Open Recommendations

The Facility Director ensures regular communication between mental health and executive leaders regarding staffing needs and mental health processes.

The Facility Director ensures the Mental Health Executive Council operates in accordance with Veterans Health Administration requirements.

The Chief of Mental Health ensures a full-time, dedicated local recovery coordinator is integrated into the inpatient mental health unit to support recovery-oriented care.

The Chief of Mental Health ensures mental health leaders develop and implement written processes for staff training, education, and recovery-oriented services.

The Chief of Mental Health ensures staff provide a minimum of four hours of recovery-oriented, interdisciplinary mental health programming on weekdays and weekends.

The Facility Director ensures veterans’ privacy in the communal shower room on the inpatient mental health unit.

The Facility Director ensures clinicians document veterans’ capacity to consent to admission to the inpatient mental health unit.

The Veterans Integrated Service Network Director ensures facilities’ involuntary hold and hospitalization processes align with applicable state laws and develops processes for ongoing oversight.

The Facility Director consults with District Counsel to establish written involuntary hold and hospitalization processes that align with West Virginia State laws and monitors compliance.

The Facility Director develops and implements written care coordination processes for veterans involuntarily admitted to non-VA healthcare facilities.

The Chief of Staff ensures providers document discussions with veterans on the risks and benefits of newly prescribed medications and monitors for compliance.

The Chief of Staff ensures veterans’ discharge instructions are written in easy-to-understand language and include the follow-up appointment location, the purpose of each medication, and an explanation when both trade and generic names are used for the same medication.

The Facility Director ensures staff comply with suicide prevention training requirements and monitors for compliance.

The Facility Director ensures Interdisciplinary Safety Inspection Team members participate in Mental Health Environment of Care Checklist inspections and document membership and attendance.

The Facility Director ensures the Interdisciplinary Safety Inspection Team accurately identifies, documents, and addresses safety hazards within the Patient Safety Assessment Tool and monitors for compliance.

The Facility Director directs staff to comply with Mental Health Environment of Care Checklist training requirements and monitors for compliance.

The Associate Chief of Staff, Mental Health ensures the implementation of written processes for staff training, education, and recovery-oriented services.

The Facility Director identifies and addresses barriers to communal room access for veterans on the inpatient unit.

The Facility Director ensures accurate reporting of inpatient mental health beds and implements processes to monitor.

The Facility Director formalizes written processes to monitor and track compliance with state involuntary commitment requirements.

The Facility Director ensures staff document veterans’ legal commitment status in the electronic health record and monitors for compliance.

The Chief of Staff ensures documentation of discussions between prescribers and veterans on the risks and benefits of newly prescribed medications and monitors for compliance.

The Chief of Staff ensures discharge instructions for veterans include appointment locations written in easy-to-understand language.

The Chief of Staff ensures discharge instructions for veterans include the purpose for each medication listed and are free of medical abbreviations.

The Chief of Staff directs staff to complete and document the Columbia-Suicide Severity Rating Scale within 24 hours before veterans’ discharge and monitors for compliance.

The Chief of Staff directs staff to complete suicide prevention safety plans and provide copies of the plans to veterans or caregivers and monitors for compliance.

The Chief of Staff directs staff to address ways to make veterans’ environments safer from potentially lethal means, beyond firearms and opioids, in safety plans and monitors for compliance.

The Under Secretary for Health identifies barriers to, and ensures documentation of, discussions specific to making the environment safer from identified lethal means in veterans’ safety plans.

The Facility Director directs staff to comply with suicide prevention training requirements and monitors for compliance.

The Facility Director ensures compliance with Veterans Health Administration requirements for the Interdisciplinary Safety Inspection Team, including recording of meeting minutes, membership, and attendance, and monitors for compliance.

The Facility Director implements processes to ensure the Interdisciplinary Safety Inspection Team applies Mental Health Environment of Care Checklist standards on the inpatient mental health unit and monitors for compliance.

The Facility Director directs inpatient unit staff and Interdisciplinary Safety Inspection Team members to comply with Mental Health Environment of Care Checklist training requirements and monitors for compliance.

The CPSC implement and provide routine training regarding an improved Employment of Relatives Directive that requires written determinations on the propriety of the workplace relationships of all related persons, employees and contractors, who work at the CPSC.

Although the marriage of two senior CPSC officials created the perception of impropriety, we found insufficient evidence to substantiate that the subjects misused their positions.

Implement written policies and training to ensure that all employees who work on multiple activities record their time in a way that supports the distribution of the employee’s salary or wages among specific activities or cost objectives.

The Commission should determine the risks associated with non-standard adjustments in its financial reporting process and develop and document appropriate controls to review and validate those non-standard transaction outputs on the aging reports created by their service provider. At a minimum, the Commission should:

• Establish a dollar value threshold to review all balances without identifying contract and vendor fields, recorded on the monthly aging reports provided to the Office of the Chief Financial Officer and the OIG and
• Review and verify all material non-standard adjustment transactions (JVs, SVs, RVs, and BB transactions) recorded without identifying contract and vendor…

To address the issues we identified, we recommend that the Executive Vice President,
Strategy and Planning, take the following action:
1. Continue to develop and implement a joint strategic fleet/facilities plan. The plan
should define company goals, timelines, and next steps to ensure that the
company’s fleet and facilities efforts align. The plan should also include an
inventory of existing facilities and a method to continuously assess which
modifications are critical to support future operations and reprioritize, as
needed.

In addition, we recommend that the Executive Vice President, Capital Delivery, take the
following action:
2. Develop and implement a management framework for its facility upgrades,
including a management plan with the requisite components outlined in
company and industry standards. This should include a risk management
process and tools, such as a risk register.

Develop new or modify existing MOU supplemental schedules to include a framework for multicycle project budgets with specific illustrative criteria describing which projects should be categorized as multicycle, as well as roles and responsibilities for
a. developing and approving the currency budget’s multicycle projects, including which costs may be conditionally approved and how to receive full approval.
b. reviewing to ensure multicycle projects’ quarterly funding requests are justified and subsequently advancing funds.
c. annually reconciling the prior year’s advances to expenses and adjusting future advances as appropriate.

Executive leaders ensure staff store clean and dirty equipment separately, repair torn furnishings, and keep the environment clean.

Executive leaders ensure the facility’s policy for test result communication aligns with the VHA directive.

The Associate Medical Center Director ensures Environmental Management Services and nutrition staff maintain clean patient food storage areas.

The Associate Medical Center Director ensures staff monitor storage areas and remove expired supplies.

The Associate Medical Center Director ensures Environmental Management Services staff make feminine hygiene products available in public women’s and unisex restrooms.

The Chief of Staff ensures staff establish written service-level workflows for the communication of test results.

Update and implement the Accountable Property Handbook to address returning IT assets that requires a secure chain of custody process, including IT assets subject to litigation holds.

Update the offboarding procedures to include instructions to employees to ensure exiting employees return their IT assets in accordance with the updated Accountable Property Handbook.

Improve the IT asset accountability process going forward to include historical IT asset tracking by employee and by addressing and implementing data access procedures for returned cell phones on litigation holds.

In coordination with OCFO and the OCIO, develop and implement a plan with defined milestones and timelines to resolve data discrepancies between Maximo and Odyssey and ensure property data are complete, accurate, and properly reconciled with the F/A module. As part of this plan, clarify roles, responsibilities, and coordination mechanisms between offices to ensure sustained accountability for property management and reconciliation activities.

Assess and, where feasible, enhance Maximo’s configuration to automate key property management controls. This assessment should include a cost–benefit analysis to determine viable improvements and identify compensating controls if system enhancements are not practical, to ensure consistent and accurate property data entry and reconciliation.