Open Recommendations

Seek reimbursement of $(REDACTED) overpayment of PSP1 financial assistance

We recommend that Treasury's Office of Capital Access disallow the questioned cost amount of $20,850 and instruct Moreno Valley to repay that amount to the Federal Government.

The Medical Center Director ensures each service develops a workflow for the communication of test results.

The Medical Center Director ensures quality management staff report deficiencies identified from the External Peer Review Program to executive leaders, and staff take corrective actions as needed.

The Medical Center Director ensures the facility has a written policy for communication of test results.

The Chief of Staff and Associate Director of Patient Care Services ensure leaders in each service develop written service-level workflows that outline the process for staff to communicate test results to providers and patients.

The Veterans Integrated Service Network Director ensures executive leaders implement a process to monitor actions related to Veterans Health Administration policy changes.

The Medical Center Director ensures the Chief of Staff and Associate Director of Patient Care Services review performance metrics for test result communications and take action for identified deficiencies.

The Medical Center Director ensures executive leaders attend Quality and Patient Safety Council meetings.

The Executive Medical Center Director ensures clinical staff can open all doors to shared bathrooms.

The Executive Medical Center Director ensures staff keep exterior doors closed to minimize risk to wandering patients.

The Executive Medical Center Director ensures each service has workflows to communicate test results.

The Facility Director ensures the Mental Health Executive Council operates in accordance with Veterans Health Administration requirements.

The Chief of Mental Health ensures compliance with Veterans Health Administration requirements for a full-time local recovery coordinator.

The Chief of Mental Health ensures a minimum of four hours of recovery-oriented, interdisciplinary programming on weekdays and weekends on the inpatient mental health unit.

The Facility Director considers consulting with the Office of Mental Health to clarify guidelines for design elements such as artwork on the inpatient unit.

The Facility Director considers alternatives to outdoor access for the inpatient unit, such as those identified in VA’s Design Guide for Inpatient Mental Health & Residential Rehabilitation Treatment Program Facilities.

The Facility Director develops and implements written processes to monitor and track compliance with state laws for involuntary hospitalization and consults with the Office of General Counsel to ensure processes are consistent with applicable laws.

The Chief of Staff ensures documentation of informed consent discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications.

The Chief of Staff ensures veterans’ discharge instructions are written in easy-to-understand language and include the follow-up mental health appointment location, the purpose of each medication, and how the medication is supposed to be taken.

The Facility Director ensures the Interdisciplinary Safety Inspection Team adheres to Veterans Health Administration requirements, including recording membership and attendance for Mental Health Environment of Care Checklist inspections.

The Veterans Integrated Service Network Director implements processes to ensure the Veterans Integrated Service Network Mental Health Environment of Care Checklist Oversight Team provides facility guidance consistent with Veterans Health Administration requirements.

The Facility Director implements processes to ensure Interdisciplinary Safety Inspection Team staff accurately identify and document safety hazards within the Patient Safety Assessment Tool.

Verify that all identified facility repairs are completed at the Shreveport Processing and Distribution Center and Package Support Annex.

Work with OSU to develop and implement policy and procedure enhancements for (a) creating and supporting required performance reports, (b) ensuring subawards receive federal authorization when required, (c) ensuring proper separation of duties for the after-the-fact review of effort distributions, and (d) incorporating the proper approval process and requirements for budget adjustments in accordance with the DOJ Grants Financial Guide.

Remedy the net total of $292,977 in unallowable costs, which include:

a. $222,157 paid to unallowable subrecipients and the $16,700 of associated indirect costs, totaling $238,857, for grant number 15PBJA 21 GK 03997 INTE.

Remedy the net total of $292,977 in unallowable costs, which include:

b. $38,693 of unallowable indirect cost payments made to an OSU subrecipient for grant number 15PBJA 21 GK 03997 INTE.

Remedy the net total of $292,977 in unallowable costs, which include:

c. $55,211 of unallowable pass-through funds made to an OSU subrecipient for grant number 15PBJA 21 GK 03997 INTE.

Remedy the net total of $292,977 in unallowable costs, which include:

d. $1,342 of unallowable personnel costs, $432 of unallowable fringe benefit costs, and $592 of associated indirect costs, totaling $2,366, charged to grant number 15PJDP 22 GG 03279 JJOP.

Remedy the net total of $292,977 in unallowable costs, which include:

e. $7,435 of unallowable Youth Advisory Board incentive payments and the $2,483 of associated indirect costs, totaling $9,919, for grant number 15PJDP 22 GG 03279 JJOP.

Remedy the net total of $292,977 in unallowable costs, which include:

f. $3,143 in unallowable indirect costs related to grant number 15PBJA 21 GK 03997 INTE.

Coordinate with OSU to identify and remedy any additional unallowable costs that were incurred after our audit work concluded related to an unapproved employee.

Ensure OSU trains its staff to help ensure adherence to: (a) subrecipient monitoring policies, specifically staff responsibilities related to reviewing subrecipient invoices and (b) payroll policies and procedures, including those regarding Time and Effort Confirmation reports and proper authorization of these reports.

Ensure OSU submits the budget modifications OJP determined were necessary.

Flag the 73,302 7(a) loans for review at guaranty purchase to assess whether borrowers met all eligibility requirements and seek remedy for all loans deemed ineligible.

(U) Rec. A.1: Recommendation is classified.

(U) Rec. A.2: Recommendation is classified.

(U) Rec. A.3: Recommendation is classified.

(U) Rec. A.4: Recommendation is classified.

(U) Rec. B.1: Recommendation is classified.

(U) Rec. B.2: Recommendation is classified.

(U) Rec. B.3: Recommendation is classified.

(U) Rec. B.4: Recommendation is classified

(U) Rec. B.5: Recommendation is classified.

(U) Rec. B.6: Recommendation is classified.

(U) Rec. B.7: Recommendation is classified.

Rec. 1: The DoD OIG recommended that the Under Secretary of Defense for Personnel and Readiness, in coordination with the Under Secretary of Defense for Acquisition and Sustainment and Secretaries of the Military Departments, develop and implement policy that fully complies with the requirements of section 706 of the FY 2024 National Defense Authorization Act.

Rec. 2.a: The DoD OIG recommended that the Secretary of the Army, in coordination with the Director of the Defense Health Agency, develop and implement a plan with milestones to make naloxone available to Military Department Security Forces in accordance with the requirements of section 706 of the FY 2024 National Defense Authorization Act and Executive Action 15.

Rec. 2.b: The DoD OIG recommended that the Secretary of the Navy, in coordination with the Director of the Defense Health Agency, develop and implement a plan with milestones to make naloxone available to Military Department Security Forces in accordance with the requirements of section 706 of the FY 2024 National Defense Authorization Act and Executive Action 15.

Rec. 2.c: The DoD OIG recommended that the Secretary of the Air Force, in coordination with the Director of the Defense Health Agency, develop and implement a plan with milestones to make naloxone available to Military Department Security Forces in accordance with the requirements of section 706 of the FY 2024 National Defense Authorization Act and Executive Action 15.