Open Recommendations

Rec. 1.p: The DoD recommended that the Director, Defense Support Services Center, require the Defense Travel Management Office to Conduct oversight, on a quarterly basis, to ensure Component Program Managers reported instances of an Agency Program Coordinator not generating the mandatory reports, on at least a monthly basis, to the Agency Program Coordinator's appropriate chain of command to allow for any administrative or disciplinary actions to be taken as appropriate for noncompliance.

The Lexington VA Healthcare System Director ensures emergency department, mental health, and inpatient medical and nursing staff responsible for suicide risk assessment understand the need to evaluate patients for a personally owned insulin pump and remove the insulin pump prior to inpatient admission, when necessary and monitors for compliance.

The Lexington VA Healthcare System Director verifies the draft insulin pump policy is finalized, and Lexington VA Healthcare System emergency department, mental health, and inpatient medical and nursing staff are educated on the policy.

The Lexington VA Healthcare System Director ensures leaders and staff review the Lexington VA Healthcare System policy evaluation and approval procedure.

The Lexington VA Healthcare System Director verifies that patients receive discharge instructions, with a follow-up care plan when discharged from the Lexington VA Healthcare System emergency department.

The Lexington VA Healthcare System Director ensures a review of Psychiatrist 2s documentation in Patient 2s electronic health record and makes certain documentation is completed according to Veteran Health Administration policy, including that entries are accurate, succinct, without extensive copy and paste, and devoid of derogatory, critical, comments, and takes action as warranted.

The Lexington VA Healthcare System Director confirms that the patient safety managers understand and apply Veteran Health Administration guidance to accurately use safety assessment codes when scoring a patient safety event.

The Lexington VA Healthcare System Director verifies that root cause analyses are completed according to Veterans Health Administration policy including interviewing individuals knowledgeable about the event.

The Lexington VA Healthcare System Director ensures peer representation at the Peer Review Committee for psychiatry case reviews.

The Under Secretary for Health considers specific VHA guidance related to the recognition of personally owned insulin pumps as a lethal means for patients with suicidal ideation and at risk for suicide in emergency departments and inpatient units to mitigate risk and improve patient safety.

Rec. 1.a: The DoD recommended that the Commanding General, Army Contracting Command, develop and implement guidance promoting the use of existing indefinite?delivery indefinite-quantity contracts for new acquisition requirements up to the maximum quantities allowed. In instances in which new acquisition requirements exceed established maximum order quantities, the guidance should: Direct contracting personnel to evaluate pricing before issuing new orders and determine whether it is advantageous to the Government to order under existing indefinite-delivery indefinite?quantity contracts or pursue other procurement options to ensure that the Government receives the best value. Include a requirement that contracting personnel enforce agreed?upon prices for quantities…

Rec. 1.b: The DoD recommended that the Commanding General, Army Contracting Command review all contracts that include the consideration language and determine whether the contractors delivered rounds late. In instances in which contracting personnel identify late deliveries, the DoD recommended that the Commanding General, Army Contracting Command, apply consideration in accordance with the contracts.

Rec. 1.c: The DoD recommended that the Commanding General, Army Contracting Command Report to the DoD OIG the total consideration collected for late deliveries identified by completing the actions in Recommendation 1.b.

Rec. 1.d: The DoD recommended that the Commanding General, Army Contracting Command collect the $1.1 million in consideration that should have been collected for late deliveries as of November 30, 2024.

Rec. 1.e: The DoD recommended that the Commanding General, Army Contracting Command prepare the outstanding contractor performance evaluations to adequately reflect the contractors' performance in the Contractor Performance Assessment Reporting System.

Rec. 2.a: The DoD recommended that the Product Lead, Special Ammunition and Weapons Systems, in conjunction with the Commanding General, Army Contracting Command evaluate whether the DoD still needs to provide the delayed ammunition to the Ukrainian Armed Forces and, if so, determine whether the existing indefinite-delivery indefinite-quantity contracts are still the most viable option to procure the ammunition or explore alternate options. If the DoD identifies a more viable alternative to procure the ammunition or determines that it does not need to provide the delayed ammunition to the Ukrainian Armed Forces, we recommend that the Product Lead, Special Ammunition…

Rec. 2.b: The DoD recommended that the Product Lead, Special Ammunition and Weapons Systems, in conjunction with the Commanding General, Army Contracting Command report to the DoD OIG the total cost the Army avoided by completing the actions outlined in Recommendation 2.a for the $907 million in ammunition orders that have not yet been delivered.

Rec. 3: The DoD recommended that the Product Lead, Special Ammunition and Weapons Systems develop lessons learned from using the ammunition indefinite?delivery indefinite?quantity contracts to support the Ukrainian Armed Forces and implement procedures to ensure timely supply and equipment deliveries during other ongoing and future contingency operations. The procedures should include steps for: Identifying when contractors cannot deliver supplies and equipment within the agreed-upon or reasonable time frames. Coordinating with Army contracting personnel to pursue alternate options to procure the necessary supplies and equipment in a timely manner.

We recommend that the Deputy Secretary of Commerce direct the Department’s Chief Information Officer to revise the Department’s VDP testing scope to align with CISA’s BOD 20-01, Develop and Publish a Vulnerability Disclosure Policy, which would include testing all internet-accessible systems.

We recommend that the Deputy Secretary of Commerce direct the Department’s Chief Information Officer to update and implement VDP reporting and resolution standard operating procedures to ensure that vulnerability remediation is comprehensive across impacted systems.

We recommend that the Deputy Secretary of Commerce direct the Department’s Chief Information Officer to work with bureaus to establish and implement an automated solution to coordinate communication between the contractor and bureaus and to prompt action on delayed vulnerability remediation based on impact level.

The Associate Director ensures staff make feminine hygiene products available in public womens and unisex restrooms.

The Medical Center Director ensures staff implement processes to secure medications from unauthorized access.

The Executive Director ensures staff address environment of care deficiencies within 14 days or have an action plan, as required.

The Executive Director ensures staff perform preventive maintenance on medical equipment in accordance with manufacturers recommendations.