Open Recommendations

The Veterans Integrated Service Network Director confirms that the patient safety officer reviews investigations by subject matter experts for Joint Patient Safety Reporting events.

The Veterans Integrated Service Network Director provides evidence to demonstrate the Patient Safety Office is completing reviews of a sample of patient safety events that includes analysis of content, recommendations, and required actions, as outlined in Veterans Health Administration Directive 1050.01.

The Veterans Integrated Service Network Director ensures that the Veterans Integrated Service Network 7 Quality and Patient Safety Committee minutes reflect that the patient safety officer conducted analysis of patient safety data to identify opportunities for
improvement and provided guidance on facilities’ action plans to address the deficiencies.

Should program Destination Delivery Unit scanners to automatically identify mis-shipped packages dropped at the facility in error.

Should program the package tracking software to automatically apply mis-shipped scans to packages dropshipped at plants but manifested at a rate associated with a different type of facility.

Should develop a reliable software-based indicator that identifies where and when the Postal Service first took custody of a package.

Design and implement the USPS SHIP system to analyze package data that identifies Parcel Select packages dropped at the wrong location and flags them for additional postage due.

Should enforce the nonmailable package fee collection policy by implementing an automated fee collection system for nonmailable packages dropped at Destination Delivery Units, or implementing an alternative solution.

Complete a needs assessment to ascertain DEA ONSI's AI needs and identify specific ways it can use AI to improve intelligence collection and analysis.

Submit to Congress its report on efforts to develop, acquire, adopt, and maintain AI to improve intelligence collection and analysis and optimize internal workflows as required by Section 6721(a) of Title LXVII of the FY 2023 NDAA.

Complete the Analytical Framework for Emerging and Disruptive Technology (AFEDT) process to ascertain its AI needs and identify specific ways it can use AI to improve intelligence collection and analysis.

Delegate other transaction authority to officials responsible for basic, applied, or advanced research activities and prototype projects in support of intelligence activities, or the adoption of such activities; or justify why this action cannot be completed.

Submit to Congress its report on efforts to develop, acquire, adopt, and maintain AI to improve intelligence collection and analysis and optimize internal workflows as required by Section 6721(a) of Title LXVII of the FY 2023 NDAA.

We recommend that USAID/Democratic Republic of the Congo determine the allowability of $32,560 in ineligible questioned costs on page 19 of the audit report and recover any amount that is unallowable.

We recommend that USAID/Democratic Republic of the Congo verify that Virunga Foundation corrects the two material weaknesses in internal control detailed on pages 21, 23 through 25 of the audit report.

We recommend that USAID/Democratic Republic of the Congo verify that Virunga Foundation corrects the two instances of material noncompliance detailed on pages 29 and 30 of the audit report.

We recommend that Triple-S Advantage, Inc. refund to the Federal Government $296,758 in net overpayments.

We recommend that Triple-S Advantage, Inc. identify, for the high-risk diagnoses included in this report, similar instances of noncompliance that occurred before or after our audit period and refund any resulting overpayments to the Federal Government.

We recommend that Triple-S Advantage, Inc. continue to examine its existing compliance procedures to identify areas where improvements can be made to ensure that diagnosis codes that are at high risk of being miscoded comply with Federal requirements (when submitted to CMS for use in CMS's risk adjustment program) and take the necessary steps to enhance those procedures.

We recommend that Bridge Home Health refund the $6,046 in overpayments to the Medicare program.

We recommend that Bridge Home Health identify similar instances of noncompliance that occurred before, during, and after the audit period and determine the impact and return any overpayments to the Federal Government.

We recommend that Bridge Home Health strengthen its review of medical record documentation to ensure compleance with Medicare billing requirements.

Meet with Commission members and stakeholders to determine whether incorporating evidence-building into its next strategic planning process would assist the Commission in identifying key areas for improvement and improve outcomes to ensure a comprehensive and evidence-based approach for measuring the progress toward goals and objectives in the AbilityOne program. This determination should include, but not be limited to, meetings, information sessions, determinations of key learning areas, and how the information will be used in its next strategic planning process.

Meet with Commission members and stakeholders to determine whether incorporating internal program evaluations into its next strategic planning process would assist the Commission in better informing stakeholders about the program's impact and contributions. This determination should include, but not be limited to, meetings, information sessions, determinations of potential program evaluations, and how information from those potential evaluations will be used in its next strategic planning process.

Enhance its ability to track and monitor progress and the successful implementation of agency goals by establishing and incorporating quantitative measures into its 2026-2030 strategic plan.