Open Recommendations

Implement training on processing and tracking appeals that is mandatory for VHA staff who process decision reviews.

Rec. A.1.a: The DoD OIG recommended that the Assistant Secretary of Defense (Health Affairs) conduct a study concerning triage levels for sexual assault victims, including a review of industry standards and revise DoD guidance to prescribe a specific triage level for sexual assault victims or a minimum level that meets the requirements for priority and uniformity.

Rec. A.1.b: The DoD OIG recommended that the Assistant Secretary of Defense (Health Affairs) develop a process to review and ensure that emergency department providers implement and consistently apply the new guidance for assigning a triage level for sexual assault victims.

Rec. B.1.a: The DoD OIG recommended that the Assistant Secretary of Defense (Health Affairs) revise guidance to require emergency department providers to document in the sexual assault victim's medical record: (1) the triage level of care assigned; (2) whether providers offered and documented a Sexual Assault Forensic Examination to the victim; and (3) whether the Sexual Assault Response Coordinator, Sexual Assault Prevention and Response Victim Advocate, or Family Advocacy Program clinical provider was notified, and the details of the notification including who was notified and when they were notified.

Rec. B.1.b: The DoD OIG recommended that the Assistant Secretary of Defense (Health Affairs) develop a process to review and ensure that emergency department providers implement and consistently apply the new guidance on documentation requirements for sexual assault victims.

Rec. B.1.c: The DoD OIG recommended that the Assistant Secretary of Defense (Health Affairs) update Military Health System GENESIS to add an automated control requiring emergency department providers to enter: (1) triage level of care assigned; (2) whether providers offered a Sexual Assault Forensic Examination; and (3) whether providers notified the Sexual Assault Response Coordinator, Sexual Assault Prevention and Response Victim Advocate, or Family Advocacy Program clinical provider for care provided at medical treatment facility emergency departments for sexual assault victims, and the details of the notification, including who was notified and when they were notified.

We recommend the Acting Director of U.S. Immigration and Customs Enforcement establish a policy for ICE field personnel to validate migrant addresses and to elevate address concerns, such as recurring or invalid migrant release addresses, recorded into U.S. Customs and Border Protection and ICE systems.

We recommend the Executive Associate Director of U.S. Immigration and Customs Enforcement’s Enforcement and Removal Operations analyze migrant U.S. release address data on a recurring basis to identify trends, such as recurring and uninhabitable addresses, and share known address concerns with U.S. Border Patrol.

Create a single Service-wide comprehensive digitalization strategy that identifies priorities, objectives, interim target dates, milestones, etc. The strategy should identify the IRS business units responsible for the applicable actions and should be updated annually.

Develop processes to require management to track digitalization efforts and compare results against the plans, goals, objectives, milestone dates, etc., and analyze any significant deviations to identify needed strategic changes.

(U) Rec. B.1: Report is Classified.

(U) Rec. B.2: Report is Classified.

(U) Rec. B.3: Report is Classified.

(U) Rec. B.4: Report is Classified.

Develop a formal and clear guidance on the roles, responsibilities, and expectations for the inclusion of applications within Earth Venture Class projects.

Develop a methodology for funding applications in Earth Venture Class projects.

CMS should Ensure that HHAs submit required OASIS assessments whentheir patients are hospitalized

CMS should take steps to ensure the completeness and accuracy of the HHA-reported OASIS data used to calculate the falls with major injury quality measure.

CMS should explore whether improvements to the quality measure related to falls can also be used to improve the accuracy of other home health measures.

CMS should ese data sources, in addition to OASIS assessments, to improve the accuracy of the quality measure related to falls with major injury.

Take steps to ensure that periodic supervisory reviews are conducted on a consistent basis and that case files i.nclude documentation of supervisory approvals.

Build upon its efforts to increase referrals of patient abuse or neglect.

Implement a comprehensive case management system that allows for efficient access to case documents and information.

Continue efforts to hire a second-line supervisor and assess whether additional supervisors are warranted to meet the Unit's oversight needs.

3. We recommend the NOAA Deputy Undersecretary of Operations direct the Assistant Administrator for Satellite and Information Services ensure the JPSS program updates its JPSS Program Plan and JPSS Flight Project Plan to describe a lessons-learned approach that is executable and meets the needs of the program and NASA. The update should include specific management controls that ensure these needs are met.