Open Recommendations

The San Francisco Healthcare System Director confirms the Sierra Pacific Veterans Integrated Service Network Clinical Resource Hub sleep medicine licensed independent practitioners are privileged in accordance with policy and monitors for compliance

The Sierra Pacific Veterans Integrated Service Network Director ensures Sierra Pacific Veterans Integrated Service Network leaders and San Francisco Healthcare System leaders are educated on Veterans Health Administration policies regarding actions required following licensed independent practitioners’ lapse in privileges.

The Sierra Pacific Veterans Integrated Service Network Director confirms the San Francisco Healthcare System and the Sierra Pacific Veterans Integrated Service Network Clinical Resource Hub leaders complete a review of clinical care rendered by physicians with lapsed privileges as required by the Veterans Health Administration directive.

The Under Secretary for Health ensures the Veterans Health Administration National Program Director, Sleep Medicine and the National Sleep Medicine Field Advisory Board review sleep medicine privileges and provide national guidance for sleep medicine physicians who seek other specialty privileges.

The San Francisco Healthcare System Director ensures that the Sierra Pacific Veterans Integrated Service Network Clinical Resource Hub director addresses sleep medicine physicians’ concern of potential for disruptions in sleep medicine services without dual privileges and notifies sites receiving Sierra Pacific Veterans Integrated Service Network Clinical Resource Hub services if sleep medicine privilege changes will disrupt services.

The under secretary for benefits to iIdentify all veterans using dual entitlement on VA-guaranteed joint home loans who were charged funding fees and received a retroactive disability rating that precedes their loan closing date since July 2019 when the veteran refund eligibility list was implemented, and issue required refunds.

The under secretary for benefits update systems to ensure eligible veterans using dual entitlement on joint VA-guaranteed home loans are identified for funding fee refunds and ensure that any system updates are tested to demonstrate that the entire population of eligible veterans is included.

We recommend that the Acting GSA Administrator continue to collaborate with federal law enforcement agencies to address security risks at GSA-owned federal buildings.

Establish a common framework with roles and responsibilities for deferred maintenance that applies throughout the organization, standardizing what is considered deferred maintenance and the process for prioritizing and addressing it.

Prioritize and track all deferred maintenance and associated costs, including capital and maintenance projects, and begin addressing its backlog of maintenance in order of priority.

Establish procedures, responsibilities, and accountability mechanisms for staff and supervisors to periodically review and validate all data including "estimated cost" within the maintenance system, for completeness and accuracy.

Ensure that the maintenance system has functionality and reporting capabilities to assist project managers with identifying outstanding maintenance calls and alert supervisors of maintenance calls without periodic updates or resolution.

Establish a policy requiring project managers to provide local management with periodic status updates on reported maintenance issues and document statuses until resolved.

Improve oversight of its local self-assessment programs by assigning staff to conduct periodic reviews of assessments for facilities under 6,500 square feet and establishing an escalation process to obtain annual assessments from larger facilities for review.

Address all building maintenance, safety, and security issues identified during site visits.

Develop processes and requirements for routinely collecting excess and underutilized space data across its property portfolio and include accountability mechanisms for ensuring this data is collected on a regular basis.

Develop processes to periodically assess and verify the accuracy of excess and underutilized space data and update in the designated system of record.

Develop and implement a comprehensive strategy for managing excess and underutilized space, which would include processes for identifying space at properties throughout the network, centralized tracking and reporting, and corrective action plans (such as for renting, disposing, or repurposing).

Verify that all rooms and spaces reported in the Real Asset Management Program Out-leasing module are properly coded.

Reconcile property space data across all modules within the property management system to verify consistency and accuracy of the data.

The Lexington VA Healthcare System Director ensures emergency department, mental health, and inpatient medical and nursing staff responsible for suicide risk assessment understand the need to evaluate patients for a personally owned insulin pump and remove the insulin pump prior to inpatient admission, when necessary and monitors for compliance.

The Lexington VA Healthcare System Director verifies the draft insulin pump policy is finalized, and Lexington VA Healthcare System emergency department, mental health, and inpatient medical and nursing staff are educated on the policy.

The Lexington VA Healthcare System Director ensures leaders and staff review the Lexington VA Healthcare System policy evaluation and approval procedure.

The Lexington VA Healthcare System Director verifies that patients receive discharge instructions, with a follow-up care plan when discharged from the Lexington VA Healthcare System emergency department.

The Lexington VA Healthcare System Director ensures a review of Psychiatrist 2s documentation in Patient 2s electronic health record and makes certain documentation is completed according to Veteran Health Administration policy, including that entries are accurate, succinct, without extensive copy and paste, and devoid of derogatory, critical, comments, and takes action as warranted.