Open Recommendations

Develop an implementation plan for deploying a scheduling system for controllers that includes schedule milestones, system requirements, risk assessment and mitigation, and funding requirements.

Assess and quantify the expected benefits of a customized controller scheduling tool.

We recommend that the Penobscot Nation establish a preventative maintenance program for the facility and medical equipment to ensure that it provides a safe, clean, and accessible environment.

We recommend that Penobscot Nation implement Federal and Tribal preemployment screening controls for employees who have not been fully screened prior to employment and for new staff hired at PNHD, including the performance of fingerprinting and FBI background checks for all staff currently working with Indian children, and maintain complete employee personnel files that include current licensing information when applicable.

(3) We recommend that the Penobscot Nation conduct annual program evaluations in accordance with Federal requirements, review the results of the program evaluations, and take corrective actions as appropriate.

(6) We recommend that Penobscot Nation work with the Penobscot Nation’s Tribal government to ensure that its emergency preparedness program is reviewed, updated, and tested annually, in accordance with Federal requirements, and review and update PNHD’s standard operating procedures in accordance with Tribal requirements.

(2) We recommend that the Penobscot Nation develop, approve, and implement written medical policies and procedures, with the advice of the required group of professional medical staff, that include: - pain-management treatment prioritization requirements for opioid prescription and compliance monitoring, and - requirements for timely completion, signature, and review of patient health records.

(1) We recommend that the Penobscot Nation ensure that PNHD is under the medical direction of a physician who performs all of the duties required in the job description and in accordance with Federal and Tribal requirements.

We recommend that the Acting Assistant Secretary of the Office of Management require the Privacy Office to allocate appropriate resources to the Compliance Office based on the stated priority of reducing or eliminating the investigation backlog so that FERPA complaints are resolved in a timely manner.

We recommend that the Acting Assistant Secretary of the Office of Management require the Privacy Office to work with the Office of General Counsel to resolve outstanding policy issues that impede the Compliance Office's ability to investigate certain FERPA complaints.

We recommend that the Acting Assistant Secretary of the Office of Management require the Privacy Office to implement an effective FERPA complaint tracking system that allows the Compliance Office to account for and track all complaints it receives, including the status and outcome of each complaint, and that provides an effective mechanism for reliable performance measurement and reporting.

We recommend that the Acting Assistant Secretary of the Office of Management require the Privacy Office to use reliable performance data to design and implement appropriate performance standards for the Compliance Office as a whole and for individual personnel responsible for handling complaints.

We recommend that the Acting Assistant Secretary of the Office of Management require the Privacy Office to investigate all complaints that meet the criteria requiring investigation and do not place complaints into an "inactive" status.

We recommend that the Acting Assistant Secretary of the Office of Management require the Privacy Office to revise processes for resolving FERPA complaints to ensure effective and appropriate communication with the complainant, to include providing dismissal notifications, updates, and responses to inquiries in a timely manner and recording all communication in the tracking system.

We recommend that the Acting Assistant Secretary of the Office of Management require the Privacy Office to design and implement a risk-based approach to processing and resolving FERPA complaints, where complaints deemed highest risk are prioritized. Risk can be evaluated based on the subject matter of the complaint, the severity of risk to student privacy, the number of students affected, or other relevant factors.

We recommend that the Acting Assistant Secretary of the Office of Management require the Privacy Office to review and evaluate its current policies and procedures for processing FERPA complaints to ensure they are complete and appropriate.

Grant Thornton recommends that OPM establish a means of documenting a list of users with significant information system responsibilities to ensure the listing is complete and accurate and the appropriate training is completed.

Grant Thornton recommends that OPM ensures policies and procedures governing the provisioning and de-provisioning of access to information systems are followed in a timely manner and documentation of completion of these processes is maintained.

Grant Thornton recommends that OPM perform a comprehensive periodic review of the appropriateness of personnel with access to systems.

Grant Thornton recommends that OPM document access rights to systems to include roles, role descriptions and privileges or activities associated with each role and role or activity assignments that may cause a segregation of duties conflict.

Grant Thornton recommends that OPM review audit logs on a pre-defined periodic basis for violations or suspicious activity and identify individuals responsible for follow up or elevation of issues to the appropriate team members for review. The review of audit logs should be documented for record retention purposes.

Grant Thornton recommends that OPM establish a means of documenting all users who have access to systems.

Grant Thornton recommends that OPM establish a methodology to systematically track all configuration items that are migrated to production and be able to produce a complete and accurate listing of all configuration items for both internal and external audit purposes, which will in turn support closer monitoring and management of the configuration management process.

Grant Thornton recommends that OPM enforce existing policy developed by OPM, vendors or federal agencies requiring mandatory security configuration settings and implement a process to periodically validate the settings are appropriate.

Grant Thornton recommends that OPM develop interface/data transmission design documentation that specifies data fields being transmitted, controls to ensure the completeness and accuracy of data transmitted, and definition of responsibilities.