Open Recommendations

(U) Rec. A.2: Recommendation is Classified.

(U) Rec. B.2.a: Recommendation is Classified.

We recommend that the NRC OCIO management, in coordination with OCHCO and ADM, evaluate the NRC’s separation policies and procedures and re-engineer the related business processes and the automation used to disable separated employees’ accounts to ensure that the NRC terminates these accounts in a timely manner.

We recommend that the TTC and NRC management evaluate the TTC system ATO memorandum for revision and update it to reflect the current operating environment.

We recommend that the NRC’s TTC management install a server cage on the second floor of the facility for the NRC Information Technology Infrastructure Patch Panel.

We recommend that the NRC’s TTC management install protective covers over the emergency power shut-off switches throughout the facility.

We recommend that NRC management define and implement a risk-based process for regularly reviewing users who have badged access to the NRC general access group and restricting badged access to the Regions based on business needs.

We recommend that NRC management perform a risk-based analysis of the practice of allowing users to have general badge access to multiple NRC facilities. As a part of this risk-based analysis, NRC management should define, document, and implement mitigating controls that reduce the potential impact of having users with badged access to multiple facilities.

The Carl T. Hayden Medical Center Director ensures that supervisory staff take effective actions to correct clinical deficiencies.

The Carl T. Hayden Medical Center Director identifies electronic health records containing the dermatologists misuse of copy and paste and takes action as warranted to ensure the safety of patients.

The Carl T. Hayden Medical Center Director ensures that service chiefs and patient safety staff report instances of misuse of copy and paste to Health Information Management System staff.

The Carl T. Hayden Medical Center Director ensures a comprehensive review is conducted to determine if the dermatologist documented electrodesiccation and curettage procedures that were not performed and takes action as warranted, including providing patients with clinical care and disclosures if needed, and notifying the Office of Inspector General.

The Carl T. Hayden Medical Center Director ensures that the Chief of Staff is aware of and addresses pervasive deficiencies, when they exist, in clinical care provided at the facility.

The Desert Pacific Healthcare System Network Director evaluates reasons for noncompliance with the state licensing board reporting policy with regard to the dermatologist, and takes action as needed.

The Carl T. Hayden Medical Center Director ensures that a dermatologist conducts a review of the dermatologists patients with consideration of the concerns laid out in this report, to identify patients who may need follow-up care and disclosures, and takes action as warranted.

The Carl T. Hayden Medical Center Director reviews with facility leaders, disclosure requirements outlined in VHA Directive 1004.08, Disclosure of Adverse Events to Patients.

[Description omitted; CSOSA has determined that this recommendation contains information that is limited official use or classified.]

[Description omitted; CSOSA has determined that this recommendation contains information that is limited official use or classified.]

[Description omitted; CSOSA has determined that this recommendation contains information that is limited official use or classified.]

[Description omitted; CSOSA has determined that this recommendation contains information that is limited official use or classified.]

[Description omitted; CSOSA has determined that this recommendation contains information that is limited official use or classified.]

[Description omitted; CSOSA has determined that this recommendation contains information that is limited official use or classified.]

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures community care oversight councils function according to their charters and meet the required number of times per fiscal year.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff enter community care patient safety events into the Joint Patient Safety Reporting system.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures patient safety managers or designees brief community care patient safety event trends, lessons learned, and corrective actions at community care oversight council meetings.