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Inspector General Open Recommendations

05/12/2021 - Consumer Product Safety Commission Audit of the CPSC’s Implementation of FMFIA for FYs 2018 and 2019 [Report Details] Audit - Open Recommendations

1
Provide guidance identifying programs and/or activities as a part of its internal guidance and in accordance with achieving its mission requirements.
2
Align programs and/or activities with applicable reporting requirements.
3
Report programs and/or activities in accordance with applicable Federal criteria.
4
Provide training to CPSC program managers on how to develop and implement a formal internal controls program in accordance with Standards for Internal Control in the Federal Government, OMB Circular A-123, and CPSC policies and procedures.
5
Develop a formal internal controls program over operations for CPSC programs.
6
Evaluate staffing needs within the Office of Financial Management, Planning and Evaluation to support internal controls and FMFIA reporting requirements.
7
Establish formal lines of communication between the Office of Financial Management, Planning and Evaluation and CPSC program management for the purpose of assessing and monitoring internal control programs and compliance with FMFIA requirements.

05/11/2021 - Department of Veterans Affairs Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia [Report Details] Inspection / Evaluation - Open Recommendations

01
The Under Secretary for Health ensures actions are taken to clarify and broadly disseminate adjudicator expectations for follow-up of an unreturned INV Form 41.
02
The Louis A. Johnson Medical Center Director ensures Pharmacy Service utilizes the required Veterans Health Information Systems and Technology Architecture Automatic Replenishment System to record medication usage data and maintain the records for inventory accountability.
03
The Veterans Integrated Service Network 5 Director conducts management reviews of the care of patients 1–10 as discussed in this report and takes action as indicated.
04
The Louis A. Johnson VA Medical Center Director reviews the availability and timeliness of endocrinology consults, and takes any corrective action needed.
05
The Veterans Integrated Service Network 5 Director ensures evaluation of quality of care concerns or other irregularities (beyond hypoglycemia) of: cases provided by the OIG; cases that may otherwise be pertinent or concerning; and cases brought forward by patients and/or family members who express concerns or make other inquiries about care they received from Ms. Mays. As determined by the VISN, clinical experts external to the facility should be utilized when appropriate.
06
The Louis A. Johnson Medical Center Director develops and disseminates guidance on clinical communication(s) to ensure that patient care and outcomes are routinely discussed in appropriate forums, such as interdisciplinary team meetings, and the discussions are documented.
07
The Louis A. Johnson Medical Center Director ensures that close observation documentation is readily available in the electronic health record, and monitors for compliance.
08
The Louis A. Johnson Medical Center Director ensures clinical documentation reviews are completed timely for patient safety and continuity of care.
09
The Louis A. Johnson VA Medical Center Director evaluates the factors and processes surrounding employees’ failures to report and follow up on the unexplained hypoglycemic events, and takes action to ensure appropriate reporting of actual or potential patient safety events, system vulnerabilities, or other unexpected events that offer opportunities for lessons learned.
10
The Louis A. Johnson Medical Center Director requires that all staff are trained on reporting patient safety events using the correct reporting system and monitors for compliance.
11
The Louis A. Johnson Medical Center Director ensures that the interdisciplinary mortality review workgroup meet as required with appropriate reporting through oversight council(s), and monitors for compliance.
12
The Louis A. Johnson Medical Center Director ensures that oversight and reporting practices align with Louis A. Johnson Medical Center policy requirements.
13
The Under Secretary for Health determines the potential advantage of a rescue medication flagging system as an additional tool to evaluate unexplained adverse patient events, including but not limited to mortalities, and takes action as indicated.

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