Open Recommendations

The Facility Director ensures the mental health executive council operates in accordance with VHA requirements.

The Chief of Mental Health identifies barriers and implements processes to provide a minimum of four hours of recovery-oriented, interdisciplinary programming on weekends on the inpatient mental health unit and monitors for compliance.

The Facility Director develops and implements processes to monitor and track compliance with involuntary commitment requirements.

The Chief of Staff ensures timely documentation of informed consent discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications and monitors for compliance.

The Chief of Staff ensures discharge instructions for veterans are written in easy-to-understand language and include the purpose for each medication.

The Chief of Staff directs staff to complete or review safety plans with veterans prior to discharge and monitors for compliance.

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

The Chief of Staff directs staff to address ways to make the veteran’s environment safer from potentially lethal means in safety plans and monitors for compliance.

The Facility Director directs staff to comply with Lethal Means Safety training and monitors for compliance.

The Facility Director directs staff to comply with Skills Training for Evaluation and Management of Suicide training and monitors for compliance.

The Facility Director directs staff to comply with VA S.A.V.E. training and monitors for compliance.

The Facility Director ensures Interdisciplinary Safety Inspection Team requirements are met and monitors for compliance.

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

The Facility Director uses VHA guidelines to develop a facility-specific policy for the use of restraint chairs.

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

We recommend the Vice President, River Operations, develop a plan to prioritize and complete overdue inspections.

We recommend the Vice President, River Operations, emphasize the importance of recording the correct completion date for informal inspections.

We recommend the Vice President, River Operations, evaluate the open recommendations and determine a priority and schedule for completion.

We recommend the Vice President, River Operations, evaluate the engineering task list and determine if open items should be closed, addressed, or left on the list.

We recommend the Vice President, River Operations, revise operations, maintenance, and inspection manuals to include an accurate listing of required inspections for all dams.

We recommend the Vice President, River Operations, add required frequency for all inspections.

We recommend the Vice President, River Operations, emphasize the importance of reviewing required weekly inspections and inspecting all monthly checklist items for supplemental inspections.

Verify that Appleseeds Tapuach Association for Advancement of the Information Age corrects the one instance of material noncompliance detailed on pages 24-26 of the audit report.

We recommended the Assistant Secretary for Information and Technology consistently implement an improved continuous monitoring program in accordance with the National Institute of Standards and Technology (NIST) Risk Management Framework (RMF). Specifically, implement an independent security control assessment process to evaluate the effectiveness of security controls prior to granting authorization decisions.

We recommended the Assistant Secretary for Information and Technology implement improved processes for reviewing and updating key security documentation, including Security Control Assessments, Risk Assessments, and Privacy Impact Assessments as needed. Such updates will ensure all required information is included and accurately reflects the current environment, new security risks, and applicable federal standards.