Open Recommendations

Perform a full inventory of all non-capitalized and capitalized property during its annual physical inventory, including identifying and following up on items that have been reported as lost or stolen or for which the stated location is not accurate.

Develop a process to: a. identify and track all unusual transactions, including corrections relating to prior year activity that were processed during the current fiscal year; b. review the posting logic that was applied within Oracle for each correcting entry to ensure the entries had the intended effect; and c. record reclassification journal entries in the general ledger using the appropriate general ledger accounts for the correction of errors, in accordance with generally accepted accounting principles and Department of Treasury requirements, when appropriate.

Update written standard operating procedures and desk procedures to include the steps to be performed when recording unusual transactions and error corrections within Oracle and any additional actions to be taken, such as the recording of reclassification journal entries.

Update its written procedures or develop a desk procedure that provides detailed guidance or instructions for the calculation of the organization's year-end accounts payable and other accruals.

Develop a look-back analysis or otherwise document its review and assessment of disbursements made early in the subsequent reporting period (i.e., at the beginning of the next fiscal year) to identify items which should have been included in its year-end accounts payable balance and amend the existing accrual, if needed, prior to the preparation of the financial statements.

The Human Capital Officer should coordinate with IT to determine the time frame when managers must request laptops for new employees. Once determined, formalize the requirement in the standard new employee orientation guidance and update the Manager’s Onboarding Checklist.

The Human Capital Officer should update the Manager’s Onboarding Checklist with a step to issue the performance plan within 30 calendar days of the employee’s start date.

The Human Capital Officer should work with the ITM administrator to ensure that processes are put in place to alert managers when important due dates pass; for example, if the performance plan is past due.

The Human Capital Officer should establish a formal written policy that requires managers to conduct quarterly touchpoint discussions with new employees in their first year and require that managers attend the updated training on conducting quarterly touchpoint activities.

The Human Capital Officer should work with the ITM administrator to add quarterly touchpoint activities to the manager’s ITM module as part of the new employee onboarding, send managers notifications of upcoming due dates for quarterly touchpoint activity discussions and alert managers if the discussions are past due.

The Oklahoma City VA Health Care System Director, with Pathology and Laboratory Medicine Service leaders, conducts a comprehensive review of the quality of care for the four patients identified in this report, including determinations of cytopathology processing delays and assessment of patient harm, and takes action as warranted.

The Oklahoma City VA Health Care System Director ensures that routine non-gynecological turnaround time corrective actions are documented and monitored for effectiveness, as required by the Veterans Health Administration.

The Oklahoma City VA Health Care System Director conducts a comprehensive review of the quality of care provided by the Chief of Pathology and Laboratory Medicine Service, identifies deficiencies, and takes action as warranted.

The Oklahoma City VA Health Care System Director reviews the Pathology and Laboratory Medicine Service event reporting requirements for variance events and ensures completion according to facility policy and Veterans Health Administration requirements.

The Oklahoma City VA Health Care System Director, in conjunction with the National Center for Patient Safety, evaluates patient safety event reporting processes within the Pathology and Laboratory Medicine Service, and ensures completion according to Veterans Health Administration requirements.

The Oklahoma City VA Health Care System Director, with Pathology and Laboratory Medicine Service leaders, conducts a comprehensive review of the quality of care for the four patients identified in this report, including determinations of cytopathology processing delays and assessment of patient harm, and takes action as warranted.

The Oklahoma City VA Health Care System Director ensures that routine non-gynecological turnaround time corrective actions are documented and monitored for effectiveness, as required by the Veterans Health Administration.

The Oklahoma City VA Health Care System Director conducts a comprehensive review of the quality of care provided by the Chief of Pathology and Laboratory Medicine Service, identifies deficiencies, and takes action as warranted.

The Oklahoma City VA Health Care System Director reviews the Pathology and Laboratory Medicine Service event reporting requirements for variance events and ensures completion according to facility policy and Veterans Health Administration requirements.

The Oklahoma City VA Health Care System Director, in conjunction with the National Center for Patient Safety, evaluates patient safety event reporting processes within the Pathology and Laboratory Medicine Service, and ensures completion according to Veterans Health Administration requirements.

Implement vulnerability management processes to ensure all vulnerabilities are identified and plans of action and milestones are created for vulnerabilities that cannot be mitigated by VA deadlines.

Implement a more effective baseline configuration process to ensure network devices and databases are running authorized software that is configured to approved baselines and free of vulnerabilities.

Perform a cost-benefit analysis and implement appropriate controls within the federal Electronic Health Record to limit disclosure of veteran personally identifiable information based on job responsibility.

Segregate the duties of maintaining key stock and making keys.

Place network infrastructure equipment in a communications closet or approved enclosure to restrict access to only authorized personnel.