Open Recommendations

Confirm that medical facility directors develop local guidance on using automated dispensing cabinets in accordance with VHA Directive 1108.21 (and any revisions to this directive) and that facilities comply with that local guidance.

Require Pharmacy Benefits Management Services to revise VHA Directive 1108.21 to include routine monitoring for the use of generic information as a requirement in facility-level guidance for automated dispensing cabinets.

Ensure, in coordination with the controlled substance coordinator, or appropriate designee, and Veterans Integrated Service Networks, that reports detailing cabinet transactions for controlled substances removed using generic information are reviewed as part of required controlled substance inspections.

We recommend that the PBS Commissioner institute policies and procedures to ensure battery systems are designed, installed, operated, and maintained in accordance with federal regulations, PBS policy, and building code requirements.

We recommend that the PBS Commissioner institute policies and procedures to ensure training requirements are designed and implemented for PBS and PBS contractor personnel working with battery systems and associated technologies.

We recommend that the PBS Commissioner institute policies and procedures to ensure appropriate action is taken to address PBS personnel performance deficiencies identified in this report, including supervisory chains of command and individuals responsible for managing the battery systems.

We recommend that the PBS Regional Commissioner of the Pacific Rim Region take immediate action to safeguard the occupants and assets in the Anderson and Reagan Buildings by: (1)verifying that the ESCO removed the batteries and any other hazards from both the Anderson and Reagan Buildings using only qualified personnel; and, (2) obtaining the complete third-party investigation report into the cause of the battery system fire at the Anderson Building. Upon receipt, ensuring any remaining health and safety hazards listed in the report are addressed or mitigated.

We recommend that the PBS Regional Commissioner of the Pacific Rim Region take immediate action to improve management oversight of the region’s facilities to ensure that: (1) code violations and maintenance deficiencies brought to management’s attention are immediately addressed; (2) local fire department personnel are involved in pre-fire planning activities for future battery system projects; (3) local fire department personnel are involved in post-fire assessments; and (4) final certificates of occupancy are not issued until all outstanding fire and life safety deficiencies are corrected.

We recommend the Council document and implement FFR reporting procedures that adhere to cost allowability restrictions prohibiting state agencies from reporting subrecipient cost shares as their own cost share (General Terms #13), or reporting the same costs across multiple awards (2 CFR 200.403).

We recommend the Council establish controls over its FFR reporting procedures that ensure the procedures were followed and report costs are allowable.

We recommend the Council works with its subrecipient to ensure understanding of, and compliance with, Poetry Out Loud (POL) regulations and requirements.

We recommend the Council update its contract template to include the total amount of that Arts Endowment award's funds issued to the subrecipient to date, and the total amount of Arts Endowment funds issued to the subrecipient from all active Arts Endowment awards (2 CFR 200.332(b)(1)(viii) & (ix)).

We recommend the Council document subrecipient notification procedures that adhere to the requirements established in 2 CFR 200.332(b)1, and establish controls that ensure the procedures are followed.

We recommend the NEA disallow $5,894,428 of unallowable subrecipient cost share from the 2019 Award.

We recommend the NEA disallow $6,566,008 of duplicate costs - $5,673 from the 2020 Award and $892,400 from the 2021 Award.

We recommend the NEA disallow $16,175 in unsupported costs - $500 from the 2019 Award and $15,675 from the 2021 Award.

We recommend the NEA review any additional Poetry Out Loud costs provided by the Council and determine allowability.

We recommend the NEA disallow $7,206 in unallowable Poetry Out Loud cash prize and reception costs - $3,600 from the 2020 Award and $3,606 from the 2021 Award.

We recommend the NEA disallow $3,154 in pre-award subrecipient costs from the 2019 Award.

We recommend the NEA disallow $503 in unreasonable subrecipient costs from the 2019 Award.

We recommend that the Acting GSA Administrator, for buildings where GSA employees access the roof, include a requirement to perform roof inspections during annual Occupational Safety and Health surveys conducted in accordance with GSA Order 5940.2, General Services Administration Occupational Safety and Health Program.

We recommend that the PBS Commissioner improve oversight of O&M contractors to ensure they develop and use safety and health plans that comply with the National O&M Specification and National Consolidated Maintenance Specification contract templates.

We recommend that the PBS Commissioner provide training to PBS contracting officer’s representatives and regional safety offices on their roles and responsibilities for accepting, reviewing, and approving compliant safety and health plans.

We recommend that the PBS Commissioner provide fall protection training to PBS facility managers that addresses roof fall hazards and fall protection requirements issued by OSHA and GSA.

We recommend that the PBS Commissioner resolve identified roof fall hazards in a timely manner by installing necessary OSHA- compliant fall protection on roofs with equipment located near unprotected roof edges. If no funding is available to do so, implement interim controls to protect against fall hazards and monitor the performance of those controls to ensure they remain effective.