Open Recommendations

Facility leaders attain appropriate primary care staffing and manageable panel sizes to ensure patients have timely access to high-quality care.

Facility leaders direct staff to conduct a risk assessment on liquid nitrogen storage, to include the small devices stored in examination rooms, and implement changes if needed.

Facility leaders determine appropriate supply storage locations and, for any supplies stored outside of the defined locations, implement a process to ensure staff identify and remove expired supplies.

Facility leaders ensure staff label opened multidose medications with expiration dates.

Facility leaders ensure staff store clean and dirty items separately.

The Director ensures staff implement processes to prevent repeat environment of care findings.

The OIG recommends facility leaders ensure the facility has a policy for the communication of test results and staff develop service-level workflows that align with VHA requirements.

Veterans Integrated Service Network 19 leaders assess the staffing needs for the facilitys radiology service and provide additional resources to ensure services are readily available to patients.

Veterans Integrated Service Network 19 leaders evaluate the reasons for delays in uploading images and reporting test results and assist the facilitys community care leaders to mitigate future delays.

Executive leaders monitor root cause analysis improvement actions through completion, monitor outcome measures, and ensure staff implement processes to sustain the improvements.

Conduct a comprehensive review of IAF's software and hardware inventories and update them to ensure that they are accurate and complete.

IAF's Chief Information Security Officer update IAF's procedures to include all elements for tracking the Agency's software and hardware assets. At a minimum these elements should include device type, location, and software license information.

IAF's Chief Information Security Officer conduct a security controls assessment for the two systems identified.

IAF's Chief Information Security Officer develop and implement procedures to hold system owners accountable for conducting security controls assessments and completing system security plans, and document which security controls are assessed and when.

IAF's Chief Information Security Officer update security plans for the two systems identified to include all required components as outlined in NIST Special Publication 800-53.

IAF's Chief Information Security Officer document the controls IAF is responsible for implementing for the external system identified and develop and implement a security plan for the system.

Design and implement monitoring controls to help ensure that password configurations for the FMS-NG
application are in compliance with the FMS-NG Operations Manual [language withheld based on applicable Freedom of Information Act exemptions].

Document that NTSB's preparation of the financial statements and footnotes is compliant with the most recent version of the financial reporting requirements as of the interim submission deadline stated in OMB Circular A-136, including any revisions required for new reporting requirements, before providing the financial statements and footnotes to external parties.

Develop a process for ensuring that all initial and subsequent benefits coverage changes requested by employees are processed timely and accurately.

Develop policies and procedures that include the performance of periodic reviews of employees' Official Personnel Folders to ensure that they are complete and accurate.

Create and enforce written procedures to review all employee onboarding documents, including documentation received for transferred employees and individuals returning to Federal civilian service, to ensure that the documentation is complete and accurate.

Perform and document routine reviews of employees' Official Personnel Folders to verify that payroll and benefits elections are correct, including retirement plan assignments and benefit elections. Take action to correct any errors, including the collection or return of excess employee contributions, when warranted.

Verify that all accountable and sensitive property has been located during the agency's annual self-audit process, including educating employees regarding their responsibility to report damaged, lost, and stolen property immediately after a loss has been identified.

Develop and implement a follow up procedure to verify that (1) all assets marked for disposal have been moved to a disposal holding area immediately before or after the assets' status is changed to disposal and (2) the disposal of the asset has taken place in a timely manner.

Create and enforce agency-specific written policies and procedures that specify how personnel actions should be initiated, reviewed, and submitted. These policies and procedures should specify the roles and responsibilities of human resources personnel relating to this process and the required elements and documentation of management's review of personnel actions prior to submission.

Review and revise its current methodology relating to the estimation and recording of accounts payable accruals to ensure that the bases used to calculate these accruals do not include any expense types or amounts for which separate accruals are recorded.

The Chief, Taxpayer Services, should ensure that the programming change to accurately update the secondary taxpayer’s account with the date of death annotated on a tax return is implemented in January 2026 and is functioning as intended.

The Chief, Taxpayer Services, should ensure that the requested programming to change how the date of death and corrections are posted to the taxpayer’s account is implemented in January 2027 and is functioning as intended.

The Chief, Taxpayer Services, should verify that the approximately 55,000 taxpayer accounts from the unprocessed January 2023 SSA file are locked.

The Commissioner, Taxpayer Services Division, should ensure that appropriate steps are taken to recover the erroneous RRC payments, including issuing Letter 510C.

Update its guidance and procedures to include procedures performed by the reviewer to ensure that all reconciliation procedures have been performed and the reconciliation documentation is complete, accurate, and internally consistent.

Develop a contingency plan that assigns a backup designated point of contact for the Federal Personnel and Payroll System who is trained to perform the required functions and can immediately take over those responsibilities, if needed.

Perform and document, at least monthly, a follow up review of any User Access Request forms that were submitted during that period to verify that the forms were processed in Federal Personnel and Payroll System and access was terminated.

Correct and then regularly update all listings of GLS's non-capitalized assets to enable the agency to quickly and accurately locate all items issued to GLS personnel.

Perform a full inventory of all non-capitalized and capitalized property during its annual physical inventory, including identifying and following up on items that have been reported as lost or stolen or for which the stated location is not accurate.

Develop a process to: a. identify and track all unusual transactions, including corrections relating to prior year activity that were processed during the current fiscal year; b. review the posting logic that was applied within Oracle for each correcting entry to ensure the entries had the intended effect; and c. record reclassification journal entries in the general ledger using the appropriate general ledger accounts for the correction of errors, in accordance with generally accepted accounting principles and Department of Treasury requirements, when appropriate.

Update written standard operating procedures and desk procedures to include the steps to be performed when recording unusual transactions and error corrections within Oracle and any additional actions to be taken, such as the recording of reclassification journal entries.

Update its written procedures or develop a desk procedure that provides detailed guidance or instructions for the calculation of the organization's year-end accounts payable and other accruals.

Develop a look-back analysis or otherwise document its review and assessment of disbursements made early in the subsequent reporting period (i.e., at the beginning of the next fiscal year) to identify items which should have been included in its year-end accounts payable balance and amend the existing accrual, if needed, prior to the preparation of the financial statements.

The Human Capital Officer should coordinate with IT to determine the time frame when managers must request laptops for new employees. Once determined, formalize the requirement in the standard new employee orientation guidance and update the Manager’s Onboarding Checklist.

The Human Capital Officer should update the Manager’s Onboarding Checklist with a step to issue the performance plan within 30 calendar days of the employee’s start date.

The Human Capital Officer should work with the ITM administrator to ensure that processes are put in place to alert managers when important due dates pass; for example, if the performance plan is past due.

The Human Capital Officer should establish a formal written policy that requires managers to conduct quarterly touchpoint discussions with new employees in their first year and require that managers attend the updated training on conducting quarterly touchpoint activities.

The Human Capital Officer should work with the ITM administrator to add quarterly touchpoint activities to the manager’s ITM module as part of the new employee onboarding, send managers notifications of upcoming due dates for quarterly touchpoint activity discussions and alert managers if the discussions are past due.

The Oklahoma City VA Health Care System Director, with Pathology and Laboratory Medicine Service leaders, conducts a comprehensive review of the quality of care for the four patients identified in this report, including determinations of cytopathology processing delays and assessment of patient harm, and takes action as warranted.

The Oklahoma City VA Health Care System Director ensures that routine non-gynecological turnaround time corrective actions are documented and monitored for effectiveness, as required by the Veterans Health Administration.

The Oklahoma City VA Health Care System Director conducts a comprehensive review of the quality of care provided by the Chief of Pathology and Laboratory Medicine Service, identifies deficiencies, and takes action as warranted.

The Oklahoma City VA Health Care System Director reviews the Pathology and Laboratory Medicine Service event reporting requirements for variance events and ensures completion according to facility policy and Veterans Health Administration requirements.

The Oklahoma City VA Health Care System Director, in conjunction with the National Center for Patient Safety, evaluates patient safety event reporting processes within the Pathology and Laboratory Medicine Service, and ensures completion according to Veterans Health Administration requirements.

The Oklahoma City VA Health Care System Director, with Pathology and Laboratory Medicine Service leaders, conducts a comprehensive review of the quality of care for the four patients identified in this report, including determinations of cytopathology processing delays and assessment of patient harm, and takes action as warranted.