Open Recommendations

The Phoenix VA Health Care System Director ensures Phoenix VA Health Care System policy is in alignment with Veterans Health Administration Directive 1101.14, Emergency Medicine.

The Phoenix VA Health Care System Director makes certain that investigation and closure of events placed into the Joint Patient Safety Reporting system are completed per the Veterans Health Administrations established time frame, and monitors compliance.

Conduct in-depth evaluations to monitor the performance of EPA regional offices' oversight of delegated agencies' implementation of the EPA's Clean Air Act Stationary Source Compliance Monitoring Strategy.

Ensure that Region 9 develops a plan to conduct Clean Air Act state reviews of California's largest air quality management districts every five years, in accordance with the State Review Framework Compliance and Enforcement Program Oversight, SRF Reviewer's Guide.

Formalize a state review framework recommendation resolution process to ensure that the EPA's senior managers and delegated agencies are accountable for the resolution of state review framework recommendations.

In collaboration with the Office of General Counsel and the Office of Air and Radiation, determine to what extent the Clean Air Act authorizes the EPA to require periodic identification and inspection of nonmajor stationary sources such as SM-80s by states, local government agencies, federally recognized Indian tribes, and U.S. territories. Document the EPA's determination and exercise such authority, if applicable, as the EPA deems appropriate.

Clarify Agency policies and guidance to: a. Communicate the EPA's expectations for the EPA regions and states, local government agencies, federally recognized Indian tribes, and U.S. territories to identify, inspect, report, and verify data for SM-80 sources. b. Communicate steps the EPA will take, if any, to periodically identify and inspect SM-80s if these entities do not meet such expectations. c. Clearly define SM-80 sources.

Establish routine training to reinforce EPA guidance and policies regarding delegated Agency requirements and responsibilities to identify and inspect SM-80 sources. Training is to include coordination among EPA regional managers, including division directors, deputy directors, branch chiefs, section chiefs, managers, and staff in the Office of Air and Radiation and the Office of Enforcement and Compliance Assurance.

In coordination with the Office of Enforcement and Compliance Assurance and the Texas Commission on Environmental Quality, determine a complete and accurate list of SM-80 sources in Texas and ensure that each Clean Air Act Stationary Source Compliance Monitoring Strategy plan includes a list of SM-80s along with an expected inspection date. This corrective action should be completed by August 2025.

In coordination with the Office of Enforcement and Compliance Assurance and the South Coast Air Quality Management District, confirm that California's South Coast Air Quality Management Districts list of SM-80 sources is complete and accurate and ensure that the district reports SM-80 data in the EPA's data systems by August 2025.

Collect and review California's South Coast Air Quality Management District's Clean Air Act Stationary Source Compliance Monitoring Strategy plan by October 2026 and biennially thereafter and ensure that each plan includes a list of SM-80 sources along with an expected inspection date.

Ensure that a process is in place to validate that all audit trail data elements, including investigative elements provided by TIGTA Office of Investigations, are being captured and can be provided by Login.gov prior to using its identity proofing services for IRS IAL2 applications.

The Chief Information Officer should ensure that appropriate IRS management works in conjunction with Login.gov management to assess the extent and impact that the critical vulnerability had on the users who authenticated via Login.gov to access IRS applications and may have had their Personally Identifiable Information sent to unauthorized locations outside of the United States.

The Hampton VA Medical Center Director conducts focused clinical care reviews in accordance with Veterans Health Administration requirements, and monitors for compliance.

The Hampton VA Medical Center Director ensures that summary suspensions are conducted in accordance with Veterans Health Administration policy, and monitors for compliance.

The Hampton VA Medical Center Director confirms that proposed reduction or revocation of privileges complies with Veterans Health Administration policies and procedures, and monitors for compliance.

The Hampton VA Medical Center Director complies with Veterans Health Administration requirements when reporting licensed independent practitioners to state licensing boards.

The Hampton VA Medical Center Director completes a review of Medical Executive Committee meeting minutes and ensures recommendations made for focused professional practice evaluations for cause for licensed independent practitioners have been completed according to Veterans Health Administration requirements.

The Hampton VA Medical Center Director ensures that, when providers are transitioned from an initial focused professional practice evaluation to an ongoing professional practice evaluation, the transition is reported and documented as required by Veterans Health Administration policy, and monitors for compliance.

The Hampton VA Medical Center Director ensures that ongoing professional practice evaluations include documentation of all conclusionary outcomes required by Veterans Health Administration policy.

Implement an action plan to address needs identified in the independent workplace survey.

Provide training to all AGC-500 attorneys on the capabilities and use of the modified Case Document Management System.

Develop a management control that ensures that the attorneys use the Case Document Management System to input, track, and monitor their work, including all case-related communications.

We recommend that the PBS Commissioner provide appropriate oversight to ensure water is safe to occupants in its buildings by defining roles and responsibilities for maintaining water quality in GSA-controlled facilities.

We recommend that the PBS Commissioner provide appropriate oversight to ensure water is safe to occupants in its buildings by ensuring that: water quality is maintained through consistent policies and practices nationwide; deviations to PBS’s Drinking Water Quality Management policy and the PBS water safety guidance are approved by PBS’s Central Office; and any water safety policies or guidance developed by regional offices do not contradict policies and guidance issued at the national level.