Open Recommendations

The VA Eastern Kansas Healthcare System Director reviews institutional disclosures conducted by the system over the past 12 months, including the patients institutional disclosure, and ensures these disclosures fully adhere to Veterans Health Administration Directive 1004.08, Disclosure of Adverse Events to Patients, October 31, 2018, including documenting the details of the adverse event and discussion points of the disclosure, and takes action needed to remediate disclosures that do not meet these standards.

The VA Eastern Kansas Healthcare System Director ensures community care staff make the required three attempts to obtain patients community care records within 90 days of completed appointments, and monitors for compliance.

The VA Eastern Kansas Healthcare System Director collaborates with the Kansas City VA Medical Center Director to review the frequency and circumstances of community care records being sent to the incorrect VA facility, develops, and implements a process for ensuring community care records are delivered to the correct ordering VA facility, educates staff on the process, and monitors for compliance.

The Under Secretary for Health establishes and monitors compliance with a process that ensures the Veterans Health Administration ordering provider receives urgent non-life-threatening abnormal test results from care obtained in the community, such as the diagnostic positron emission tomography scan results described in this report, within a time frame that allows timely attention and appropriate action to be taken.

The Veterans Integrated Service Network Director, in conjunction with the Veterans Health Administration National Center for Lung Cancer Screening Program Office, evaluates the VA Eastern Kansas Healthcare Systems Lung Cancer Screening Program to ensure operational adherence to the Lung Cancer Screening Program requirements, and takes action as needed.

We recommend that CFTC implement a training framework that ensures all travel cardholders complete mandatory training requirements prior to card issuance and that purchase card AOs complete mandatory training requirements prior to performing AO task approvals.

We recommend that CFTC include pre-approval checks for fund availability in its training; enhance controls to alert AOs of disbursements requiring approval before the 30-day timeframe expires and ensure that disbursements are not approved without adequate supporting documents.

We recommend that CFTC enforce the use of centrally billed accounts for travel cards used for international travel.

We recommend that CFTC develop and implement a comprehensive policy that mandates the immediate deactivation of all purchase and travel cards upon notification by HR of an employee’s separation or transfer. Additionally, instituting a regular monitoring system to track and validate the deactivation status of charge cards for all separated employees is recommended. Monthly reviews of charge card activity reports should also be conducted to identify any lapses in the deactivation process to prevent unauthorized use.

We recommended that CFTC review, revise, and update all travel policies to align with the current requirements of the Federal Travel Regulations, OMB directives, and the Government Charge Card Abuse Prevention Act.

We recommend the official Acting Chief Operating Officer for FSA continue to solicit, analyze, and incorporate feedback regarding the completion, submission, and processing of the 2025–2026 FAFSA until FSA confirms that issues with the FAFSA process have been resolved.

We recommend the official Acting Chief Operating Officer for FSA ensure that when the FAFSA process undergoes significant revisions in subsequent award years, FSA use the positive practices it implemented for soliciting and incorporating feedback in the 2025–2026 FAFSA process.

We recommend that USAID's Office of Acquisition and Assistance Cost, Audit and Support Division/Contract Audit Management Branch verify that GiveDirectly, Inc., corrects the material weaknesses in
internal control over financial reporting detailed on pages 32 to 34 of the audit report.

We recommend that USAID's Office of Acquisition and Assistance Cost, Audit and Support Division/Contract Audit Management Branch verify that GiveDirectly, Inc., corrects the instances of material
noncompliances detailed on pages 32 to 34 of the audit report.

We recommend that USAID/Uganda verify that Ministry of Finance, Planning and Economic Development corrects the seven material weaknesses in internal control detailed on pages 36, 42-46, 50-51 and 55 of the audit report.

We recommend that USAID/Uganda verify that Ministry of Finance, Planning and Economic Development corrects the 14 instances of material noncompliance detailed on pages 58 to 86 of the audit report.

We recommend that USAID/Mozambique verify that Centro de Aprendizagem e Capacitao da Sociedade Civil corrects the one material weakness in internal control identified on pages 25 and 28 of the audit report.

We recommend that USAID/Southern Africa determine the allowability of $205,140 in questioned costs ($169,956 ineligible, $35,184 unsupported) on pages 20, 25, 27, and 28 of the audit report and recover any amount that is unallowable.

We recommend that USAID Southern Africa verify that Africa Resource Centre NPC corrects the one material weakness in internal control detailed on pages 33 and 34 of the audit report.

We recommend that USAID/Southern Africa verify that Africa Resource Centre NPC corrects the five instances of material noncompliance detailed on pages 37 to 46 of the audit report.

We recommend the Vice President, Transmission PIanning and Projects, increase collaboration with Major Projects early in the project process to mitigate the risk of inadequate funding.

We recommend the Vice President, Transmission PIanning and Projects, ensure planning estimates are adequately developed and account for cost inflation.

We recommend the Vice President, Transmission PIanning and Projects, take steps to involve Joint Project Team members in risk identification and notify risk owners of their assigned responsibilities.

Create a job aid for claims processors on how to determine the correct effective date for PACT Act"related claims.

Remove the outdated effective date builder from the Veterans Benefits Administrations internal job aids page.

Continue updating the Veterans Benefits Management System-Rating systems effective date builder to add functionality that applies liberalizing laws on claims when the Veterans Benefits Administration receives an intent to file.

Update the Veterans Benefits Management System-Rating systems effective date builder to add functionality that applies liberalizing laws on claims when a veterans service connection is based on a toxic exposure risk activity.

Evaluate PACT Act refresher training by monitoring the results to assess the effectiveness of the training.

Correct all processing errors on cases identified by the review team and report the results to the Office of Inspector General.

The Director, Submission Processing, should lead a review that includes the Directors of Accounts Management, Field Assistance, Media and Publications, and Online Services to add cautionary language to the appropriate forms and publications instructing taxpayers not to use a third-party carrier when paying a balance due that is addressed to a P.O. Box address (Lockbox).

The Director, Submission Processing, should lead a review that includes the Directors of Accounts Management, Field Assistance, Media and Publications, and Online Services to add cautionary language to the appropriate IRS.gov web pages instructing taxpayers not to use a third-party carrier when paying a balance due for third-party payer processor that is addressed to a P.O. Box address (Lockbox).

The Director, Submission Processing, should coordinate with FMSS to create a guide for shared mailrooms not staffed with full-time IRS personnel or contracted staff. The guide should clearly document the time within which taxpayers’ checks and related documents must be routed to the appropriate Submission Processing Center.

The Director, Submission Processing, should coordinate with other Taxpayer Service functions, such as Field Assistance, Accounts Management, and FMSS to include a requirement to identify on Form 3210 any forms received with misrouted remittances.

The Director, Submission Processing, should coordinate with Field Assistance, Accounts Management, and FMSS to create an annual MOU, agree on appropriate staffing, and clearly establish roles and responsibilities when 1) misrouted mail is received and 2) misrouted mail is to be sent to a local TAC for processing rather than a specific Submission Processing Center.

The Director, Submission Processing, should include instructions in the Annual Lockbox Filing Season Readiness Plan to conduct readiness checks or inspections of IRS mailrooms closest to the Lockbox sites. Ensure the sites are staffed and have current instructions specific to processing misrouted Lockbox mail.

The Director, Submission Processing, should implement policies or procedures requiring mailroom staff, or persons assigned to work in non-staffed mailrooms, report the volume of misrouted Lockbox mail received to the LPO Section on a weekly basis from the start of the calendar year to the Lockbox site’s specific program completion date.

Develop, implement, and document a comprehensive process for proactively identifying and managing the risk of train strikes. In the context of this new process, the company should consider formalizing successful initiatives that it is currently piloting, as well as expanding implementation of the key practices we identified in this report.

Develop, implement, and document a process to regularly review and reconcile its train strike data to ensure their accuracy.

We recommend the Vice President, Transmission Planning and Projects, work with Financial Operations and Performance to develop a strategy to align their forecasted spend and funding.

We recommend the Vice President, Transmission Planning and Projects, continue to identify opportunities to improve project estimation and execution.

Executive leaders evaluate the toxic exposure screening process and develop a sustainable action plan to ensure staff complete secondary screenings.

Executive leaders ensure facility staff conduct all required monthly and annual fire extinguisher inspections, document the completion date and results, and report compliance rates to the Comprehensive Environment of Care Committee.

Executive leaders ensure facility staff complete preventive maintenance inspections for all medical equipment.

Executive leaders ensure facility staff develop and implement processes to properly disinfect wheelchairs, remove dust from ceiling vents, and repair walls.

Executive leaders ensure facility staff keep clean and dirty equipment and supplies separated in storage areas and ensure staff can access medical equipment when needed.

Executive leaders ensure facility staff use video monitors for patient safety purposes only and limit them to staff directly involved in the patients care.

Veterans Integrated Service Network leaders ensure facility executive leaders provide effective oversight of the environment of care program.

Executive leaders ensure quality management staff implement a system-wide process to monitor the effectiveness of patient notification of all urgent, noncritical test results.

Determine whether any administrative action should be taken with respect to the conduct of the medical facility director and the chief of staff of the Omaha VA Medical Center.

Direct the medical facility director to educate and train those involved with consults on the process, including how to customize the clinically indicated date to reflect the date of care agreed to by the provider and the veteran. The training should be mandatory, its contents should comply with national policy, and its frequency should be determined by the medical facility director.