Open Recommendations

Establish procedures to enhance the review process of progress reports to analyze the completeness, accuracy, and success of the AHTF Program.

CMS should update and broaden its lists of hospital-acquired conditions to capture common, preventable, and high-cost harm events.

CMS should explore expanding the use of patient safety metrics in pilots and demonstrations for health care payment and service delivery, as appropriate.

CMS should develop and release interpretive guidance to surveyors for assessing hospital compliance with requirements to track and monitor patient harm events.

AHRQ should, with support from HHS leadership, coordinate agency efforts to update agency-specific Quality Strategic Plans.

AHRQ should optimize use of the Quality and Safety Review System (QSRS), including assessing the feasibility of automating data capture for national measurement and to facilitate local use.

AHRQ should develop an effective model to disseminate information on national clinical practice guidelines or best practices to improve patient safety.

AHRQ should continue efforts to identify and develop new strategies to prevent common patient harm events in hospitals.

Record death information on the Numident, as appropriate, for the 40 deceased beneficiaries in our sample.

Take action, as appropriate, to record death information in the Numident for the 15,714 beneficiaries identified by our current audit.

Take appropriate action to record death information to the Numident for the 595,514 beneficiaries identified by our prior audits.

Working with the Office of the Secretary and “group of four” oversight entities as appropriate, identify and implement changes to thereview and dissemination process for I&A’s election-related intelligence products to ensure they are in accordance with applicable policies andguidelines.

We recommend that the FWS work with the Department to require the electronic system for volunteer work to limit the number of hours that can be claimed on a specific day to ensure hours are reported daily.

We recommend that the FWS work with the Department to update policies and procedures to include guidance for daily entry of hours.

We recommend that the FWS work with the Department to develop and implement training for supervisors and volunteers to ensure proper documentation and approval of volunteer time.

We recommend CBP and CWMD key stakeholders develop an agreed to support plan to monitor and sustain RPM systems that includes: • An assessment of RPM panel condition; and • Operational Analysis to assess RPM system performance and operations to identify evolving requirements and future capability needs, and changes to sustainment approach.

Use a system-approach that complies with Public Law 116-92, EEO MD-715, and 29 CFR 1614.

Review and evaluate current processes, procedures, and practices, make revisions, and implement guidance to improve efficiencies associated with obtaining contract award for conducting investigations and drafting final agency decisions.

Develop and implement processes and procedures to ensure the contractors adhere to the Statement of Work for Equal Employment Opportunity services, to include, but not limited to (1) completing investigations timely, (2) submitting authorizations for extensions, if necessary, and (3) submitting weekly status reports; and where applicable enforce any associated penalties for delays.

Define and formalize the roles and responsibilities of the Office of General Counsel in the processing of discrimination complaints. Specifically, implement policies and procedures to demonstrate the agency has a fair and impartial Equal Employment Opportunity process, to include but not limited to, ensuring: a clear separation between the agency’s Equal Employment Opportunity complaint program and its defensive function, and the agency representative does not intrude or have the appearance of intruding upon Equal Employment Opportunity counseling, investigations, and final agency decisions.

Establish and implement procedures to ensure agency responses submitted to Equal Employment Opportunity Commission in its EEO MD-715 submissions are accurate, complete, and supported by documentation.

Develop and implement controls to ensure standard operating procedures are kept up to date to reflect subsequent organizational, policy, or procedural changes that can affect processing of discrimination complaints.

Ensure the continuity of operations plan is tested annually, as required by Federal Continuity Directive 1.

CMS should Issue new guidance on the appropriate use of MAO clinical criteria in medical necessity reviews.

CMS should Update its audit protocols to address the issues identified in this report, such as MAO use of clinical criteria, and/or examine particular service types.