Federal Reports

EAC OIG issued this advisory to alert EAC's Chairman and Executive Director that EAC did not timely report assistance transactions on USASpending.gov.

The Cybersecurity and Infrastructure Security Agency (CISA) does not effectively coordinate and share best practices to enhance security across the commercial facilities sector. Specifically, CISA does not coordinate within DHS on security assessments to prevent potential overlap, does not always ensure completion of required After Action Reports to share best practices with the commercial facilities sector, and does not adequately inform all commercial facility owners and operators of available DHS resources. This occurred because CISA does not have comprehensive policies and procedures to support its role as the commercial facilities’ Sector-Specific Agency (SSA). Without such policies and procedures, CISA cannot effectively fulfill its SSA responsibilities and limits its ability to measure the Department’s progress toward accomplishing its sector-specific objectives. CISA may also be missing opportunities to help commercial facility owners and operators identify threats and mitigate risks, leaving the commercial facilities sector vulnerable to terrorist attacks and physical threats that may cause serious damage and loss of life. We made three recommendations to improve CISA’s coordination and outreach to safeguard the commercial facilities sector. CISA concurred with all three recommendations.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate allegations regarding management and patient safety at the Community Living Center (CLC). The complainant alleged that CLC managers discouraged incident reporting, coached staff on how to talk to residents or the resident’s personal representative following adverse events, and made staff fearful of retaliation for reporting concerns. Allegations also included inadequate staffing and oversight for resident care, mismanagement of laboratory specimens and medication delivery, and regulation of environmental temperatures. The OIG identified additional concerns related to employee dissatisfaction and laboratory staff’s failures to notify healthcare providers of critical laboratory results. The OIG did not substantiate managers discouraged incident reporting, inappropriately coached staff, or made staff fearful of retaliation for reporting concerns. System leaders acknowledged persistent staff dissatisfaction could have affected resident care. Although actions were taken to improve operations, unresolved issues related to employee satisfaction persisted. However, the OIG concluded the system maintained adequate nurse and provider staffing for resident care. The system exceeded Veterans Health Administration requirements for evaluating nurse staffing. Laboratory specimen handling led to falsely elevated potassium results and unnecessary treatment. Laboratory staff failed to thoroughly investigate and resolve the cause of inaccurate results. Additionally, the OIG found providers were inconsistently notified of critical laboratory results. CLC medication deliveries were also delayed. Although the causes for delays were undetermined, the lack of an on-site pharmacy likely contributed. During the inspection, the System Director announced plans for a pharmacy at the CLC. The OIG did not substantiate additional allegations of an inability to regulate environmental temperatures. Facility and engineering staff provided timely responses to periodic temperature issues. The OIG made five recommendations to the System Director related to CLC employee satisfaction, laboratory specimen handling, investigation of laboratory concerns, critical laboratory result notifications, and medication delivery.