Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations concerning Sterile Processing Services (SPS) at the Carl T. Hayden VA Medical Center (facility) in Phoenix, Arizona.The OIG substantiated that SPS staff failed to don personal protective equipment (PPE) in SPS decontamination areas. The OIG observed SPS and other facility staff enter decontamination areas without required PPE.The OIG did not substantiate that SPS staff falsified Resi-Tests by documenting the same lot number for endoscopes. The OIG found that some Resi-Test kits had the same lot numbers but that was not indicative of falsified tests. Additionally, the OIG identified missing documentation of Resi-Test results from October through December 2020; however, based on review of subsequent documentation, direct observations, and interviews, the OIG concluded that SPS staff completed Resi-Tests in accordance with policy.The OIG did not substantiate that SPS staff failed to follow validation testing requirements for biological indicators and Bowie-Dick tests for sterilizers. The OIG found no infection concerns associated with inadequate reprocessing of equipment.The OIG found that SPS staff followed reprocessing steps according to standard operating procedures and instructions for use. The OIG did not substantiate that SPS staff did not have adequate reprocessing supplies. The OIG found that floor grade instruments received in decontamination areas were discarded and not reprocessed. The OIG found that SPS staff reviewed instructions for use for loaner trays upon receipt at the facility. The OIG did not substantiate that SPS staff failed to receive documentation for instruments sterilized at another VA facility. The OIG concluded that SPS leaders were knowledgeable of the practice standards. The OIG made one recommendation to the Facility Director to ensure staff comply with requirements for donning required personal protective equipment prior to entry into decontamination areas.

For our final report on our audit of the U.S. Department of Commerce's (the Department's) system security assessment process, our objective was to assess the effectiveness of the Department's system security assessment and continuous monitoring program to ensure security deficiencies were identified, monitored, and adequately resolved. We found the Department did not effectively execute its continuous monitoring and systemassessment process. Specifically, we found the following: I. the Department did not effectively plan for system assessments; II. the Department did not consistently conduct reliable system assessments; III. the Department did not resolve security control deficiencies within defined completion dates; and IV. the Department’s security system of record—i.e., the cyber security asset and management tool—did not provide accurate and complete assessment and plan of action & milestone data.