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.

The VA Office of Inspector General (OIG) initiated an inspection to assess allegations regarding deficiencies in nursing care in the Community Living Center (CLC). The OIG substantiated the allegation that a CLC nurse improperly left medication in a patient’s room. The inspectors conducted an observation of 35 patient rooms and did not find any medications left in rooms or hallways other than two creams on a bedside table. While the OIG was unable to determine the validity of many of the allegations due to a lack of information from the complainants or within the patients’ electronic health records, there were nursing documentation deficiencies identified in the CLC related to the allegations. These deficiencies included inconsistent documentation of compliance with medication order instructions, pain assessments and pain management plans, fall prevention and post-fall assessments, fall prevention measures (including inconsistent answering of call bells), and nursing wound prevention processes. The OIG made other findings not specifically related to the allegations, including failure to follow the approval procedure for a new hourly rounding form, ineffective implementation of a new procedure for nurse rounding, incomplete fact-finding reviews, inconsistent facility committee documentation, and inoperable CLC safety equipment. A contributing factor for the identified deficiencies was an outdated facility staffing policy that did not follow all Veterans Health Administration (VHA) staffing methodology requirements for calculating adequate levels. The OIG made nine recommendations addressing nursing processes including documentation of fall prevention and post-fall assessments, placement and use of call bells, wound prevention processes, medication administration, and pain assessments and pain management plans; compliance of rounding forms to facility procedures; establishment of fact-finding review processes; leadership committees’ tracking and monitoring of issues to resolution; checks that safety equipment used for transfers is operational; and staffing policy consistency with VHA requirements.