in which supervisors perform and document reviews on proper handling of Carrier Identified Forward mail and verification of Change of Address forms, and implement accordingly.

Perform a root cause analysis on the inaccuracy of the PostalPro Undeliverable-as-Addressed data.

Revise Undeliverable-as-Addressed data shared to PostalPro in fiscal years 2023 and 2024 to ensure it is accurate and reliable.

We recommend that the Ohio Department of Medicaid ensure providers correct the 117 instances of provider noncompliance identified in this report.

We recommend that the Ohio Department of Medicaid improve its oversight and monitoring of all providers.

We recommend that the Ohio Department of Medicaid work with providers to improve their facilities, staffing, and training.

Seek the opinion of the Office of General Counsel on whether the identified potential overbillings could or should be recouped.

Embassy Algiers should maintain and destroy immigrant visa files in accordance with Department standards.

Embassy Algiers should establish a consular communication structure in line with Department guidance.

Embassy Algiers, in coordination with the Bureau of Overseas Buildings Operations, should bring its safety, health, and environmental management program into compliance with Department standards.

Embassy Algiers, in coordination with the Bureau of Overseas Buildings Operations, should bring its mitigation program for non-high-rise buildings into compliance with Department standards.

Embassy Algiers should bring its fire protection program into compliance with Department standards.

The Bureau of Overseas Buildings Operations should determine the level of priority and funding required to bring Embassy Algiers' facilities into compliance with federal law regarding accessibility.