Open Recommendations

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.

Implement vulnerability management processes to ensure all vulnerabilities are identified and plans of action and milestones are created for vulnerabilities that cannot be mitigated by VA deadlines.

Implement vulnerability management processes to ensure all vulnerabilities are identified and plans of action and milestones are created for vulnerabilities that cannot be mitigated by VA deadlines.

Develop and approve an authorization to operate for the special-purpose systems.

Include facility personnel during the security categorization process to ensure all necessary information types are considered when determining the security categorization for special-purpose systems.

Segregate the pharmacy application administrative access from individuals who are custodians of the pharmaceutical inventory.

We recommend that OJP work with the Louisiana Commission on Law Enforcement to ensure its FYs 2020, 2021, and 2022 Crime Victim State Certification Forms accurately reflect all activity and payments and take necessary steps to recover the excess awarded funds as appropriate.

(U) Rec. 1.b.1: The DoD OIG recommended that the Under Secretary of Defense for Intelligence and Security update DoD Instruction 5200.48, Controlled Unclassified Information (CUI) to clarify the implications of using the limited dissemination controls of Federal Employees and Contractors Only (FEDCON) and Federal Employees Only (FED ONLY) for releasability outside the Executive Branch and emphasize the use of limited dissemination controls by exception, with a limited dissemination control of None as the default option unless required otherwise.

(U) Rec. 1.b.2: The DoD OIG recommended that the Under Secretary of Defense for Intelligence and Security update Defense Office of Prepublication and Security Review 25-P-0275 to clarify the implications of using the limited dissemination controls of Federal Employees and Contractors Only (FEDCON) and Federal Employees Only (FED ONLY) for releasability outside the Executive Branch and emphasize the use of limited dissemination controls by exception, with a limited dissemination control of None as the default option unless required otherwise.

(U) Rec. 1.b.3: The DoD OIG recommended that the Under Secretary of Defense for Intelligence and Security update Center for Development of Security Excellences DoD Mandatory CUI Training course to clarify the implications of using the limited dissemination controls of Federal Employees and Contractors Only (FEDCON) and Federal Employees Only (FED ONLY) for releasability outside the Executive Branch and emphasize the use of limited dissemination controls by exception, with a limited dissemination control of None as the default option unless required otherwise.

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.

We recommend that USAID verify that Baylor College of Medicine Children's Foundation Uganda corrects the one instance of material noncompliance detailed on page 31 of the audit report.

Finalize and implement a policy outlining responsibilities and procedures for using administrative funds for purchases, including procedures for documenting justifications and approvals of requests.

Determine the allowability of approximately $26,900 in questioned costs.

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.