Open Recommendations

The Chief Information Officer should require a unique system identifier for each new and legacy system in the authoritative inventory be implemented and applied to system records in the other inventory systems.

The Chief Information Officer should conduct an annual reconciliation of the multiple inventory systems to ensure that all systems are using unique system identifiers.

The Chief Information Officer should improve its annual validation process to ensure that all systems with PII and FTI inventory data are consistently designated across the multiple inventory systems, and that system owners are communicating changes to impacted groups.

The OIG recommends the Director evaluates accessible parking spaces at the circle of the main entrance and ensures access aisles have visible pavement markings and remain available for use.

The OIG recommends facility leaders improve crosswalk visibility and monitor pedestrian safety at the crosswalks until completion.

The OIG recommends facility leaders improve doorway safety at the main entrance.

The OIG recommends the Director ensures staff have adequate hand hygiene supplies in or near soiled utility rooms that contain biohazardous materials.

The OIG recommends facility leaders ensure the facility policy for communication of test results and service-level workflows comply with VHA requirements, and staff implement processes to monitor patient notification of test results.

The OIG recommends facility leaders increase hiring efforts for the vacant social work positions in the Housing and Urban Development"Veterans Affairs Supportive Housing program, and in the interim, provide staff to support program enrollment.

The Hampton VA Medical Center Director directs nursing leaders to review records of medical intensive care unit patients with Clinical Institute Withdrawal Assessment of Alcohol Scale Protocol orders to confirm that medical intensive care unit nurses document Clinical Institute Withdrawal Assessment of Alcohol Scale scores consistent with patients documented behavior and symptoms and takes actions to address any deficiencies that are identified.

The Hampton VA Medical Center Director confirms that nursing leaders complete review of records of medical intensive care unit patients with Clinical Institute Withdrawal Assessment of Alcohol Scale protocol orders to determine the extent with which administration of medication is in adherence with the protocol and take actions to address any deficiencies that are identified.

The Hampton VA Medical Center Director ensures that a review of records of medical intensive care unit patients with Clinical Institute Withdrawal Assessment of Alcohol Scale protocol orders is completed by nursing leaders to (a) assess the degree of compliance with completing Clinical Institute Withdrawal Assessment of Alcohol Scale assessments based on the last assessment score, as outlined in the protocol, and (b) review the actual time Clinical Institute Withdrawal Assessment of Alcohol Scale is completed in comparison to the time it is documented in the electronic health records to identify significant delays, if any, and based on analysis of…

The Hampton VA Medical Center Director works with the facility Chief of Staff to ensure medical intensive care unit providers have reviewed a clinical practice guideline specific to management of alcohol withdrawal from an accredited source, such as The American Society of Addiction Medicine.

The Hampton VA Medical Center Director confirms completion of a review to assess the current process for communicating unit-based medication shortages and how staff can confirm the availability of shortage medications when use of the medication is key to the patients treatment, and updates the process as warranted.

The Hampton VA Medical Center Director ensures that the facilitys Alcohol Withdrawal Management standard operating procedure aligns with requirements for a standard operating procedure outlined in Veterans Health Administration Notice 2024-09.

The Hampton VA Medical Center Director confirms that training requirements specified in Veterans Health Administration Notice 2024-09 are completed, training attendance is tracked, and a process is in place to monitor accurate and consistent use of the alcohol withdrawal scale identified in the facility standard operating procedure

We recommend the Regional Administrator, FEMA Region IV, complete the insurance review for Jacksonville State and offset and disallow $14.1 million ($10.6 million Federal share) of ineligible duplicate benefits for insurance proceeds received by Jacksonville State not previously reduced from the corresponding project worksheet amounts.

We recommend the Acting Director for ICE review and revise as needed Memoranda of Agreement and the Joint Concept of Operations between ICE and the U.S. Department of Health and Human Services and continue to work on information-sharing agreements related to unaccompanied alien children.

We recommend the Acting Director for ICE develop and implement a formal process to review ICE system data and identify inaccurate and incomplete addresses for unaccompanied alien children and share this information externally with the U.S. Department of Health and Human Services.

We recommend the Acting Director for ICE develop and implement a plan to address the backlog of unserved Notices to Appear for unaccompanied alien children, including a timeframe for reducing the backlog.

We recommend the Acting Director for ICE update existing guidance, such as the Field Office Juvenile Coordinator Handbook, to clarify how ICE ERO officers should elevate concerns regarding the safety or circumstances of unaccompanied alien children and ensure wide dissemination of all updated guidance.

Establish clearly defined, measurable objectives for the ECAP program that align with the expectations in the GAO Green Book and FS policy.

Establish and document a hiring strategy to ensure FS has sufficient qualified staff at all levels of the ECAP Program.

Document a knowledge management plan to ensure all relevant information from ECAP program activities is communicated and provided to successors.

Confirm management at the Revere Carrier Annex is following the required Redline process and properly documenting delayed mail.

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

We recommend that the USAID/Kenya and East Africa verify that Northern Rangelands Trust corrects the three instances of material noncompliance identified on pages 40, 41 to 47 of the audit report.

We recommend that USAID/Kenya and East Africa determine the allowability of $35,821 in ineligible questioned costs on pages 17 and 22 of the audit report and recover any amount that is unallowable.

We recommend that USAID/Senegal verify that African Center for Advanced Studies in Management corrects the one material weakness in internal control detailed on page 37 of the audit report.

We recommend that USAID Power Africa determine the allowability of $41,552 in questioned costs ($41,032 ineligible, $520 unsupported) on pages 11, 13, and 20 to 25 of the audit report and recover any amount that is unallowable.

Mint Director ensures that the Mint recovers its costs on the lost 120 Congressional Award Program (CAP) medals from the sole source contractor.

Mint Director ensures that the Mint engages its Protection officials to complete the Mint’s investigation of the lost CAP medals and conducts a lessons-learned review of this incident to implement process improvements for future contracts.

Mint Director ensures that the Mint conducts a fully competitive solicitation for a source that can provide plating for the CAP medals.

Some or all of the recommendation is not publicly available due to concerns with information protected under the Freedom of Information Act.

Some or all of the recommendation is not publicly available due to concerns with information protected under the Freedom of Information Act.

Some or all of the recommendation is not publicly available due to concerns with information protected under the Freedom of Information Act.

Some or all of the recommendation is not publicly available due to concerns with information protected under the Freedom of Information Act.

Some or all of the recommendation is not publicly available due to concerns with information protected under the Freedom of Information Act.

Some or all of the recommendation is not publicly available due to concerns with information protected under the Freedom of Information Act.

Some or all of the recommendation is not publicly available due to concerns with information protected under the Freedom of Information Act.

Some or all of the recommendation is not publicly available due to concerns with information protected under the Freedom of Information Act.

Some or all of the recommendation is not publicly available due to concerns with information protected under the Freedom of Information Act.

Some or all of the recommendation is not publicly available due to concerns with information protected under the Freedom of Information Act.

Some or all of the recommendation is not publicly available due to concerns with information protected under the Freedom of Information Act.

Some or all of the recommendation is not publicly available due to concerns with information protected under the Freedom of Information Act.

Some or all of the recommendation is not publicly available due to concerns with information protected under the Freedom of Information Act.

Some or all of the recommendation is not publicly available due to concerns with information protected under the Freedom of Information Act.

Review GPO Instructions 810.26, Motor Vehicle Management Program, and 810.11B, GPO Property Management Program, for
applicability and update or replace them with policies and standard operating procedures that align with current organizational structure and business operations.

Establish clear roles and responsibilities in fleet management policies and standard operating procedures for the Fleet Manager and Agency-wide supervisors and employees.

Develop procedures to maintain a complete and accurate database of fleet assets. Assess and leverage opportunities to incorporate automation to improve process efficiencies.