Open Recommendations

Finalize and implement policies and procedures for creating and maintaining current and target cybersecurity profiles in alignment with National Institute of Standards and Technology Cybersecurity Framework Guidance.

Finalize and implement a comprehensive Risk Management Strategy that defines roles and responsibilities, enterprise risk priorities, objectives, and communication protocols, including third-party risk considerations.

Continue to develop and implement an Enterprise Risk Management program based on National Institute of Standards and Technology and Enterprise Risk Management Playbook (Office of Management and Budget Circular A- 123, Section II requirement) guidance.

Develop and implement policies and procedures for developing and maintaining a comprehensive and accurate inventory of data and corresponding metadata for the Consumer Product Safety Commission data types.

Fully implement, assess, and maintain secure configuration settings in accordance with defined configuration management policy and security configuration baseline procedures.

Update all relevant Information Security Continuous Monitoring policies, procedures, and supporting documentation based on latest National Institute of Standard and Technology guidance.

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

This recommendation contains sensitive information that should not be made public. Therefore, we are not including the wording for this recommendation.

The VA Southern Nevada Healthcare System Director ensures that clinical service chiefs take action to address concerns substantiated in factfindings, and that all patient safety concerns identified in factfindings are reviewed and addressed.

The VA Southern Nevada Healthcare System Director evaluates the need for additional factfinders, and takes action as warranted.

The VA Southern Nevada Healthcare System Director ensures that clinical service chiefs take action timely when aware of patient safety concerns.

The VA Southern Nevada Healthcare System Director reviews the information outlined in this report, determines the need to initiate the state licensing board reporting process, and takes action as warranted.

The VA Southern Nevada Healthcare System Director requires clinical service chiefs and credentialing and privileging managers to receive education on the completion of provider exit review forms and that, when supervisory staff contact credentialing and privileging staff for initiation of the state licensing board reporting process, a process is in place to ensure the message is clear and received.

The VA Southern Nevada Healthcare System Director ensures that clinical service chiefs and staff are educated on the need and process for submitting Joint Patient Safety Reporting reports upon awareness of patient safety events in accordance with facility policy.