Open Recommendations

Develop and implement procedures to require VA medical centers and contracting offices to verify that the Office of Information Technology can meet start-up requirements for new community-based outpatient clinic locations as part of the contract review process.

Review and evaluate how contracting offices rated community-based outpatient clinic contractors in the Contractor Performance Appraisal Reporting System, and if necessary, develop and disseminate additional guidance or training to contracting offices to help them appropriately rate community-based outpatient clinic contractors in accordance with the performance metrics and the broad categories in the Contractor Performance Appraisal Reporting System.

Determine whether positive and negative performance incentives should be used for community-based outpatient clinic contracts to motivate the contractors to provide high-quality health care, in accordance with FAR 37.6, FAR 16.202, and FAR 16.402-2.

a. If performance incentives are appropriate for community-based outpatient clinic contracts, ensure the Medical Sharing/Affiliate Office coordinates with the Office of General Counsel to develop and implement measurable, reasonable, and defensible positive and negative performance incentives.

b. If performance incentives are not appropriate for community-based outpatient clinic contracts, ensure the Medical Sharing/Affiliate Office and each network contracting office documents in the contract files the reasons why…

Develop and implement procedures to identify, evaluate, and incorporate commercial practices and contract types into the community-based outpatient clinic contract requirements templates before publishing updated versions, in accordance with 38 U.S.C. § 8153 and FAR part 10; the procedures should evaluate whether the contract payment structure for community-based outpatient clinic contracts is consistent with current commercial practices.

We recommend that the PBS Commissioner develop and implement a method to track and monitor building studies and ensure that PBS can retrieve all studies efficiently.

We recommend that the PBS Commissioner develop and implement policies and procedures to ensure that: PBS building study data is complete, accurate, and reliable; PBS is not wasting tax dollars on unnecessary or duplicative building studies; and building studies are preserved in accordance with the Federal Records Act of 1950 and GSA records-retention policies.

The Richard L. Roudebush VA Medical Center Director ensures that residents, fellows, and clinical service leaders understand and follow the requirement to document complete and pertinent information, including assessments and recommendations, in patients’ electronic health records.

The Richard L. Roudebush VA Medical Center Director educates providers on the requirements related to completing a clinical disclosure when an adverse event occurs, such as a delay in care.

The Richard L. Roudebush VA Medical Center Director ensures the episode of care related to the patient’s transfer is reviewed to determine whether an institutional disclosure is needed in accordance with Veterans Health Administration requirements, and takes action as warranted.

The Richard L. Roudebush VA Medical Center Director monitors to ensure that Joint Patient Safety Reporting system reports are included or rejected in accordance with Veterans Health Administration guidance.

The Richard L. Roudebush VA Medical Center Director ensures a comprehensive review of the patient’s care and transfer is completed to identify factors that contributed to the patient’s unnecessary transfer and takes action as warranted.

Rec. 1: The DoD OIG recommended that the Assistant Secretary of Defense for Health Affairs, in coordination with the Director of the Defense Health Agency, develop and implement a plan to implement the 24 open recommendations made by the DoD OIG in the prior audits of the DoDs healthcare cost recovery programs, including collection of the remaining potential monetary benefits, totaling $188.3 million.

Rec. 2.c: The DoD OIG recommended that the Assistant Secretary of Defense for Health Affairs, in coordination with the Director of the Defense Health Agency, develop and implement a plan to pursue collection of the remaining $662.3 million in aged debts identified by the Defense Health Agency through September 30, 2021.

Rec. 3: The DoD OIG recommended that the Assistant Secretary of Defense for Health Affairs, in coordination with the Director of the Defense Health Agency, identify all delinquent debts that have accumulated since September 30, 2021, including civilian non'beneficiary debts currently on hold or not yet billed, and develop and implement a plan to pursue collection.

Rec. 1.a: The DoD OIG recommended that the Commander, Naval Facilities Engineering Systems Command Europe, Africa, Central, direct their staff to conduct a review of the circumstances surrounding the contract delays and document the results of the review in the contract file for future use when requesting liquidated damages.

Rec. 1.b: The DoD OIG recommended that the Commander, Naval Facilities Engineering Systems Command Europe, Africa, Central, upon installation of the replacement incinerators, direct the administrative contracting officer to assess liquidated damages of up to $667,295 plus $1,431.92 for each calendar day, per incinerator, that the incinerators were delayed past the original delivery date, as appropriate.

Rec. 1.c: The DoD OIG recommended that the Commander, Naval Facilities Engineering Systems Command Europe, Africa, Central, direct their staff to complete a review of the contractors emissions testing plan and ensure that the plan includes all the required tests to determine compliance with emissions standards in the Overseas Environmental Baseline Guidance Document, and if necessary, require the contractor to modify the plan, at no additional cost to the Government.

Rec. 2.b: The DoD OIG recommended that the Commander, Navy Region Europe, Africa, Central, coordinate with the Camp Lemonnier, Djibouti Commander to ensure annual emissions testing is performed on the medical incinerator.

Rec. 2.c: The DoD OIG recommended that the Commander, Navy Region Europe, Africa, Central, coordinate with the Camp Lemonnier, Djibouti Commander to determine whether the justification for an in-kind replacement of Camp Lemonnier, Djibouti solid waste incinerators was appropriate to meet the DoDs solid waste removal needs in Djibouti. If the justification was not appropriate, initiate a review and determine the cost and feasibility of expanding incinerator capacity.

Rec. 3.a: The DoD OIG recommended that the Commander, Camp Lemonnier, Djibouti, before accepting the replacement incinerators, verify that the incinerators meet Overseas Environmental Baseline Guidance Document emissions standards based on the contractors emissions testing. If the incinerators are noncompliant, the Commander should coordinate with the Naval Facilities Engineering Systems Command Europe, Africa, Central contracting officer to require the contractor to modify the incinerators to meet Overseas Environmental Baseline Guidance Document standards and retest, at no additional cost to the Government.

Rec. 3.b: The DoD OIG recommended that the Commander, Camp Lemonnier, Djibouti, if, after completing emissions testing, the medical incinerator is found noncompliant with Overseas Environmental Baseline Guidance Document standards, perform a cost-benefit analysis, which takes into consideration the potential health risk to personnel stationed at Camp Lemonnier, Djibouti, and implement the best course of action to ensure the medical incinerator complies with Overseas Environmental Baseline Guidance Document standards.

Rec. 1.a: The DoD OIG recommended that the Surgeon General and Commanding General of the U.S. Army Medical Command, in coordination with the Commanding General of the Medical Readiness Command, Europe and Director of U.S. Army Installation Management Command"Europe, assess and document the extent of medical oversight necessary at U.S. Army garrisons in the U.S. Army Europe and Africa area of responsibility. If determined that Fire and Emergency Services personnel in the U.S. Army Europe and Africa area of responsibility should have medical oversight in support of the non-transport basic life support mission, identify the appropriate medical oversight provider and…

Rec. 1.b: The DoD OIG recommended that the Surgeon General and Commanding General of the U.S. Army Medical Command, in coordination with the Commanding General of the Medical Readiness Command, Europe and Director of U.S. Army Installation Management Command"Europe, assess and document the extent to which medications can and should be stored, carried, and administered by U.S. Army garrison Fire and Emergency Services personnel in the U.S. Army Europe and Africa area of responsibility in support of the non-transport basic life support mission. If determined that Fire and Emergency Services personnel in the U.S. Army Europe and Africa area of…

Rec. 2: The DoD OIG recommended that the Assistant Secretary of the Army for Manpower and Reserve Affairs update Army guidance to include which Emergency Medical Services requirements should apply to Fire and Emergency Services personnel who perform non-transport basic life support outside the continental United States, ensure consistency with other regulations and policies, and communicate updated guidance to Fire and Emergency Services personnel.

The Bureau of Diplomatic Technology, in coordination with the Bureau of International Narcotics and Law Enforcement Affairs (INL), should update the Integrated Logistics Management System's INL -End-Use Monitoring Module to ensure that acquisition costs and inspection data for assets that are retired or disposed are readily available to end-users for purposes of analyses and informed decision making.

The Bureau of International Narcotics and Law Enforcement Affairs should define policies and procedures related to non-end-use monitoring acquisitions and donations, and then consistently follow those policies and procedures to ensure consistent and accurate updates of non-end-use monitoring data within transfer letter trackers.

The Bureau of International Narcotics and Law Enforcement Affairs should revise its end-use monitoring standard operating policies and procedures to ensure timely and accurate recording of in-service end-use monitoring assets, retired assets, and disposals within the Integrated Logistics Management System.

The Bureau of International Narcotics and Law Enforcement Affairs should revise the end-use monitoring standard operating policies and procedures to ensure that data within the transfer letter trackers accurately reflect data for non-end-use monitoring assets.

We recommend that the NOAA Deputy Under Secretary for Operations direct the Assistant Administrator for the National Environmental Satellite, Data, and Information Service take measures to ensure that waivers of TAYF requirements are requested, fully evaluated, and approved as part of the waiver process.

We recommend that the NOAA Deputy Under Secretary for Operations direct the Assistant Administrator for the National Environmental Satellite, Data, and Information Service to consider taking the following actions for future programs update the SRR success criteria for rideshare missions to ensure that plans for disposition of any undefined requirement include an overestimated value for the requirement.

We recommend that the NOAA Deputy Under Secretary for Operations direct the Assistant Administrator for the National Environmental Satellite, Data, and Information Service to consider taking the following actions for future programs update the rideshare cost estimate for SWFO-L1 to support decision-making for future rideshare programs.

We recommend that the NOAA Deputy Under Secretary for Operations direct the Assistant Administrator for the National Environmental Satellite, Data, and Information Service to consider taking the following actions for future programs update policies to ensure that rideshare costs are tracked accurately.

We recommend that the NOAA Deputy Under Secretary for Operations direct the Assistant Administrator for the National Environmental Satellite, Data, and Information Service to consider taking the following actions for future programs conduct PaL sessions after completing project-level milestone reviews to elicit and capture lessons learned on a routine basis and in accordance with program plans.

We recommend that the NOAA Deputy Under Secretary for Operations direct the Assistant Administrator for the National Environmental Satellite, Data, and Information Service to consider taking the following actions for future programs ensure that the NESDIS SAE group develops a management control to provide reasonable assurance that programs under its purview execute their knowledge management responsibilities.

We recommend that the NOAA Deputy Under Secretary for Operations direct the Assistant Administrator for the National Environmental Satellite, Data, and Information Service to consider taking the following actions for future programs define the necessary space weather observations and satellite capabilities to ensure the continuity of satellite operations to meet PROSWIFT Act requirements.

USAID's Chief Information Officer conduct updated risk assessments for the two systems we identified

USAID's Chief Information Officer perform security controls assessments for the two systems we identified.

USAID's Chief Information Officer determine whether the Agency included cybersecurity duties in position descriptions and performance plans. If not, take corrective action, including addressing the causes for not doing so.

USAID's Chief Information Officer determine whether the Agency developed and implemented policies and procedures for maintaining data and metadata inventories for its various data types, including data from third-party providers. If not, take corrective action, including addressing the causes for not doing so.

USAID's Chief Information Officer determine whether the Agency implemented network monitoring and enforcement mechanisms to identify and disconnect or isolate noncompliant devices. If not, take corrective action, including addressing the causes for not doing so.

We recommend that the Grantee revise its procurement policies and procedures, to ensure strict adherence to competitive bidding requirements for future projects.

We recommend that the Grantee maintain adequate documentation justifying all sole-source vendor selection to ensure compliance with all applicable regulations.

We recommend that the Grantee work with ARC, to solve the $396,000 of questioned costs.

We recommend that the Grantee develop procedures to hold their partners accountable for preparing and submitting quarterly reports in a timely manner.

We recommend that USAID or other U.S. government officials responsible for the administration and oversight of the Dubai warehouse take the following actions: Update the warehouse contract to clarify requirements for temperature and humidity control, maintaining mechanical equipment, and inspecting commodities in the warehouse.

We recommend that USAID or other U.S. government officials responsible for the administration and oversight of the Dubai warehouse take the following actions: Update the statement of work for third-party inspections to clarify quarterly inspection requirements of Dubai warehouse conditions, such as pest control and temperature.

USAID or other U.S. government officials responsible for the administration and oversight of the direct budget support funds work with contractor KPMG to develop a plan to submit the required oversight deliverables to ensure U.S. government funds are being used as intended

USAID or other U.S. government officials responsible for the administration and oversight of the direct budget support funds develop and implement a plan to review the internally displaced persons expenditure category from June 2022 through December 2023 in the scope of work for future contracted audits of the Government of Ukraine to confirm that preventative controls screen beneficiaries for duplicate payments

USAID or other U.S. government officials responsible for the administration and oversight of the direct budget support funds work with the the Government of Ukraine to develop a plan to identify the extent to which payments were made to internally displaced persons living abroad between June 2022 and July 2023 that were reimbursed by USAID's contributions to the Public Expenditures for Administrative Capacity Endurance fund, and use the reconciliation process outlined in the World Bank's 2024 Project Operation Manual for any amounts determined to be ineligible

We recommend that USGS amend all active Infrastructure Investment and Jobs Act cooperative agreements to include performance measures or metrics.