Open Recommendations

Review and pay claimants the underpayments we identified, as applicable.

Add controls to ensure employees properly notify claimants when disability claims are denied and manual notifications are required.

Add controls to ensure employees complete all mandatory claim development prior to denying disability claims.

The principal executive director of the Office of Acquisition, Logistics, and Construction considers whether any additional training or other measures are necessary with respect to reporting the wrongdoing of a supervisor and the acceptance of free meals and drinks by VA employees during the February 2023 site visit.

The principal executive director of the Office of Acquisition, Logistics, and Construction determines whether any additional guidance, training, or oversight is needed with respect to ensuring VA employees do not improperly solicit sponsorships for VA events that do not primarily benefit veterans.

VA’s designated agency ethics official determines whether any additional steps need to be taken in connection with Ms. Dawson’s 2023 public financial disclosure based on the findings of this report.

Facility leaders identify barriers to providers completing toxic exposure screenings and implement actions to ensure providers complete screenings within 30 days of initiation.

Confirm that medical facility directors develop local guidance on using automated dispensing cabinets in accordance with VHA Directive 1108.21 (and any revisions to this directive) and that facilities comply with that local guidance.

Require Pharmacy Benefits Management Services to revise VHA Directive 1108.21 to include routine monitoring for the use of generic information as a requirement in facility-level guidance for automated dispensing cabinets.

Ensure, in coordination with the controlled substance coordinator, or appropriate designee, and Veterans Integrated Service Networks, that reports detailing cabinet transactions for controlled substances removed using generic information are reviewed as part of required controlled substance inspections.

The Overton Brooks VA Medical Center Director conducts a comprehensive review of the patient’s hospitalization and takes action as indicated, including quality management improvement processes such as a peer review.

The Overton Brooks VA Medical Center Director ensures medical staff recognize the importance of obtaining hospitalized patients’ non-VA medical records and assesses the current processes for obtaining non-VA medical records, identifies any barriers to completion, and takes action as warranted.

The Overton Brooks VA Medical Center Director assesses the application of the one-to-one observation policy and practices at the facility, and takes action as warranted.

The Overton Brooks VA Medical Center Director reviews interim behavioral patient record flag processes to ensure implementation of safety strategies for staff and patients, and takes action as warranted.

The Overton Brooks VA Medical Center Director evaluates whether documentation of patient and patient-related behavioral events are reflected accurately in the electronic health record to facilitate continuity of care and communication among medical staff and takes action as necessary.

Verify that Ministry of Health in Jordan corrects the instance of material noncompliance detailed on page 7 of the audit report.

We recommend that the PBS Commissioner institute policies and procedures to ensure battery systems are designed, installed, operated, and maintained in accordance with federal regulations, PBS policy, and building code requirements.

We recommend that the PBS Commissioner institute policies and procedures to ensure training requirements are designed and implemented for PBS and PBS contractor personnel working with battery systems and associated technologies.

We recommend that the PBS Commissioner institute policies and procedures to ensure appropriate action is taken to address PBS personnel performance deficiencies identified in this report, including supervisory chains of command and individuals responsible for managing the battery systems.

We recommend that the PBS Regional Commissioner of the Pacific Rim Region take immediate action to safeguard the occupants and assets in the Anderson and Reagan Buildings by: (1)verifying that the ESCO removed the batteries and any other hazards from both the Anderson and Reagan Buildings using only qualified personnel; and, (2) obtaining the complete third-party investigation report into the cause of the battery system fire at the Anderson Building. Upon receipt, ensuring any remaining health and safety hazards listed in the report are addressed or mitigated.

We recommend that the PBS Regional Commissioner of the Pacific Rim Region take immediate action to improve management oversight of the region’s facilities to ensure that: (1) code violations and maintenance deficiencies brought to management’s attention are immediately addressed; (2) local fire department personnel are involved in pre-fire planning activities for future battery system projects; (3) local fire department personnel are involved in post-fire assessments; and (4) final certificates of occupancy are not issued until all outstanding fire and life safety deficiencies are corrected.

We recommend the Council document and implement FFR reporting procedures that adhere to cost allowability restrictions prohibiting state agencies from reporting subrecipient cost shares as their own cost share (General Terms #13), or reporting the same costs across multiple awards (2 CFR 200.403).

We recommend the Council establish controls over its FFR reporting procedures that ensure the procedures were followed and report costs are allowable.

We recommend the Council works with its subrecipient to ensure understanding of, and compliance with, Poetry Out Loud (POL) regulations and requirements.

We recommend the Council update its contract template to include the total amount of that Arts Endowment award's funds issued to the subrecipient to date, and the total amount of Arts Endowment funds issued to the subrecipient from all active Arts Endowment awards (2 CFR 200.332(b)(1)(viii) & (ix)).