Open Recommendations

(U) Rec. 1.a: The DoD OIG recommended that the Director of the Defense Security Cooperation Agency revise the Security Assistance Management Manual to clarify its description of the third-party transfer authorization process for the transfer of defense articles designated as requiring enhanced end use monitoring from partner nations to non-state entities.

(U) Rec. 1.b: The DoD OIG recommended that the Director of the Defense Security Cooperation Agency in coordination with the Department of State Bureau of Political and Military Affairs Office of Regional Security and Arms Transfers, develop procedures for DoD program executive offices to confirm that a foreign government that acquired U.S.-origin defense articles subject to enhanced end use monitoring obtained the appropriate written consent of the U.S. Government to transfer defense articles to non-government entities through those program offices.

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

The VA Southern Nevada Healthcare System Director ensures that clinical service chiefs take action to address concerns substantiated in factfindings, and that all patient safety concerns identified in factfindings are reviewed and addressed.

The VA Southern Nevada Healthcare System Director evaluates the need for additional factfinders, and takes action as warranted.

The VA Southern Nevada Healthcare System Director ensures that clinical service chiefs take action timely when aware of patient safety concerns.

The VA Southern Nevada Healthcare System Director reviews the information outlined in this report, determines the need to initiate the state licensing board reporting process, and takes action as warranted.

The VA Southern Nevada Healthcare System Director requires clinical service chiefs and credentialing and privileging managers to receive education on the completion of provider exit review forms and that, when supervisory staff contact credentialing and privileging staff for initiation of the state licensing board reporting process, a process is in place to ensure the message is clear and received.

The VA Southern Nevada Healthcare System Director ensures that clinical service chiefs and staff are educated on the need and process for submitting Joint Patient Safety Reporting reports upon awareness of patient safety events in accordance with facility policy.

The VA Southern Nevada Healthcare System Director educates the Chief of Staff on the need to complete management reviews when warranted, ensures that a review occurs of the dental hygienist’s care of Patient C, and ensures disclosure is provided if warranted.

The VA Southern Nevada Healthcare System Director makes certain that the Chief of Staff utilizes high reliability organization principles and establishes a process for the communication of pervasive concerns regarding a provider’s care.

Require 180TLA to develop written policies and procedures to ensure it calculates indirect costs according to the DOJ Grants Financial Guide and approved grant budgets.

Require 180TLA to strengthen its grant management policies and procedures to include written subrecipient monitoring guidance that addresses: (1) evaluating a subrecipient's risk of non-compliance with award conditions to help ensure the appropriate design of subrecipient monitoring plans, and (2) reviewing and taking action on subrecipient annual audit reports in compliance with the DOJ Grants Financial Guide.