Open Recommendations

We recommend that the Washington State Department of Social and Health Services follow up with the 20 nursing homes reviewed in this audit to ensure that these nursing homes have taken corrective actions to address the life safety, emergency preparedness, and infection control deficiencies identified.

We recommend that the Washington State Department of Social and Health Services provide training to State surveyors to ensure that deficiencies related to life safety, emergency preparedness, and infection control are consistently identified.

Rec. 2.b: The DoD OIG recommended that the Director of the Defense Health Agency increase the number of required Prescription Monitoring Program candidate reviews for the Managed Care Support Contractors, while also implementing standard Prescription Monitoring Program processes and review requirements for all DoD medical treatment facilities to include the number of candidates to review.

Rec. 3.c: The DoD OIG recommended that the Director of the Defense Health Agency develop and implement a process to obtain medical documentation for DoD beneficiaries from DoD medical treatment facilities and other agencies or health insurance providers to support routine monitoring and medical reviews of at-risk beneficiaries.

We recommend that the Connecticut Department of Social Services continue to coordinate with the Department of Developmental Services to provide training for staff of DDS and private group homes on how to monitor and report reasonable suspicions of abuse and neglect, especially in light of the significant staff hiring and retention problems in Connecticut group homes.

We recommend that the Connecticut Department of Social Services continue to coordinate with the Department of Developmental Services to use the new analytical procedures to identify potential cases of abuse or neglect involving Medicaid enrollees with developmental disabilities that incurred injuries and are treated in hospital emergency room settings.

We recommend that the Manager, ORNL Site Office, ensure that UT-Battelle:2. Maintains PRVs in the data centers in accordance with its Procedure.

We recommend that the Pennsylvania Department of Human Services expand the pilot program to other regions to periodically match Medicaid claims with diagnosis codes indicating potential abuse or neglect to 24-hour reportable incidents recorded in the incident reporting system.

We recommend that the Pennsylvania Department of Human Services continue working with community-based providers to ensure that all community-based providers' staff identify and understand the requirements for reporting 24-hour reportable incidents within required timeframes.

We recommend that the Pennsylvania Department of Human Services continue working with supports coordinators to ensure they verify with the community-based provider that incidents that they are aware of are reported in the EIM system.

We recommend that the Pennsylvania Department of Human Services provide targeted training to community-based providers that repeatedly do not report 24-hour reportable incidents.

(U) Rec. B.1.a: The DoD OIG recommended that the Commander, Navy Installations Command, in coordination with the Commander, Navy Region Mid'Atlantic, and the Commanding Officer, Naval Facilities Engineering Systems Command Mid'Atlantic update the Norfolk Naval Shipyard master plan to comply with the 5'year requirement in accordance with DoD Instruction 4165.70, "Real Property Management," April 6, 2005 Incorporating Change 1, August 31, 2018).

(U) Rec. B.1.a: The DoD OIG recommended that the Commander, Navy Installations Command, in coordination with the Commander, Navy Region Mid'Atlantic, and the Commanding Officer, Naval Facilities Engineering Systems Command Mid'Atlantic update the Norfolk Naval Shipyard master plan to comply with the 5'year requirement in accordance with DoD Instruction 4165.70, "Real Property Management," April 6, 2005 Incorporating Change 1, August 31, 2018).

(U) Rec. B.1.b: The DoD OIG recommended that the Commander, Navy Installations Command, in coordination with the Commander, Navy Region Mid'Atlantic, and the Commanding Officer, Naval Facilities Engineering Systems Command Mid'Atlantic update the Norfolk Naval Shipyard master plan to include a military installation resiliency component in accordance with section 2864, title 10, United States Code, and Unified Facilities Criteria 2'100'01, "Installation Master Planning," September 30, 2020 (Change 1, April 8, 2022).

(U) Rec. B.1.b: The DoD OIG recommended that the Commander, Navy Installations Command, in coordination with the Commander, Navy Region Mid'Atlantic, and the Commanding Officer, Naval Facilities Engineering Systems Command Mid'Atlantic update the Norfolk Naval Shipyard master plan to include a military installation resiliency component in accordance with section 2864, title 10, United States Code, and Unified Facilities Criteria 2'100'01, "Installation Master Planning," September 30, 2020 (Change 1, April 8, 2022).

(U) Rec. B.1.c: The DoD OIG recommended that the Commander, Navy Installations Command, in coordination with the Commander, Navy Region Mid-Atlantic, and the Commanding Officer, Naval Facilities Engineering Systems Command Mid-Atlantic review and document the prioritization of Norfolk Naval Shipyard's future master planning efforts to ensure compliance with Federal and DoD requirements.

(U) Rec. B.1.c: The DoD OIG recommended that the Commander, Navy Installations Command, in coordination with the Commander, Navy Region Mid'Atlantic, and the Commanding Officer, Naval Facilities Engineering Systems Command Mid'Atlantic review and document the prioritization of Norfolk Naval Shipyard's future master planning efforts to ensure compliance with Federal and DoD requirements.

(U) Rec. B.2.a: The DoD OIG recommended that the Commander, Navy Installations Command, in coordination with the Commander, Navy Region Hawaii, and the Commanding Officer, Naval Facilities Engineering Systems Command Hawaii update the Joint Base Pearl Harbor'Hickam master plan to comply with the 5'year requirement in accordance with DoD Instruction 4165.70, "Real Property Management," April 6, 2005 (Incorporating Change 1, August 31, 2018).

(U) Rec. B.2.a: The DoD OIG recommended that the Commander, Navy Installations Command, in coordination with the Commander, Navy Region Hawaii, and the Commanding Officer, Naval Facilities Engineering Systems Command Hawaii update the Joint Base Pearl Harbor'Hickam master plan to comply with the 5'year requirement in accordance with DoD Instruction 4165.70, "Real Property Management," April 6, 2005 (Incorporating Change 1, August 31, 2018).

(U) Rec. B.2.b: The DoD OIG recommended that the Commander, Navy Installations Command, in coordination with the Commander, Navy Region Hawaii, and the Commanding Officer, Naval Facilities Engineering Systems Command Hawaii update the Joint Base Pearl Harbor'Hickam master plan to include a military installation resiliency component in accordance with section 2864, title 10, United States Code, and Unified Facilities Criteria 2'100'01, "Installation Master Planning," September 30, 2020 (Change 1, April 8, 2022).

(U) Rec. B.2.b: The DoD OIG recommended that the Commander, Navy Installations Command, in coordination with the Commander, Navy Region Hawaii, and the Commanding Officer, Naval Facilities Engineering Systems Command Hawaii update the Joint Base Pearl Harbor'Hickam master plan to include a military installation resiliency component in accordance with section 2864, title 10, United States Code, and Unified Facilities Criteria 2'100'01, "Installation Master Planning," September 30, 2020 (Change 1, April 8, 2022).

(U) Rec. B.2.c: The DoD OIG recommended that the Commander, Navy Installations Command, in coordination with the Commander, Navy Region Hawaii, and the Commanding Officer, Naval Facilities Engineering Systems Command Hawaii review and document the prioritization of Joint Base Pearl Harbor'Hickam's future master planning efforts to ensure compliance with Federal and DoD requirements.

(U) Rec. B.3: The DoD OIG recommended that the Commanding Officer, Naval Facilities Engineering Systems Command Hawaii, in coordination with the Commander, Pearl Harbor Naval Shipyard, direct planning officials to apply environmental threat policies, such as DoD Directive 4715.21 and relevant Unified Facilities Criteria, when developing and executing projects to address the risks identified during the master planning process for the existing dry docks at Pearl Harbor Naval Shipyard.

(U) Rec. B.4.a: The DoD OIG recommended that once the Shipyard Infrastructure Optimization Program Area Development Plan has been completed, the Commander, Navy Installations Command, in coordination with the Commander, Navy Region Northwest and the Commanding Officer, Naval Facilities Engineering Systems Command Northwest incorporate the results of the Shipyard Infrastructure Optimization Program Puget Sound Naval Shipyard Area Development Plan into the Naval Base Kitsap master plan to comply with the 5'year requirement in accordance with DoD Instruction 4165.70, "Real Property Management," April 6, 2005 (Incorporating Change 1, August 31, 2018).

(U) Rec. B.4.a: The DoD OIG recommended that once the Shipyard Infrastructure Optimization Program Area Development Plan has been completed, the Commander, Navy Installations Command, in coordination with the Commander, Navy Region Northwest and the Commanding Officer, Naval Facilities Engineering Systems Command Northwest incorporate the results of the Shipyard Infrastructure Optimization Program Puget Sound Naval Shipyard Area Development Plan into the Naval Base Kitsap master plan to comply with the 5'year requirement in accordance with DoD Instruction 4165.70, "Real Property Management," April 6, 2005 (Incorporating Change 1, August 31, 2018).