Open Recommendations

The Executive Director of Operations for a national cancer testing program ensures the project has met the requirements for Institutional Review Board review for research with human subjects and takes action as needed.

The Executive Director of Operations for a national cancer testing program ensures national cancer prevention, treatment, and research program staff are trained on Institutional Review Board project submission and privacy requirements.

The National Specialty Care Program Office Chief Officer ensures the national cancer prevention, treatment, and research program staff reviews and provides required approvals before the release of protected health information for research.

The National Specialty Care Program Office Chief Officer, in conjunction with the Office of Research & Development ensures that VA privacy officers report privacy incidents involving data obtained from or for national cancer prevention, treatment, and research program activities timely and monitors for compliance.

The Office of Research Oversight Executive Director in conjunction with the Chief Research and Development Officer, VHA Office of Research & Development, reviews the national cancer prevention, treatment, and research program final mitigation plan and ensures corrective actions address system-wide issues for determining whether a national cancer prevention, treatment, and research program project constitutes research, safeguarding privacy when data is shared for projects, and ensuring data security requirements are met.

The National Specialty Care Program Office Chief Officer ensures the national cancer prevention, treatment, and research program has safeguards in place including biostatistician expertise to ensure that data containing sensitive patient information and protected health information is deidentified before sharing outside of VA as required.

The Executive Director of Operations for a national cancer testing program ensures the project has met the requirements for Institutional Review Board review for research with human subjects and takes action as needed.

The Executive Director of Operations for a national cancer testing program ensures national cancer prevention, treatment, and research program staff are trained on Institutional Review Board project submission and privacy requirements.

The National Specialty Care Program Office Chief Officer ensures the national cancer prevention, treatment, and research program staff reviews and provides required approvals before the release of protected health information for research.

The National Specialty Care Program Office Chief Officer, in conjunction with the Office of Research & Development ensures that VA privacy officers report privacy incidents involving data obtained from or for national cancer prevention, treatment, and research program activities timely and monitors for compliance.

The Office of Research Oversight Executive Director in conjunction with the Chief Research and Development Officer, VHA Office of Research & Development, reviews the national cancer prevention, treatment, and research program final mitigation plan and ensures corrective actions address system-wide issues for determining whether a national cancer prevention, treatment, and research program project constitutes research, safeguarding privacy when data is shared for projects, and ensuring data security requirements are met.

The National Specialty Care Program Office Chief Officer ensures the national cancer prevention, treatment, and research program has safeguards in place including biostatistician expertise to ensure that data containing sensitive patient information and protected health information is deidentified before sharing outside of VA as required.

Facility leaders install detectable warning surfaces where crosswalks transition onto a vehicle roadway.

Facility leaders ensure clinical staff who perform toxic exposure screenings complete mandatory training.

The Director ensures staff implement processes to prevent repeat environment of care findings related to dusty sprinkler heads.

Facility leaders evaluate all areas where biohazardous materials are located to ensure staff store clean and dirty items separately.

The Director ensures staff keep the environment clean and safe.

Facility leaders ensure their policy aligns with VHA Directive 1088(1) and develop workflows for all services that communicate test results to patients.

The Chief of Staff and Associate Director for Patient Care Services ensure corrective actions address unfavorable trends in communication of test result data.

The Director ensures the Chief of Staff chairs and attends the Peer Review Committee meetings as required by VHA.

The Director ensures patient safety managers identify adverse events as sentinel events when they meet criteria.

Facility leaders evaluate and improve processes to identify adverse events that warrant an institutional disclosure.

The Director implements processes to ensure staff track action plans until they are completed and report to leaders those that are outstanding.

The Director ensures leaders train staff on their roles and responsibilities when responding to a medical emergency, including the location of equipment used for medical emergencies.

The Director ensures leaders revise the emergency response policy based on recertification time frames in VHA Directive 0999(1) or sooner, if warranted.

Facility leaders ensure all applicable staff maintain basic life support certification and take appropriate action for those staff without it.

The Director ensures facility leaders manage primary care teams panel sizes to support patients access to care.

Facility leaders install detectable warning surfaces where crosswalks transition onto a vehicle roadway.

Facility leaders ensure clinical staff who perform toxic exposure screenings complete mandatory training.

The Director ensures staff implement processes to prevent repeat environment of care findings related to dusty sprinkler heads.

Facility leaders evaluate all areas where biohazardous materials are located to ensure staff store clean and dirty items separately.

The Director ensures staff keep the environment clean and safe.

Facility leaders ensure their policy aligns with VHA Directive 1088(1) and develop workflows for all services that communicate test results to patients.

The Chief of Staff and Associate Director for Patient Care Services ensure corrective actions address unfavorable trends in communication of test result data.

The Director ensures the Chief of Staff chairs and attends the Peer Review Committee meetings as required by VHA.

The Director ensures patient safety managers identify adverse events as sentinel events when they meet criteria.

USDA OIG has determined that this recommendation contains sensitive information and will not be publicly released due to privacy concerns.

USDA OIG has determined that this recommendation contains sensitive information and will not be publicly released due to privacy concerns.

USDA OIG has determined that this recommendation contains sensitive information and will not be publicly released due to privacy concerns.

USDA OIG has determined that this recommendation contains sensitive information and will not be publicly released due to privacy concerns.

USDA OIG has determined that this recommendation contains sensitive information and will not be publicly released due to privacy concerns.

USDA OIG has determined that this recommendation contains sensitive information and will not be publicly released due to privacy concerns.

USDA OIG has determined that this recommendation contains sensitive information and will not be publicly released due to privacy concerns.

USDA OIG has determined that this recommendation contains sensitive information and will not be publicly released due to privacy concerns.

Ensure the Disability Determination Services (DDS) established appropriate procedures to verify and document medical providers’ licensing status.

Work with the Oklahoma Department of Rehabilitation Services to ensure any contracts paid with Federal funds to support the services the DDS provides the Social Security Administration adhere to Federal requirements

Create a means of tracking issues identified in the Purchase Card Program Coordinator’s monthly reviews and verify that corrective action is taken to resolve the issues in a timely manner.

Develop a process to measure desired outcomes and efficiencies for future organizational changes.

Develop a program and project management framework or roadmap for organizational change.

We recommend that management:
• Implement audit logging monitoring controls to reduce the risk that inappropriate and/or unusual activitythat may compromise the integrity and availability of systems and data goes undetected and resolved.
• Design, document, and enforce controls to remove system application access within an acceptabletimeframe following a user’s separation date.
• Design, document, and implement controls to grant system application access upon requested andapproved business need and maintain evidence of such user access requests.