Open Recommendations

We recommend that the PBS Commissioner strengthen oversight to ensure full compliance with fire protection requirements by:
a. Establishing and implementing procedures and controls to verify compliance with National Fire Protection Association (NFPA) standards and PBS policies, including consistent use of the National Computerized Maintenance Management System for planning, tracking, and documentation.
b. Ensuring all fire doors are promptly inspected, repaired, or replaced to maintain proper functionality and compliance with applicable safety standards and fire codes.
c. Conducting and documenting fire drills at sufficient frequency to meet NFPA Standard 101, Life Safety Code; Federal Management Regulation Part 102-74, Facility Management…

We recommend that the PBS Commissioner provide training to PBS building management at the U.S. Tax Court Building and the contracting officer’s representatives to ensure the building’s operations and maintenance contractor adheres to contract provisions related to the building’s fire protection requirements.

We recommend that the Director of the Census Bureau strengthen the independent review process for future site selections to ensure that independent reviews are rigorous, transparent, and well documented, with clear evidence to verify that site selection criteria are data driven, methodology is consistently applied, review findings are thoroughly recorded and justified, and final decisions receive explicit approval.

We recommend that the Director of the Census Bureau document all aspects of the site selection process, including independent
reviews, plans, methodology, assumptions, data analyses, meetings, substantive deliberations and feedback, and interim and final decisions before making future site selections.

For the questioned PCNs and any future firm-fixed-price construction contracts, require the Project team to obtain documentation supporting overhead and profit markups on work for which SI is entitled to a credit and ensure that the contractors and/or subcontractors credit SI the appropriate markup amount.

Determine and document the allowability of the $14,112 in questioned costs (or less if the proposed price used a markup that was less than 21 percent) for the overhead and profit markup that should have been accounted for when calculating the total credits due from PCNs 4 and 17, and recover any amount determined to be unallowable.

Review Air Wisconsin’s requested amount for unallowable expenses under PSP2 and PSP3, and seek reimbursement for overpayment, if applicable.

Seek reimbursement of $(REDACTED) overpayment of PSP1 financial assistance

The Medical Center Director ensures each service develops a workflow for the communication of test results.

The Medical Center Director ensures quality management staff report deficiencies identified from the External Peer Review Program to executive leaders, and staff take corrective actions as needed.

The Medical Center Director ensures the facility has a written policy for communication of test results.

The Chief of Staff and Associate Director of Patient Care Services ensure leaders in each service develop written service-level workflows that outline the process for staff to communicate test results to providers and patients.

The Veterans Integrated Service Network Director ensures executive leaders implement a process to monitor actions related to Veterans Health Administration policy changes.

The Medical Center Director ensures the Chief of Staff and Associate Director of Patient Care Services review performance metrics for test result communications and take action for identified deficiencies.

The Medical Center Director ensures executive leaders attend Quality and Patient Safety Council meetings.

Facility leaders ensure the community living centers dementia unit shower room is clean and free from hazards, and that leaders conduct a risk assessment to determine the need for other safety measures.

The Medical Center Director ensures facility staff conduct a privacy assessment and take actions to protect patient information in the Emergency Department.

Facility leaders ensure all eyewash stations are clean and function properly.

The Medical Center Director ensures the facility has a written policy for communication of test results.

The Chief of Staff and Associate Director of Patient Care Services ensure leaders in each service develop written service-level workflows that outline the process for staff to communicate test results to providers and patients.

The Veterans Integrated Service Network Director ensures executive leaders implement a process to monitor actions related to Veterans Health Administration policy changes.

The Medical Center Director ensures the Chief of Staff and Associate Director of Patient Care Services review performance metrics for test result communications and take action for identified deficiencies.

The Medical Center Director ensures executive leaders attend Quality and Patient Safety Council meetings.

The Executive Medical Center Director ensures clinical staff can open all doors to shared bathrooms.

The Executive Medical Center Director ensures staff keep exterior doors closed to minimize risk to wandering patients.