Open Recommendations

The Overton Brooks VA Medical Center Director makes certain that oversight of the intensive care unit physician credentialing and privileging process is completed prior to physicians being scheduled and providing patient care, and monitors compliance.

The Overton Brooks VA Medical Center Director ensures root cause analyses are completed according to Veterans Health Administration policy including team composition, root cause analysis process steps, and timeliness.

In our August and September 2024 alerts, we recommended that the Chief, Business Continuity Operations Officer, should ensure that the identified primary and spare pad-paks that have expired are replaced immediately.

In our August and September 2024 alerts, we recommended that the Chief, Business Continuity Operations Officer, should ensure that where TIGTA identified missing spare pad-paks, they are replaced.

In our August and September 2024 alerts, we recommended that the Chief, Business Continuity Operations Officer, should ensure that where TIGTA did not conduct an inspection, an immediate assessment is conducted on AEDs across the IRS AED program to identify and replace AED pad-paks expired or missing.

The Chief, Business Continuity Operations Officer, should ensure that appropriate signage identifying the location of mounted AEDs is provided.

In our September 2024 alert, we recommended that the Chief, Business Continuity Operations Officer, should ensure that where TIGTA did not conduct an inspection, an immediate assessment is conducted of AED wall cabinets across the IRS AED program to identify and mount AEDs within an approved cabinet and comply with proper placement guidelines, as appropriate.

In our August 2024 alert, we recommended that the Chief, Business Continuity Operations Officer, should ensure that where TIGTA did not conduct an inspection, an immediate assessment is conducted of AEDs across the IRS AED program to identify, repair, or replace AEDs that are nonoperational.

In our September 2024 alert, we recommended that the Chief, Business Continuity Operations Officer, should ensure that an immediate assessment is conducted to ensure that AED trainer models are not distributed, mounted, and available for use in the event of an emergency. If any AED trainer models exist, they should be immediately removed and stored away from AED cabinets and signage to avoid confusion.

The Chief, Business Continuity Operations Officer, should ensure that AED site coordinators complete their monthly maintenance inspections as required.

In our September 2024 alert, we recommended that the Chief, Business Continuity Operations Officer, should determine whether AEDs have been implemented at these IRS PODs. If so, provide documentation that supports AEDs have been provided at these PODs, e.g., serial numbers and locations of AEDs.

In our September 2024 alert, we recommended that the Chief, Business Continuity Operations Officer, should identify where AEDs have not been implemented at IRS PODs with more than 100 employees and determine whether an AED program will be implemented at these PODs, e.g., recruiting and training volunteers, installing AEDs, etc.

We recommend that ACL develop mitigating controls and strategies to address the high and moderate risks we identified.

Issue guidelines that clearly and comprehensively address MCSAP oversight responsibilities, to include: (a) reimbursement request review steps and documentation in support of these steps, (b) expectations for program and process reviews as well as onsite monitoring, and (c) documentation and supervisory review of quarterly report monitoring.

Revise annual risk assessment guidelines to: (a) include an assessment of MCSAP-specific risks; (b) place a necessary level of emphasis on Organizational Management factors; (c) clarify how to address risk factors and Division Office flexibility to change the priority level to something other than what the tool suggests; and (d) provide steps to revise the annual risk assessment template, as needed, to reflect risk changes.

Develop and implement a process to notify FMCSA's State Programs Division of grantees that receive a medium or high priority level-from the annual risk assessment; document and maintain these risk levels in a centralized location.

Revise monitoring plan guidelines to: (a) incorporate supervisory review and approvals of monitoring plans; (b) verify plans are fully completed and include rationale for any activities not completed; and (c) update the monitoring plan template, as needed, to reflect these changes.

Revise guidelines: (a) on the impact of Commercial Vehicle Safety Plan (CVSP) goal performance for creating a clear line between the performance of CVSP goals and when to take enforcement action and (b) for CVSP goal performance tracking to urge Division Offices to document oversight of CVSP goals; identify which systems to review and how often to review them; and follow-up with the State grantee when needed.

USDA OIG has determined that this recommendation contains sensitive information and will not be publicly released due to privacy concerns.

USDA OIG has determined that this recommendation contains sensitive information and will not be publicly released due to privacy concerns.

USDA OIG has determined that this recommendation contains sensitive information and will not be publicly released due to privacy concerns.

USDA OIG has determined that this recommendation contains sensitive information and will not be publicly released due to privacy concerns.

Take corrective actions to ensure that facilities and programs remove unauthorized sensitive information from collaborative application sites.

Expand roles and responsibilities of facility and program information system security officers and privacy officers to include the routine review of SharePoint and Teams site permissions and content.

Implement automated tools and policies, supported with training, to enable the timely and routine detection and correction of improper sharing and unauthorized content throughout VA.

Mandate standardized training for SharePoint administrators and owners to clarify and reinforce data security requirements.

USAID/Indonesia determine the allowability of $42,764 ineligible questioned costs, as detailed on pages 25 to 37 of the audit report and recover any amount that is unallowable.

USAID/Indonesia verify that Yayasan Project HOPE corrects the seven instances of material noncompliance detailed on pages 25 to 37 of the audit report.

2. We recommend that the Under Secretary of Commerce for Intellectual Property and USPTO Director direct the Commissioner for Patents and the Chief Information Officer to develop clear, specific, and measurable objectives and system success criteria for the CPC-related and patent search AI tools.

3. We recommend that the Under Secretary of Commerce for Intellectual Property and USPTO Director direct the Commissioner for Patents and the Chief Information Officer to revise project management policies and practices to encourage increased engagement, as appropriate, with end users and others affected by the system, such as the public, earlier in the project lifecycle.

4. We recommend that the Under Secretary of Commerce for Intellectual Property and USPTO Director direct the Commissioner for Patents and the Chief Information Officer to create an AI-specific risk management plan (or revise existing policies and procedures to reflect the same) that requires a system-specific risk management approach, including identifying, documenting, analyzing, and managing risks.

5. We recommend that the Under Secretary of Commerce for Intellectual Property and USPTO Director direct the Commissioner for Patents and the Chief Information Officer to implement AI-specific risk management practices for the next-generation CPC AI tool and the patent search AI tool.

We recommend the Senior Vice President, Grid, update configuration management processes to improve periodic reviews.

The Chief, Taxpayer Services, should ensure that taxpayers without scheduled appointments are provided an opportunity to wait for an available TAC assistor on a first-come, first-served basis.

The Chief, Taxpayer Services, should communicate clearer guidance to the public on the procedures for future extended weekday hours at the TACs, including that scheduled appointments take priority over walk-in customers.

The Chief, Taxpayer Services, should ensure that TAC managers enforce procedures for providing CSS cards at TACs.

The Chief, Taxpayer Services, should Ensure that TAC managers enforce procedures for wearing name tags at TACs.

The Chief, Taxpayer Services should ensure that TAC managers enforce procedures for treating non-English speaking customers properly at TACs.

Charge First-Class Mail rates for Ballot Mail because service is comparable to or exceeds First-Class Mail service.

Finalize electronic Election and Political Mail reporting tools, written expectations for their use, and user guides in advance of the next federal election season.

Use carrier data to prohibit managers from completing the delivery all clear certification before carriers leave and arrive back from their delivery duties.

Work with District Managers to develop a plan to identify hub and spoke locations, including Regional Transportation Optimization sites, and communicate operational expectations in advance of the extraordinary measures period.

Create a method for scanning local turnaround ballots at delivery units.

Establish a plan of when and how it will implement the remaining deliverables provided under the contract, as well as how SSA will track progress of the implementation to determine whether the analyses, prototypes and recommendations provided in those deliverables improve SSA’s disability programs.

The VA Eastern Kansas Healthcare System Director ensures the chief of primary care reviews, strengthens, and implements system Patient Aligned Care Team processes for tracking and following up on community care consults ordered, particularly diagnostic consults, to verify patients receive care and to review and act upon consult results, as clinically indicated.

The VA Eastern Kansas Healthcare System Director reviews institutional disclosures conducted by the system over the past 12 months, including the patient’s institutional disclosure, and ensures these disclosures fully adhere to Veterans Health Administration Directive 1004.08, Disclosure of Adverse Events to Patients, October 31, 2018, including documenting the details of the adverse event and discussion points of the disclosure, and takes action needed to remediate disclosures that do not meet these standards.

The VA Eastern Kansas Healthcare System Director ensures community care staff make the required three attempts to obtain patients’ community care records within 90 days of completed appointments, and monitors for compliance.

The VA Eastern Kansas Healthcare System Director collaborates with the Kansas City VA Medical Center Director to review the frequency and circumstances of community care records being sent to the incorrect VA facility, develops, and implements a process for ensuring community care records are delivered to the correct ordering VA facility, educates staff on the process, and monitors for compliance.

The Under Secretary for Health establishes and monitors compliance with a process that ensures the Veterans Health Administration ordering provider receives urgent non-life-threatening abnormal test results from care obtained in the community, such as the diagnostic positron emission tomography scan results described in this report, within a time frame that allows timely attention and appropriate action to be taken.

The Veterans Integrated Service Network Director, in conjunction with the Veterans Health Administration National Center for Lung Cancer Screening Program Office, evaluates the VA Eastern Kansas Healthcare System’s Lung Cancer Screening Program to ensure operational adherence to the Lung Cancer Screening Program requirements, and takes action as needed.