Open Recommendations

We recommend that the Utah Department of Health and Human Services improve its estate recovery program by establishing formal written estate recovery policies and procedures, to include policies and procedures regarding documentation to support its performance of estate recovery procedures for deceased Medicaid enrollees.

We recommend that the Utah Department of Health and Human Services improve its estate recovery program by implementing formal procedures to periodically review open cases and establish a timeframe for doing so.

We recommend that the Utah Department of Health and Human Services improve its estate recovery program by verifying that system edits are functioning properly and improving those system edits as necessary, and by verifying that caseworkers perform and document all applicable estate recovery procedures (including determining the amount of Medicaid paid claims, determining whether the enrollee had a surviving spouse or child(ren), and performing asset research) for deceased Medicaid enrollees.

We recommend that the Centers for Medicare & Medicaid Services take the following actions, which could have saved Medicare an estimated $190.1 million in payments made to acute-care
hospitals for outpatient services provided to hospice enrollees and could have saved enrollees an estimated $43.6 million in deductibles and coinsurance that may have been incorrectly
collected from them or from someone on their behalf during our audit period:

Improve system edit processes to help reduce improper payments for outpatient services provided by acute-care hospitals to hospice enrollees.

We recommend that the Centers for Medicare & Medicaid Services take the following actions, which could have saved Medicare an estimated $190.1 million in payments made to acute-care hospitals for outpatient services provided to hospice enrollees and could have saved enrollees an estimated $43.6 million in deductibles and coinsurance that may have been incorrectly collected from them or from someone on their behalf during our audit period:

Educate acute-care hospitals to understand that each hospice enrollee's hospice election statement addendum is available on request, and educate hospices to provide the addendum if requested to help an acute-care hospital assess whether…

We recommend that the Centers for Medicare & Medicaid Services take the following actions, which could have saved Medicare an estimated $190.1 million in payments made to acute-care hospitals for outpatient services provided to hospice enrollees and could have saved enrollees an estimated $43.6 million in deductibles and coinsurance that may have been incorrectly collected from them or from someone on their behalf during our audit period:

Continue to educate hospices that they should be providing to enrollees virtually all necessary services that palliate or manage terminal illnesses and related conditions either directly or through arrangements.

We recommend that the Centers for Medicare & Medicaid Services take the following actions, which could have saved Medicare an estimated $190.1 million in payments made to acute-care hospitals for outpatient services provided to hospice enrollees and could have saved enrollees an estimated $43.6 million in deductibles and coinsurance that may have been incorrectly collected from them or from someone on their behalf during our audit period:

Educate acute-care hospitals to analyze not only whether outpatient services palliated or managed enrollees' terminal illnesses but also whether outpatient services palliated or managed a condition related to a terminal illness.

We recommend that the Centers for Medicare & Medicaid Services take the following actions, which could have saved Medicare an estimated $190.1 million in payments made to acute-care hospitals for outpatient services provided to hospice enrollees and could have saved enrollees an estimated $43.6 million in deductibles and coinsurance that may have been incorrectly
collected from them or from someone on their behalf during our audit period:

Clarify the language in the Manual (chapter 11, section 50), and in other CMS or MAC guidance documents or educational initiatives, if necessary, to specifically mention "related conditions" so that the language is…

We recommend that the Centers for Medicare & Medicaid Services take the following actions, which could have saved Medicare an estimated $190.1 million in payments made to acute-care
hospitals for outpatient services provided to hospice enrollees and could have saved enrollees an estimated $43.6 million in deductibles and coinsurance that may have been incorrectly collected from them or from someone on their behalf during our audit period:

Direct MACs or other appropriate contractors, such as Recovery Audit Contractors, to: (1) analyze Medicare claims data to identify acute-care hospitals that have aberrant billing patterns for condition code 07, and conduct Targeted…

(U) Rec. 1: The DoD OIG recommended that the that the Defense Security Cooperation Agency Director update Chapter 7 of the Security Assistance Management Manual to include a requirement that U.S. personnel conduct and record a detailed inventory of defense items purchased outside of the continental United States and provided to a foreign government under Foreign Military Financing at the point of title transfer, similar to the requirements for defense items provided under Chapter 15. At a minimum, the inventory should include written documentation of observed item counts, as well as signatures demonstrating the agreement of both the U.S. and…

(U) Rec 2.a: The DoD OIG recommended that the Commander of the U.S. Air Forces in Europe, in coordination with the Security Assistance Group-Ukraine and the Joint Program Executive Office for Armaments and Ammunition, develop and issue updated standard operating procedures for the Logistics Enabling Node-Romania mission personnel. The procedures should include key information and requirements necessary to accurately account for and document the quantity of DoD-procured defense items transferred to Ukraine through Romania, including a requirement to independently document visual inspection results for
each shipment through an inventory and photographic evidence of obvious damage or tampering.

(U) Rec 2.b: The DoD OIG recommended that the Commander of the U.S. Air Forces in Europe, in coordination with the Security Assistance Group-Ukraine and the Joint Program Executive Office for Armaments and Ammunition, develop and issue updated standard operating procedures for the Logistics Enabling Node-Romania mission personnel. The procedures should establish requirements to adequately maintain and transmit accountability records and other mission information consistent with DoD policy and the information needs of other DoD components.

Clarify the Manual to ensure that supervisory activities that do not meet the minimum requirements for a full-scope examination, including visitations and limited-scope examinations, provide adequate documentation in support of conclusions and retain this documentation in the FDIC system of record.

Revise examiner guidance to ensure supervisory personnel consider significant delays in required financial filings and any associated perspectives of external auditors when assessing UFIRS ratings.

Revise the FDIC’s Internal Formal and Informal Actions Procedures to include specific process and documentation requirements related to circumstances in which an approved formal enforcement action is replaced with a less severe action.

Develop detailed guidance that clarifies what information should be considered when assessing whether it is appropriate to approve a brokered deposit waiver for “Adequately Capitalized” IDIs.

Incorporate the BIA results into USITC's overall contingency planning efforts, as well decisions regarding risk, priorities, security, and the budget.

We recommend that the Health Resources and Services Administration require the six hospices identified in our report as having used PRF payments for unallowable expenditures, totaling $8,306,519, to return the PRF payments to the Federal Government or ensure that the hospices properly replace the unallowable expenditures with allowable unreimbursed lost revenues or eligible expenses, if applicable.

We recommend that the Health Resources and Services Administration work with the hospice identified in our report as having used $3,967,025 of its PRF payments for potentially unallowable expenditures to determine what amounts should have been allocated and require the hospice to return unallowable amounts to the Federal Government or ensure that the hospice properly replaces these unallowable expenditures with unreimbursed lost revenues or eligible expenses, if applicable.

(U) Rec 9: The DoD OIG recommended that the Secretary of the Navy initiate a review of the P-1551 Military Construction project to determine whether any Federal law, acquisition regulation, or contracting requirements were violated or funds were wasted and take appropriate action.

(U) Rec 1: The DoD OIG recommended that the Secretary of Defense, in coordination with the Secretary of the Navy, designate a single point of command or leadership for Defense Fuel Support Point Joint Base Pearl Harbor-Hickam operations, maintenance, safety, and environmental protection.

(U) Rec 2.a: The DoD OIG recommended that the Secretary of Defense direct the Secretary of the Navy and the Director of the Defense Logistics Agency to perform a review of leak detection systems at Navy Defense Fuel Support Points, including an analysis of leak detection effectiveness and reliability.

(U) Rec 2.b: The DoD OIG recommended that the Secretary of Defense direct the Secretary of the Navy and the Director of the Defense Logistics Agency to implement corrective actions based on the review that will ensure effective leak detection at Navy Defense Fuel Support Points.

(U) Rec 3: The DoD OIG recommened that the Secretary of Defense direct the Under Secretary of Defense for Acquisition and Sustainment to update the DoD Manual 4140.25 series to address the deficiencies discussed in this report.

(U) Rec 4.a: The DoD OIG recommended that the Secretary of the Navy designate an entity to be responsible for ensuring that all laws, policies, and agreements made in response to the fuel incident at Defense Fuel Support Point Joint Base Pearl Harbor-Hickam are implemented, and that appropriate action is taken with regard to recommendations made in prior oversight and command investigation reports. Specifically, implement the requirements of the 2015 Administrative Order on Consent and 2023 Administrative Consent Order related to Defense Fuel Support Point Joint Base Pearl Harbor-Hickam.

(U) Rec 4.b: The DoD OIG recommended that the Secretary of the Navy designate an entity to be responsible for ensuring that all laws, policies, and agreements made in response to the fuel incident at Defense Fuel Support Point Joint Base Pearl Harbor-Hickam are implemented, and that appropriate action is taken with regard to recommendations made in prior oversight and command investigation reports. Specifically, implement the recommendations of the U.S. Environmental Protection Agency Region 9 compliance evaluation inspections for Oil Pollution Prevention regulations.

(U) Rec 4.d: The DoD OIG recommended that the Secretary of the Navy designate an entity to be responsible for ensuring that all laws, policies, and agreements made in response to the fuel incident at Defense Fuel Support Point Joint Base Pearl Harbor-Hickam are implemented, and that appropriate action is taken with regard to recommendations made in prior oversight and command investigation reports. Specifically, implement the recommendations of the Vice Chief of Naval Operations command investigation related to Defense Fuel Support Point Joint Base Pearl Harbor-Hickam.

(U) Rec 5.a: The DoD OIG recommended that the Secretary of the Navy direct a comprehensive review of the operation and maintenance programs at Defense Fuel Support Point Joint Base Pearl Harbor-Hickam. This review should include a review of: authorities; reporting chain of command; operational procedures; process control; change management; records management; maintenance planning, tracking, and support programs, such as supply and tool control; staffing levels and skill sets; training; and safety.

(U) Rec 5.b: The DoD OIG recommended that the Secretary of the Navy direct implementation of corrective actions based on the review that will ensure safe operations at Defense Fuel Support Point Joint Base
Pearl Harbor-Hickam.

(U) Rec 6.a: The DoD OIG recommended that the Secretary of the Navy direct a comprehensive review of the operational safety programs at Joint Base Pearl Harbor-Hickam. This review should include a review of authorities, reporting chain of command, policies, and safety office staffing levels at the Joint Base Pearl Harbor-Hickam, including safety oversight of tenant commands.

(U) Rec 6.b: The DoD OIG recommended that the Secretary of the Navy direct implementation of corrective actions based on the review that will ensure safe operations at Joint Base Pearl Harbor-Hickam, including tenant commands.

(U) Rec 7: The DoD OIG recommended that the Secretary of the Navy direct the Commander, Navy Region Hawaii, in coordination with the Director of the Defense Logistics Agency, to update the oil and hazardous substance incident response plans to address the deficiencies discussed in this report and implement the updated oil and hazardous substance incident response plans, including training and exercises.

(U) Rec 8 The DoD OIG recommended that the Secretary of the Navy direct the Commander, Naval Supply Systems Command to develop and implement a standard operating procedure for causative research and post?incident investigations and reporting for oil or hazardous substance incidents at Navy Defense Fuel Support Points.

(U) Rec 1.a: The DoD OIG recommended that the Secretary of the Navy designate an entity to be responsible for ensuring that all laws, policies, and agreements made in response to the 2021 drinking water contamination incident at the Joint Base Pearl Harbor-Hickam Community Water System are implemented, and that appropriate action is taken with regard to recommendations made in prior oversight reports and command investigation reports. Specifically, implement the requirements of the 2015 Administrative Order on Consent and the 2023 Administrative Consent Order related to the Joint Base Pearl Harbor-Hickam Community Water System.

(U) Rec 1.b: The DoD OIG recommended that the Secretary of the Navy designate an entity to be responsible for ensuring that all laws, policies, and agreements made in response to the 2021 drinking water contamination incident at the Joint Base Pearl Harbor-Hickam Community Water System are implemented, and that appropriate action is taken with regard to recommendations made in prior oversight reports and command investigation reports. Specifically, implement the requirements put forth in the FY 2024 National Defense Authorization Act.

(U) Rec 1.c: The DoD OIG recommended that the Secretary of the Navy designate an entity to be responsible for ensuring that all laws, policies, and agreements made in response to the 2021 drinking water contamination incident at the Joint Base Pearl Harbor-Hickam Community Water System are implemented, and that appropriate action is taken with regard to recommendations made in prior oversight reports and command investigation reports. Specifically, implement the recommendations of the U.S. Environmental Protection Agency Safe Drinking Water Act Investigation.

(U) Rec 1.d: The DoD OIG recommended that the Secretary of the Navy designate an entity to be responsible for ensuring that all laws, policies, and agreements made in response to the 2021 drinking water contamination incident at the Joint Base Pearl Harbor-Hickam Community Water System are implemented, and that appropriate action is taken with regard to recommendations made in prior oversight reports and command investigation reports. Specifically, implement the recommendations of the Agency for Toxic Substances and Disease Registry.

(U) Rec 1.e: The DoD OIG recommended that the Secretary of the Navy designate an entity to be responsible for ensuring that all laws, policies, and agreements made in response to the 2021 drinking water contamination incident at the Joint Base Pearl Harbor-Hickam Community Water System are implemented, and that appropriate action is taken with regard to recommendations made in prior oversight reports and command investigation reports. Specifically, implement the recommendations of the Vice Chief of Naval Operations command investigation related to the Joint Base Pearl Harbor-Hickam Community Water System.

(U) Rec 1.f: The DoD OIG recommended that the Secretary of the Navy designate an entity to be responsible for ensuring that all laws, policies, and agreements made in response to the 2021 drinking water contamination incident at the Joint Base Pearl Harbor-Hickam Community Water System are implemented, and that appropriate action is taken with regard to recommendations made in prior oversight reports and command investigation reports. Specifically, implement the recommendations of the Naval Facilities Engineering Systems Command command investigation.

(U) Rec 1.g: The DoD OIG recommended that the Secretary of the Navy designate an entity to be responsible for ensuring that all laws, policies, and agreements made in response to the 2021 drinking water contamination incident at the Joint Base Pearl Harbor-Hickam Community Water System are implemented, and that appropriate action is taken with regard to recommendations made in prior oversight reports and command investigation reports. Specifically, implement the requirements of Commander, Navy Installation Command Instruction 5090.7.

(U) Rec 2.a: The DoD OIG recommended that the Secretary of the Navy revise Operations Navy Manual 5090.1. Specifically, include the roles, responsibilities, and training requirements for the Operator in Responsible Charge for Treatment and Distribution.

(U) Rec 2.b: The DoD OIG recommended that the Secretary of the Navy revise Operations Navy Manual 5090.1. Specifically, align requirements of Operations Navy Manual 5090.1 with Commander, Navy Installation Command Instruction 5090.7. Specifically, clarify conflicting requirements for roles and responsibilities, including for the preparation and publication of public notices and contingency plans for alternate drinking water supplies during a drinking water emergency

(U) Rec 3.a: The DoD OIG recommended that the Secretary of the Navy direct the Commander, Navy Installations Command to revise Commander, Navy Installation Command Instruction 5090.7. Specifically, define the roles and responsibilities of the Installation Community Officer.

(U) Rec 3.b: The DoD OIG recommended that the Secretary of the Navy direct the Commander, Navy Installations Command to revise Commander, Navy Installation Command Instruction 5090.7. Specifically, include the roles, responsibilities, and training requirements for the Operator in Responsible Charge for Treatment and Distribution.

(U) Rec 3.c: The DoD OIG recommended that the Secretary of the Navy direct the Commander, Navy Installations Command to revise Commander, Navy Installation Command Instruction 5090.7. Specifically, require the standing membership of the Installation Drinking Water
Committee to include owners and operators of consecutive water systems.

(U) Rec 3.d: The DoD OIG recommended that the Secretary of the Navy direct the Commander, Navy Installations Command to revise Commander, Navy Installation Command Instruction 5090.7. Specifically, periodically require the Installation Drinking Water Committee to assess committee membership, no less than annually, to determine whether additional stakeholders with the potential to affect drinking water quality should participate on the committee, such as users of aqueous film?forming foam, owners and operators of oil or hazardous substance facilities, or managers of solid waste facilities.

(U) Rec 3.e: The DoD OIG recommended that the Secretary of the Navy direct the Commander, Navy Installations Command to revise Commander, Navy Installation Command Instruction 5090.7. Specifically, require that the annual table?top exercise of the installation's drinking water Emergency Response Plan include triggers and timelines for updating and editing the Emergency Response Plan when the table?top exercise identifies a need.

(U) Rec 3.f: The DoD OIG recommended that the Secretary of the Navy direct the Commander, Navy Installations Command to revise Commander, Navy Installation Command Instruction 5090.7. Specifically, include roles and responsibilities for the risk communication requirements of DoD Instruction 6055.20, including recurring training.

(U) Rec 4: The DoD OIG recommended that the Secretary of the Navy direct the appropriate Joint Base Pearl Harbor-Hickam official to issue a retroactive Tier 1 public notice including the 10 required elements of information for the October 2022 water main break.

(U) Rec 5: The DoD OIG recommended that the Secretary of the Navy directt a study to assess the location of Navy?owned drinking water systems, identify all co?located infrastructure that poses a threat to the safety of the drinking water, and make plans to mitigate the threats to the drinking water systems.