Open Recommendations

The OIG recommends facility leaders ensure homeless program staff have access to appropriate vehicles to conduct their work.

The Carl Vinson VA Medical Center Director ensures applicable staff, such as Sterile Processing Services staff and end users of reusable medical devices, comply with procedures regarding the identification of and disposition of nonconforming surgical instruments.

The Carl Vinson VA Medical Center Director confirms operating room staff completes training regarding the recognition of and procedures for nonconforming surgical instruments.

The VA Southeast Network Director establishes a comprehensive strategy to review patients who may have been affected by the approximately 800 nonconforming surgical instruments to evaluate whether harm occurred, the need for patients to undergo testing or treatment, and the appropriateness of disclosures.

The VA Southeast Network Director evaluates whether administrative action is warranted for employees regarding Sterile Processing Services deficiencies at the Carl Vinson VA Medical Center, and takes action as appropriate.

The VA Southeast Network Director provides consultation and oversight to the Carl Vinson VA Medical Centers Sterile Processing Services to ensure implementation of facility-level action plans and sustainability of identified outcomes.

Clarify policies, guidance, and/or training on when admissions holds, removal of veterans from grantee facilities, and the withholding or suspension of per diem payments are appropriate and required.

Clarify policies, guidance, and/or training on how facility staff determine whether corrective actions for an identified problem related to a grantee should be required or suggested, including what factors to consider, who makes the final determination, and whether and how the determination is reviewed by others.

Implement a mechanism designed to reasonably ensure that VA oversight staff take appropriate enforcement measures to address persistent or recurring deficiencies by a Grant and Per Diem grantee that pose risks to veteran care and safety.

Ensure grant agreements require the grantee to promptly disclose to VA any adverse health or safety conditions occurring at any facility where VA-funded participants are receiving service, including the occurrence of sentinel events affecting non-VA-funded participants on the grantees premises and any adverse health or safety inspection results or similar findings made concerning the grantees premises or operations by any non-VA oversight entity, such as a federal, state, county, or local regulator.

Ensure Grant and Per Diem participants residing at the Veterans Village of San Diego (VVSD) who are eligible for clinical drug treatment receive appropriate support to obtain those services despite the closure of VVSDs clinical treatment housing model.

The OIG recommends facility leaders assess storage locations that are outside of standard supply rooms and implement a process to ensure staff remove expired supplies.

The VA Central Western Massachusetts Healthcare System Director establishes a mental health executive council that operates in accordance with VHA requirements.

The VA Central Western Massachusetts Healthcare System Director ensures staff consistently solicit and incorporate veteran feedback into process improvements.

The VA Central Western Massachusetts Healthcare System Director ensures the development of written processes for the admission of veterans on an involuntary hold and monitors and tracks compliance with involuntary commitment requirements.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures discharge instructions for veterans include the follow-up appointment location and contact information in easy-to-understand language.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures that discharge instructions include the purpose for each medication listed and are written in easy-to-understand language.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures staff complete the Columbia-Suicide Severity Rating Scale within 24 hours before discharge and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures that staff address ways to make veterans environments safer from potentially lethal means in safety plans and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Director ensures staff comply with Skills Training for Evaluation and Management of Suicide requirements and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures that the sally port inpatient unit doors are synchronized and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Director establishes an interdisciplinary safety inspection team that meets VHA requirements and ensures ongoing compliance.

The VA Central Western Massachusetts Healthcare System Director uses VHA guidelines to develop facility-specific policy for the use of restraint chairs.

The VA Central Western Massachusetts Healthcare System Director ensures alignment between use of physical restraint policies and practices.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures compliance with VHA requirements for Mental Health Environment of Care Checklist training completion.

Establish a Risk Management Committee and include key personnel and stakeholders from different CFTC Divisions.

Create the Governance Charter and hold regular meetings with the Risk Management Committee.

Update and finalize an ERM roadmap from 2020 which includes estimated and actual completion dates.

Develop Annual Risk Analysis Reports and distribute to the various divisions.

Implement an Enterprise Governance, Risk and Compliance (eGRC) Tool which will help aggregate risks across the enterprise and map them to strategic objectives.

Enhance ERM communication channels and hold regular meetings between the ERM team and departments.

Increase CFTC leadership support and conduct regular briefings and workshops, and actively participate in ERM activities.

Foster a collaborative environment by appointing ERM liaisons within each division.

Conduct training sessions to educate employees about the ERM program and its benefits.

Develop a formal ERM policy that outlines the framework, objectives, and scope of the program. This policy should be approved by senior management and communicated across the organization.

Create standardized procedures to conduct ERM assessments including guidelines for risk identification, assessment, mitigation, and monitoring.

Define its ERM risk rating methodology to consistently evaluate and prioritize risks and align this methodology with the organization’s risk appetite and tolerance levels.

Maintain a centralized risk register to document all identified risks as well as the risk owners, mitigation strategies, and monitoring plans.

Establish a timeline and criteria for conducting regular risk assessments and continuously monitoring and managing risk with at least an annual risk assessment.

Regularly review and update the ERM program to incorporate best practices and lessons learned to strive for continuous improvement.

Enhance its ERM team capacity and prioritize hiring skilled ERM professionals and provide ongoing training to existing staff.

Ensure ERM considerations are integrated into the strategic planning process with active involvement from senior executives.

We suggest CFTC to also Improve its processes by investing in technology that supports ERM activities, such as risk assessment tools and data analytics platforms.

Address budget constraints by reevaluating the resources dedicated to the ERM program and exploring cost-effective solutions and tools to enhance the ERM program without significant financial investment.

Strengthen its organizational resilience by conducting regular risk awareness and training sessions for all employees to build a risk-aware culture and establish a feedback loop to continuously assess and improve the ERM program based on lessons learned and emerging best practices.

We recommend that USAID's Office of Acquisition and Assistance Cost, Audit and Support Division/Contract Audit Management Branch verify that the African Institute for Development Policy corrects the instances of material noncompliance detailed on pages 45 to 57 of the audit report.

We recommend that USAID/Pakistan:

We recommend that USAID/Pakistan:

We recommend that USAID/Pakistan:

We recommend that USAID/Pakistan: