Open Recommendations

Rec. 1.a: The DoD OIG recommended that the Commanding General, Marine Corps Logistics Command, direct the Commander, Blount Island Command, to update and implement quality assurance procedures to validate the contractors' maintenance of prepositioned equipment aboard the USNS Dahl and all other maritime prepositioned ships in the U.S. Indo Pacific Command area of responsibility that are covered by the contract, including the requirement for the contractors to provide Blount Island Command officials the records supporting the maintenance results in the shipboard semi-annual start up reports; verification of the accuracy and completeness of the records supporting the maintenance results in the…

Rec. 1.b: The DoD OIG recommended that the Commanding General, Marine Corps Logistics Command analyze and document the impact to the battery life of the 3,175 batteries, valued at approximately $1 million, due to not recharging the batteries when they reach the threshold of 12.65 volts.

Rec. 1.c: The DoD OIG recommended that the Commanding General, Marine Corps Logistics Command require the contractors to implement the Technical Bulletin (TB) 9 6140 252-13, "Recharging Procedures for Automotive Valve Regulated Lead Acid Batteries," requirements and issue service requests to either recharge or replace batteries with voltage readings below the threshold of 12.65 volts aboard the USNS Dahl and all other maritime prepositioned ships in the U.S. Indo Pacific Command area of responsibility that are covered by the contract.

Rec. 1.d: The DoD OIG recommended that the Commanding General, Marine Corps Logistics Command determine whether any vehicles aboard the USNS Dahl have Class III leaks and, if so, require the contractors to take appropriate corrective maintenance actions.

Rec. 1.e: The DoD OIG recommended the Commanding General, Marine Corps Logistics Command determine why the contractor did not identify maintenance issues, such as Class III leaks, and develop and implement a solution.

We recommend the Senior Vice President, Generation Projects and Fleet Services, establish steps to verify implementation estimates include the complete scope of work and are developed using definitive costs.

We recommend the Senior Vice President, Generation Projects and Fleet Services obtain additional support for the five project change requests with insufficient details to determine if the approval amounts should be revised.

We recommend the Senior Vice President, Generation Projects and Fleet Services take steps to reinforce the (1) need for adequate support before approving project change requests and (2) requirement for project change requests to document project estimate revisions.

We recommend that the Senior Vice President, Generation Projects and Fleet Services, in conjunction with the Office of the General Counsel, educate the appropriate individuals on the importance of not sharing confidential contractor information.

The VA Fayetteville Coastal Healthcare System Director reviews the endocrine consult management process and takes actions as needed to ensure compliance with current Veterans Health Administration directives and guidance.

The VA Fayetteville Coastal Healthcare System Director implements a strategy to review patients affected by delayed endocrine consults to evaluate whether harm occurred and the appropriateness of institutional disclosures.

The VA Fayetteville Coastal Healthcare System Director ensures a sustainable and effective service line agreement between endocrine and primary care services is developed and agreed upon by both services, and monitors implementation.

The VA Fayetteville Coastal Healthcare System Director confirms effective utilization of endocrine clinic appointments to ensure timely access to care.

The VA Fayetteville Coastal Healthcare System Director ensures a process is in place for monitoring and tracking clinic profile modification requests.

The VA Mid-Atlantic Health Care Network Director reviews the leadership performance of the chief of medicine related to communication and collaboration and takes action as necessary.

The VA Fayetteville Coastal Healthcare System Director evaluates communication gaps identified in this report between leaders of primary care and the Medicine Service and takes action to ensure consistency with Veterans Health Administration High Reliability Organization goals.

Create job positions where the primary responsibility is to oversee regional coordination of the shipping and handling of day-old poultry between internal and external stakeholders.

Revise Publication 52 to define when day-old poultry should be disposed of as an injurious item.

Along with the Vice President, Delivery Operations; Vice President, Processing Operations; and Vice President, Logistics, develop and provide training to staff on the correct processes for the disposal of day-old poultry.

Establish recurring meetings throughout peak shipping season of day-old poultry with the applicable internal and external stakeholders to discuss issues and implement immediate corrective action.

Communicate to staff each year the acceptance procedures for day-old poultry prior to the start of peak shipment season.

Revise the Handling Lives Workbook and reissue annually, before each peak shipping. At a minimum, revisions to the workbook should include: performing a primary sort by transportation mode; proper bed loading; a limit for stacking packages; following first in, first out methods; and unloading day-old poultry timely from trailers.

Revise Publication 52 to require the mailer to include a "deliver by" date, which is 72-hours after hatching, on all packages of day-old poultry.

Develop electronic methods to uniquely track shipments of day-old poultry, including shipments that have perished.

Develop a process specifically for the processing and handling of missent shipments of day-old poultry.