Open Recommendations

The Facility Director formalizes 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.

Some or all of the recommendation is not publicly available due to concerns with information protected under the Freedom of Information Act.

Implement a process to verify all change requests are closed and reviewed when all change activities have been completed.

Validate all critical and high incident tickets are resolved within required timeframes.

Kearney recommends that the FCC direct USAC to perform the following: Develop an integration process in order for UNIFI to ingest HC obligations transactions including required financial internal controls. In the interim, USAC should establish a workaround whereby HC provides the obligations data to Finance and includes appropriate controls and reviews to ensure that entries are accurate and properly supported.

Inadequate Cybersecurity Governance

Inadequate Cybersecurity Governance

Risk and Asset Management

Risk and Asset Management

Risk and Asset Management

Risk and Asset Management

Risk and Asset Management

Information Security Continuous Monitoring