Open Recommendations

Executive leaders monitor the effectiveness of the patient notification process.

Facility leaders ensure staff follow facility policies and maintain a clean environment.

The under secretary for health require the chief operating officer to direct the Veterans Integrated Service Network directors to fully integrate the core services in accordance with policy to improve operational efficiencies and access for veterans.

The under secretary for health establish a process requiring medical facility directors to coordinate with the Office of Integrated Veteran Care and the clinical contact centers before setting up or maintaining a local phone queue for services the clinical contact center provides.

The under secretary for health require the Office of Integrated Veteran Care to direct the clinical contact center leaders to determine if schedulers are arbitrarily ending calls in the telephone system to remain in after-call work status longer than needed to reduce the number of calls routed to them.

The under secretary for health direct clinical contact center leaders to routinely evaluate and, if needed, address schedulers handle time and availability time to improve performance and reduce inefficiencies.

The under secretary for health direct the Office of Integrated Veteran Care to include schedulers handle time and availability time as part of VA Health Connects annual performance plans to make sure clinical contact centers monitor and address these areas.

The under secretary for health make sure the Office of Integrated Veteran Care and chief operating officer evaluate VA Health Connect staffing for scheduling and, if necessary, reallocate staff so all clinical contact centers provide core services and meet required performance standards for scheduling.

The under secretary for health direct the Office of Integrated Veteran Care to formalize and clarify internal waiver guidance and include examples of the specific evidence that would be required for a clinical contact center not to provide 24-hour services"such as exploring the use of other strategies like routing calls to another service or partnering with other centers to provide coverage.

The under secretary for health ensure the assistant under secretary for health for the Office of Integrated Veteran Care and chief operating officer periodically review the clinical contact center waiver submissions and the planned actions to comply with VA Health Connect requirements.

The Chief Taxpayer Services should conduct annual refresher training for all representatives providing customer service through IRS telephone lines and emphasize the importance of always providing professional and courteous customer service.

We recommend the Vice President, Supply Chain, establish a prescribed method for making a forecasted usage determination.

We recommend the Vice President, Supply Chain, establish a process for reorder points to be reviewed and adjusted as necessary, before surplus inventory is transferred.

We recommend the Vice President, Supply Chain, develop and review a report identifying surplus items that were repurchased within a specified period of time to determine if the purchases were appropriate and take actions to address any issues identified.

We recommend the Vice President, Supply Chain, take steps to improve surplus inventory documentation completion.

Determine the scope of the pest control problem within the dry-food storage areas at Federal Correctional Institution Terre Haute and address it.

Until permanent repairs planned by the BOP can be completed at Federal Correctional Institution Terre Haute, assess what steps can be taken to mitigate safety and security risks associated with window disrepair and make temporary repairs to the windows that present the greatest potential safety and security risks at the institution.

After reviewing a draft of this report, the FBI informed the OIG that FBI leadership had recently decided not to make a policy change at this time that would allow non-attorney supervisors to approve certain U.S. person queries. However, FBI indicated that its decision does not remove the option as a possibility in the future. In light of (1) the FBI's query compliance history described in Chapter One, (2) FBI leadership's initial decision immediately after enactment of RISAA to limit approvals of U.S. person queries to attorneys and the improved level of compliance that followed, and (3) the inherently and…

Regardless of whether RISAA's requirement for the Department to review all FBI U.S. person queries remains in place following that provision's sunset on April 20, 2026, because of the limited resources and capabilities of OIA, NSD should continue its current practice of reviewing 100 percent of the FBI's U.S. person queries.

In light of NSD's continuing independent review of all U.S. person queries and OIA's limited resources, OIA should focus its oversight to complement, rather than duplicate, NSD's work. Under such an approach, OIA's continued reviews of all U.S. person queries could be directed to areas not covered by NSD's reviews, or OIA could use sampling or other GAO-endorsed standards and methods to audit a subset of U.S. person queries with the goal of maintaining the multi-level oversight structure that was contemplated by the 2020 Barr Memorandum Regarding FBI Internal Compliance Functions and that we believe appropriate for these activities.

The FBI should maintain records of all requests to the Deputy Director for approval of sensitive queries and the dispositions of such requests, including requests that are not ultimately approved.

Strengthen its RRC contractor performance monitoring practices and procedures to ensure that the BOP adequately assesses contractor performance to the specific requirements of the contract and receives the full scope of services it has contracted with providers to deliver.

Review the questioned costs of approximately $30 million in expenditures as of May 2025, determine the value lost to the government from not receiving contracted reentry services using fully qualified personnel, and remedy an appropriate amount of the questioned costs, such as through recovery, equitable adjustment, or other options.

Ensure that Kintock takes sufficient corrective action to ensure that it is providing the required services using fully qualified personnel, thereby putting an estimated $38 million in remaining available funds for these contracts to better use.

Work with Kintock to immediately begin providing all classes and services detailed in the contract proposal and ensure it has adequate policies and procedures for documenting its compliance with contract terms and conditions.

Update its standardized IPP form to ensure it adequately addresses all requirements as outlined in the SOW.

Update its standardized RRC contract SOW to include detailed quality standards for the rehabilitation services provided and appropriately defined performance standards.

Update its training of monitoring staff to help ensure the adequacy of its monitoring activities, including IPP evaluations, and other contractor performance quality evaluations.

Ensure contractors are adequately informed of the BOP's expectations of a complete IPP.

Work with Kintock to update its hiring procedures to ensure that only qualified employees are recommended to the BOP for staffing key positions.

Develop practices and procedures to ensure the BOP's verification of contract employees submitted to work in RRCs is adequately documented and maintained, including controls surrounding the limited use of employment qualification waivers.

Ensure its written guidance to contracting personnel requires adequate documentation of appropriate and sound price reasonableness justifications when not opting to require certified cost and pricing data from RRC contractors.

Remedy the $1,791,752 in BPA-related expenditures for which the OIG has questioned the necessity of the cost.

Remedy the $24,572 in unallowable costs related to Mayvin not performing the quality control plan agreed to in the BPA.

Ensure the contractor utilizes its quality control plan to help mitigate risk of contract nonperformance and ensure the USMS receives the full value of the contracted services.

Ensure its personnel are aware of and conduct all necessary contract oversight, including annual reviews of the BPA; utilizing the QASP; performing and entering contractor performance evaluations into CPARS; and properly designating and documenting responsibilities for contract performance monitoring.

Work with Mayvin to remedy $50,686 in unallowable costs related to bills against call orders that did not fully align with the individual line item ceilings within call orders.

Identify and remedy the internal control weakness that resulted in billing errors and address the inaccurate information reported in its financial system.

Remedy the $61,521 in unsupported costs pertaining to hours billed that may not have resulted in any services performed.

Review all active call orders to assess the services associated with those call orders, and future call orders for similar services, and determine if the services are necessary and aligned with the procured labor mix, and if not, put those funds to better use.

Design and implement a control to ensure call order requisition packages include sufficient justification and support for required services as outlined in USMS policy.

Design and implement a control to ensure requests for services to the contractor specify the task(s) required, proposals regarding those tasks are required from the contractor, and the review of the level of effort and labor mix contained in those proposals are sufficiently documented, as required by FAR 8.405-(3)(c)(3).

Include individual SOWs that identify the specific services it requires and applicable performance standards in both its current and future call orders to help ensure appropriate services are procured and contractor performance can be measured.

Develop and implement a control to ensure that contracting officials comply with FAR 16.104(e) and consider utilizing fixed-price call orders, or portions of call orders, rather than labor-hour call orders.

Develop and implement a control to ensure D&Fs are completed for non-firm-fixed-price call orders, as required by FAR Subpart 8.404(h)(3).

Evaluate the structure and management of Mayvin staff on call orders to ensure the USMS is not inappropriately exercising a personal services contract.

We recommend the Commissioner of CBP: (1) conduct an analysis of the 500,000 fingerprints sent to DoS and include the findings in their risk assessments to further identify and mitigate any risks posed by individuals whose fingerprints were waived by the Department of State, and (2) share the results with the Department of State and other government partners, as appropriate, for any follow-up action.

Take appropriate action to pay the underpayments to the 42 beneficiaries identified in our audit.

Take appropriate action to pay the underpayments for the remaining population of beneficiaries identified by our audit.

Revise its semi-annual alerts to include beneficiaries whose benefits SSA withheld due to the representative payees’ deaths.