Open Recommendations

The OIG recommends that executive leaders ensure the Comprehensive Environment of Care Committee reviews environment of care deficiencies for trends and opportunities for improvement.

The OIG recommends that executive leaders ensure staff review patient safety events for trends and system vulnerabilities and implement process improvement actions to prevent future occurrences.

The OIG recommends facility leaders ensure staff secure all medications and the supplies used to administer medications in the Emergency Department.

Confirm timely completion of required training courses for Florida 3 District postmasters and supervisors.

Ensure that FMC Devens Executive Leadership and the Central Office's Human Resource Management Division discuss the staffing projection tool methodology and how it compares with FMC Devens Executive Leadership's understanding of its current and potential future mission needs to ensure greater alignment between stakeholder staffing projections.

Ensure that FMC Devens follows BOP guidance for buprenorphine and naloxone administration and observation and that all FMC Devens employees who administer medication receive training on BOP guidance and policies for medication administration.

Implement a plan to address the medical record backlog at FMC Devens.

Ensure that FMC Devens develops a consistent and accurate medical record tracking procedure with the contracted company that includes regular and recurring reconciliation of outside inmate medical records between FMC Devens and the contracted company.

Ensure that FMC Devens follows the BOP Patient Care Policy for sick call and provides training to all FMC Devens Health Services Department employees on the policy, as well as on FMC Devens sick call procedures.

Ensure that FMC Devens follows the BOP's Clinical Practice Guidelines for Preventive Healthcare Screening to establish a local preventive healthcare program and utilize all members of the healthcare team in preventive healthcare.

Ensure that all FMC Devens inmates over age 50 are receiving preventive healthcare screenings, including cognitive impairment screening.

Ensure that FMC Devens verifies the credential files of all providers prior to allowing them to administer care to inmates, and ensure that FMC Devens completes peer reviews in accordance with BOP policy.

Ensure that inmates admitted to and housed in the Memory Disorder Unit are appropriately placed in accordance with FMC Devens's established criteria.

Ensure that FMC Devens adheres to BOP policy on medical inmate companion screening and hiring and that FMC Devens employees screening and hiring these companions are trained on the policies and procedures.

Ensure that FMC Devens evaluates the roles and responsibilities of medical inmate companions to ensure that they are not performing duties outside the scope of the inmate companion program.

We recommended the CIO: Develop and implement an unambiguous standard operating procedure, utilizing Federal Risk and Authorization Management Program guidance and leading practices, to monitor cloud service providers and escalate non-compliance effectively to the agency Authorizing Official, including defined risk management deficiency triggers.

We recommended the CIO: Develop and implement a validation of the provisioned exemptions to ensure all provisioned exemptions are provisioned appropriately.

We recommended the CIO: Complete in progress efforts to modernize impacted systems and subsequently enable multi-factor authentication.

We recommended the CIO: Enhance the validation process for the quarterly Chief Information Officer FISMA Metrics to ensure all metrics are reported accurately and are in accordance with applicable guidance and standards.

We recommended the CIO: Assign appropriate resources to perform the audit log reviews as required by the system security plan.

We recommended the CIO: Develop, implement, and track privacy-focused, role-based training for employees and contractors with significant privacy responsibilities.

We recommended the CIO: Develop and implement validation controls to ensure users are properly onboarded to LearningLink and assigned required trainings.

Complete a review of Postal Vehicle Service transportation schedules and verify related actions are implemented at the Boston Processing and Distribution Center.

Meet load and unload scan goals consistently at the Boston Processing and Distribution Center.

In order for senior leadership to be able to consider and decide matters potentially raising constitutional separation of powers issues, we recommend that the Department evaluate when advance notification to a senior Department official, such as the Deputy Attorney General or Attorney General, should be required before compulsory process is issued, and any corresponding NDOs are sought, for records of a Member of Congress or congressional staffers and establish, as necessary, implementing policies and guidance.

We recommend that the Department consider the circumstances in which NDO applications and renewals should identify for the reviewing judge that the records covered by a proposed NDO are records of Members of Congress or congressional staffers.

We recommend that the Department consider whether there are circumstances in which an exhaustion requirement should be a prerequisite for issuing compulsory process to obtain records of Members of Congress and congressional staffers.

(U) Rec 1: This recommendation is Controlled Unclassified Information

Establish and implement an agency-wide resource committee to monitor and report on corporate resource needs, including existing recruiting strategies, staffing levels, and information technology resources in order to strengthen resource planning and response capabilities for large regional bank resolutions.

Complete or update, as applicable, the Regional Resolution Framework Document and related process guides to address significant process gaps.

Establish a practice of regular interdivisional participation in the development and review of the Regional Resolution Framework procedural documents, as appropriate.

Develop and implement a resolution readiness training program for key personnel responsible for executing the Regional Resolution Framework and related procedures. The training program should address awareness, plan-specific, role-based, and functional training.

Establish and implement a process of periodic interdivisional exercises of large regional bank resolution activities, to test the ongoing effectiveness of agency-wide response and coordination.

Identify from after action review documents the recommendations that are the most critical for large
regional bank resolutions and prioritize them with formal tracking and monitoring.

Establish a plan for ensuring that CISR regularly conducts internal reviews of its large regional bank resolution planning activities, as appropriate based on risk.

Mint management should reinforce and monitor the policy related to access removal tickets for separated Mint employees to effectively remove/disable access within five business days of separation.

Mint management should ensure a thorough review of the obligations classified as "de-obligate" is performed to verify that the obligation is de-obligated timely.

Mint management should ensure a thorough review of the manual journal entries is performed related to the reclassification of lease revenue.

Implement policies, procedures, and/or controls for new, transfer, and promoted employees to verify completeness and accuracy of information in eOPF.

USITC OHR should conduct reviews of eOPF documents and the underlying documentation supporting eOPF files (health insurance, life insurance, TSP, SF-50s) for all employees to ensure that 1) the deductions elected by employees are the deductions being taken on the earnings and leave statements and are present in FPPS 2) HR has properly coded employee elections and thereafter conduct reviews at least semi-annually. If discrepancies are found, USITC OHR should correct those discrepancies.

Document, clarify, and communicate requirements for assessing the price on cost-increase modifications, including
a. requirements for price reasonableness determinations.
b. expectations for legal reviews.

We recommend that BIE develop and implement a plan to monitor identified deficiencies at Tate Topa Tribal School for resolution and correction in accordance with abatement plan timelines.

We recommend that BIE during each health and safety inspection, ensure the inspector verifies that deficiencies identified in the prior year's inspection were corrected or documents them as repeat deficiencies.

We recommend that BIE develop a plan focused on hiring additional maintenance and grounds staff at Tate Topa Tribal School.

We recommend that BIE provide all Tate Topa Tribal School facilities maintenance staff the necessary computer hardware, software, and training to access the facility management system.

We recommend that BIE review and analyze all Tate Topa Tribal School work orders in the Facility Management System and update work order status as needed to ensure accuracy.

We recommend that BIE develop an updated and accurate map of the Tate Topa Tribal School campus.

We recommend that BIE develop and deliver training to emphasize the importance of accurate and complete recordkeeping in the facility management system.

Develop written timekeeping policies and procedures, including timesheet review, and provide training to SALA staff and to new employees on charging leave and holiday time.

Provide training to all SALA employees involved in coding costs as direct or indirect. The training should include the definitions of direct and indirect costs and should contain explicit guidance on how to account for each type of expense.