Open Recommendations

We recommend that HUD require the City to develop a plan for how the City will continue to fulfill the required monitoring and oversight responsibilities of the National Disaster Resilience programs and projects if it runs out of planning and administration funds before it completes these programs and projects.

We recommend that HUD require the City to provide monitoring reports and supporting documentation to show that it conducted periodic monitoring of NORA' s performance and compliance with program rules and regulations and ensured that NORA promptly remedies any findings or concerns. This includes, but is not limited to, ensuring that NORA (1) provides adequate oversight of the contractors providing service under the program and (2) maintains documentation to support eligibility for program participants.

We recommend that HUD require the City to develop and implement a methodology for NORA to conduct periodic evaluations at appropriate points during the construction process to assess the quality of the work on all new properties and correct any issues identified.

We recommend that HUD require the City to develop and implement a plan for how to review the condition of the property updates and determine where repairs are needed.

We recommend that HUD require the City to analyze the effectiveness of the Retrofit program and identify what improvements are needed to better benefit program participants and lessen their burden, to include obtaining input from program participants, and implement those improvements.

We recommend that HUD require the City to support or repay, from nonfederal funds, $5,078 in the square footage overcharge for work not completed, according to the project design and invoice documentation.

We recommend that HUD require the City to provide supporting documentation for the 4 program participants that did not have adequate income documentation. If the supporting documentation cannot be provided, repay, from nonfederal funds, $99,347.

We recommend that HUD require the City to since the property updates have been completed for the 24 program participants that did not receive the green infrastructure training, provide documentation that any subsequent program participants completed the green infrastructure training workshop before the grant agreement is signed and construction begins.

Complete the implementation of an automated solution to help ensure a complete and accurate inventory of software assets.

Define a required frequency for updating the system inventory and implement a quality control process to validate that system inventories are updated in a timely manner.

Update existing policy and procedures to ensure plans of action and milestones are closed only after the planned corrective actions and milestones have been implemented.

Review the Enterprise Risk Management Framework Guide annually and update if needed.

Develop a strategy to ensure that products, system components, systems, and services of external providers are consistent with the organization’s cybersecurity and supply chain requirements.

Define timeframe and remediation requirements for baseline and configuration weaknesses.

Properly update and remediate vulnerabilities and configuration weaknesses throughout the SBA environment.

Implement a process to track and enforce compliance with PIV implementation and multi-factor requirements.

Ensure implementation procedures for data loss prevention are updated at least on a biannual basis to reflect new processes and new requirements.

Update existing procedures that identify the roles of individuals with significant IT responsibilities who require role-based training and ensure such training is provided and tracked.

Provide training to individuals with contingency planning roles and responsibilities.

The Carl Vinson VA Medical Center Director ensures that the CensiTrac Instrument Tracking System is fully implemented, and that training is provided to the CensiTrac coordinator and Sterile Processing Services staff, and monitors for compliance.

Implement standard operating procedures on how to conduct domestic animal risk assessments for the active ingredients in pet products to support pesticide registration review decisions.

Implement a measurable standard to determine when a pet product poses unreasonable adverse effects in pets to support the pesticide registration review decision.

Establish and implement an additional data requirement for the premarket clinical testing of pet products that is consistent with the Veterinary International Conference on Harmonization Guideline GL9, Good Clinical Practice.

Assess what incident information is needed from registrants of pet products to determine when the EPA should take mitigation measures or other actions. Require pet product registrants to report that information to the EPA.

Establish policies and procedures that result in consistent implementation of mitigation measures to address unreasonable adverse effects or conduct additional analysis to determine whether a pet product is causing unreasonable adverse effects.

[Description omitted; DOJ has determined that this recommendation contains information that is limited official use or classified.]

Ensure the MSR Program establishes a stable CCRS design prior to establishing the life-cycle cost and schedule estimate at KDP-C, incorporating recommendations from the 2023 IRB as appropriate

Ensure the life-cycle cost and schedule estimates properly incorporate MSR Program complexity and performance as factors and do not only focus on external cost growth impacts and ongoing design issues.

Ensure the Agency Program Management Council is provided with a set of potential launch scenarios by KDP-C, including life-cycle cost and schedule estimates and an associated Joint Cost and Schedule Confidence Level for each.

Define freight auction applicability to Management Instruction PO-530-2009-4, Section 19 - Special Circumstances.

Update and enforce freight auction guidance and include at minimum a process to verify driver history.

CMS should implement and expand upon its policies and programs to strengthen the nursing home workforce.

CMS should reassess nurse aide training and certification requirements .

CMS should update the nursing home requirements for infection control to incorporate lessons learned from the pandemic.

CMS should provide effective guidance and assistance to nursing homes on how to comply with updated infection control requirements.

CMS should facilitate sharing of strategies and information to help nursing homes overcome challenges and improve care.

Develop and begin implementing a risk-based plan to secure inventory facilities across the company.

Provide evidence to support that the Authority corrected the 11 unit deficiencies for the 5 units and 7 building deficiencies for 4 buildings with outstanding deficiencies.

Determine the frequency of its quality control reviews of its inspections and work orders and update its quality control policy, training materials, and other resources as appropriate to ensure that its quality control process is consistently implemented.

Support that it has implemented its quality control policy for (1) monitoring the effectiveness of its unit and building inspections to ensure compliance with HUD's and its own requirements and (2) reviewing work orders to ensure that cited deficiencies are corrected in accordance with HUD's and its own requirements.

Provide evidence to support that the Authority corrected the four non-life-threatening deficiencies for the three units with outstanding deficiencies.

Implement adequate procedures and controls to ensure that the deficiencies identified during annual self-inspections are properly categorized and corrected in a timely manner.

Develop and implement a plan to manage and reduce its backlog of work orders. This plan should include but not be limited to (1) assessing and addressing staffing needs; (2) creating a timeline for completion of the work orders to ensure that its properties are maintained in decent, safe, and sanitary condition and in good repair; and (3) providing documentation showing that it is on track to meet the completion timeframe.

Implement adequate procedures and controls to ensure that inspection reports are uploaded to the Authority's electronic filing system and work orders are created in a timely manner. This process should include but not be limited to providing training to its staff on the Authority's systems, establishing timeframes for the creation of work orders, and monitoring the work order process.

Provide evidence to support that the Authority corrected the 3 non-life-threatening health and safety, and 19 non-health and safety deficiencies.

Develop and implement adequate procedures and controls to ensure that (1) the deficiencies identified during REAC inspections are corrected in a timely manner and (2) documentation is maintained to support that repairs were made.

Implement adequate controls to ensure that the Authority's information system properly tracks the completion of work orders.

Implement adequate controls to ensure that the correction of life-threatening deficiencies is reported to HUD accurately and in a timely manner.

[Description omitted; CSOSA has determined that this recommendation contains information that is limited official use or classified.]

[Description omitted; CSOSA has determined that this recommendation contains information that is limited official use or classified.]