Open Recommendations

The Marion VA Health Care System Director ensures suicide prevention staff document high-risk flag inactivation within patients’ electronic health records and notify patients when a high-risk flag is activated or inactivated as required by the Veterans Health Administration, and monitors compliance.

The Marion VA Health Care System Director ensures mental health staff adhere to Veterans Health Administration requirements on safety planning during high risk for suicide patient record flag patient contacts.

Develop a plan to timely execute IRDTS use for all programs subject to spot-check and program review, to improve the process of using spot check review results, enhance program accountability and integrity, and reduce payment errors.

Establish a process to regularly use data collected from the spot check reviews for each of its programs that rely on self-certification to identify actions it must take to improve the payment process and reduce payment inaccuracy.

Review the more than $16.4 million in questioned costs identified in one State for ECP payments made from August 2023 through May 2025. As appropriate, recover any costs determined to be unallowable due to violation of agency policy or make additional payments for identified underpayments.

Ensure the applicable State rescinds its guidance that contradicts national guidance.

Ensure that the updated OMB Circular A-136 is utilized when preparing and reviewing the financial statements and footnote disclosures.

Design and implement policies and procedures to have the reviewer of the financial statements and note disclosures thoroughly review for completeness, accuracy, and compliance with financial reporting requirements.

Implement a certification sheet detailing the EAC financial statements and note disclosures reviewer(s), and the date of the review(s). Ensure that the certification sheet is appropriately signed.

Develop, document and implement standard operating procedures over the property, plant and equipment process including an independent reconciliation of the amounts recorded in the general ledger to the Property records maintained by the EAC.

Develop and finalize processes and procedures for real property asset management-related activities, to include acquisition, management, utilization, and disposal of owned real property.

Establish and execute a data-driven decision-making process for the current and future use of the Student Residence Center and its operations. At a minimum, this process should:
a.
Identify and centralize sources of Student Residence Center-related financial and non-financial data across the FDIC, as appropriate.
b.
Utilize and analyze financial and non-financial data identified to inform Student Residence Center resource allocation decisions to achieve the best value.

Develop performance goals and objectives for the Student Residence Center, in alignment with the FDIC’s mission, strategic plan, and performance goals.

Leverage FDIC Directive 4010.03, Enterprise Risk Management and Internal Control Program to identify, assess, and manage risks specifically related to achieving the Student Residence Center performance goals and objectives, and coordinate with the Office of Risk Management and Internal Controls, as necessary.

We recommend that the Grantee develop written policies and procedures regarding the management of federal awards, in accordance with the Uniform Guidance.

We recommend that the Grantee revise the final Form SF-270 report issued to ARC to reflect the correct matching amounts.

Train management at all delivery units in the district on the proper procedures for reporting delayed mail.

Provide adequate staff to the Benson and Boystown stations to process and deliver all committed mail daily.

Recover the $125,038 in questioned costs from the ineligible claims that Maryland DHS approved.

Verify that Kenya Red Cross Society corrects the one instance of
material noncompliance detailed on page 28 of the audit report.

We recommend the Senior Vice President, Generation Projects and Fleet Services, in conjunction with the Vice President, Transmission System Projects and the Vice President, River Operations, evaluate the results of transmission studies and develop a plan to determine which transmission upgrades to pursue and responsibilities for funding.

We recommend the Senior Vice President, Generation Projects and Fleet Services, formalize a process to evaluate transmission impacts in the planning phase for Hydro Life Extension projects.

We recommend the Senior Vice President, Generation Projects and Fleet Services, reinforce the expectation to incorporate lessons learned as part of the continuous improvement process.

Implement a plan at the Cleveland Processing and Distribution Center to ensure proper mail flow is followed and hold supervisors accountable for missed pieces.

Coordinate with the Lakeshores Division Director, Logistics to provide training to supervisors on the procedures for properly monitoring and reporting employee absences and verify that all supervisors monitor attendance at the Cleveland Processing and Distribution Center.

Complete a review of Postal Vehicle Service transportation schedules and verify related actions are implemented at the Cleveland Processing and Distribution Center.

Analyze attendance and develop a contingency plan to follow when adequate staffing cannot be met at the Cleveland Processing and Distribution Center.

Coordinate with the Lakeshores Division Director, Logistics to develop and implement a plan to verify scanning at the Cleveland Processing and Distribution Center is consistently completed in accordance with policy.

Properly reconcile the Surface Visibility scanners in Ethos at the facility and take measurable actions to retrieve all lost scanners at the Cleveland Processing and Distribution Center.

Develop and implement new controls to monitor and maintain an inventory of the Surface Visibility scanners at the Cleveland Processing and Distribution Center.

Verify all drivers are using wheel chocks at the Cleveland Processing and Distribution Center.

Repair or replace all damaged dock doors and plates at the Cleveland Processing and Distribution Center.

Ensure a complete understanding is obtained as to what constitutes accounts payable and accrued
expenses and how that is different from obligated, undelivered orders. In addition, increase the
understanding of what accounts on the trial balance and line items on the financial statements are
impacted by accruals.

Improve the existing worksheet used for accrual calculations by including contract type, services/
goods received, documentation of accrual methodology and accumulate adequate support that is
readily available. The spreadsheet and supporting documentation should be presented to a
supervisor for review as part of the accrual review process.

Ensure a complete understanding is obtained as to what constitutes accounts payable and accrued
expenses and how that is different from obligated, undelivered orders. In addition, increase the
understanding of what accounts on the trial balance and line items on the financial statements are
impacted by accruals.

Improve the existing worksheet used for accrual calculations by including contract type,
services/goods received, documentation of accrual methodology and accumulate adequate support
that is readily available. The spreadsheet and supporting documentation should be presented to a
supervisor for review as part of the accrual review process.

We recommend the Administrative Services Director review all open obligations with ARC and project
management personnel to verify the accuracy of all undelivered account balances.

We suggest FLRA revisit their existing internal control procedures for reviewing ARC services to ensure
complementary customer agency controls included in the ARC SOC 1 Type 2 report have been
incorporated into the internal control process.

We understand that this submission was only one day late and acknowledge that other submissions tested did not show late reporting. We recommend that FLRA considers unexpected events or employee
absences to ensure timely filing.

Work with the Cabinet for Health and Family Services to determine whether it correctly charged indirect costs to SSA’s programs since April 2024 and make any necessary corrections.

We recommend that the Assistant Secretary for Special Education and Rehabilitative Services require Nebraska to ensure that Omaha provides sufficient training and instruction to employees responsible for developing and reviewing IEPs, which in part should remind staff to follow applicable guidance in Omaha’s Special Education Handbook, review IEPs annually, ensure that all required team members attend IEP team meetings, and complete all sections of the IEP template and Notice of IEP Team Meeting form. The training and instruction should be provided to employees on a regular and recurring basis.

We recommend that the Assistant Secretary for Special Education and Rehabilitative Services require Nebraska to ensure that Omaha develops policies, procedures, or protocols that describe how and in what level of detail special education staff and other service providers should document the IEP services they provide to each student; and how and for what amount of time that documentation should be retained.

The Facility Director ensures regular communication between mental health and executive leaders regarding staffing needs and mental health processes.

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

The Chief of Mental Health ensures a full-time, dedicated local recovery coordinator is integrated into the inpatient mental health unit to support recovery-oriented care.

The Chief of Mental Health ensures mental health leaders develop and implement written processes for staff training, education, and recovery-oriented services.

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

The Facility Director ensures veterans privacy in the communal shower room on the inpatient mental health unit.

The Facility Director ensures clinicians document veterans capacity to consent to admission to the inpatient mental health unit.

The Veterans Integrated Service Network Director ensures facilities involuntary hold and hospitalization processes align with applicable state laws and develops processes for ongoing oversight.