Open Recommendations

The VA Augusta Health Care System Director identifies and addresses barriers to admission for veterans on involuntary holds for mental health treatment.

The VA Augusta Health Care System Director ensures alignment between involuntary commitment policies and practices, consistency with state laws, and implementation of monitoring processes.

The VA Augusta Health Care System Chief of Staff ensures assignment of ongoing responsibilities for monitoring timely documentation of the change in veterans voluntary or involuntary legal status, consistent with VHA policy and state laws.

The VA Augusta Health Care System Chief of Staff ensures timely documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications and monitors for improvement.

The VA Augusta Health Care System Chief of Staff ensures discharge summaries are completed within two business days of discharge and monitors for compliance.

The VA Augusta Health Care System Chief of Staff ensures discharge instructions for veterans include appointment location and contact information in easy-to-understand language.

The VA Augusta Health Care System Director ensures that medications listed in discharge instructions include the purpose for each medication and are written in easy-to-understand language.

The VA Augusta Health Care System Chief of Staff identifies barriers to completing the Columbia-Suicide Severity Risk Scale Screener within 24 hours prior to discharge, implements processes, and monitors to ensure compliance.

The VA Augusta Health Care System Chief of Staff ensures that safety plans address ways to make the veterans environment safer from potentially lethal means and monitors for compliance.

The VA Augusta Health Care System Director ensures staff comply with lethal means safety training and suicide risk training requirements and monitors for compliance.

The VA Augusta Health Care System Chief of Staff ensures mental health leaders update inpatient unit toilets to meet safety requirements and implement processes to reduce associated safety risks.

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

Ensure that the Health Services Division (Central and/or Regional Office) reviews medication discontinuation practices at FCI Lewisburg and other holdover facilities, including the discontinuation of antidepressants without a clinical encounter, to determine whether such practices are consistent with BOP clinical guidance. If the Health Services Division determines that such practices are inconsistent with BOP clinical guidance, it should work collaboratively with FCI Lewisburg clinicians to identify practical solutions to increase the frequency with which clinicians conduct a clinical encounter with holdover inmates in advance of such decisions so that clinicians can collect complete information about an inmate's condition and the…

Ensure FCI Lewisburg's compliance with existing Central Office guidance for certain employees to carry a cut-down tool when on duty.

Establish written policies and procedures for the Special Agent Hiring panel to include defined roles and responsibilities for individuals serving on the panel and overseeing the panel.

Implement controls to ensure that the documents used to inform hiring panels are accurate, appropriately anonymized, and properly reviewed.

Implement controls and provide training to ISS Personnel Security Specialists to ensure polygraph Reports of Investigation are being appropriately reviewed.

Establish procedures for identifying and mitigating the risks associated with granting SCI access to individuals who failed a pre-employment polygraph exam.

Complete its record retention policy review, to include establishing appropriate and consistent record retention policies for the maintenance of all polygraph casefiles.

Ensure that contractors who hold a security clearance and have not successfully completed the pre-employment polygraph examination are removed from DEA contracts, in accordance with DEA policy.

Formally implement its newly established procedures to prevent foreign officials who do not successfully complete the foreign screening polygraph exam from being admitted to DEA-sponsored vetted units and ensure foreign officials receive timely foreign screening polygraph exams as required by DEA policy.

Complete its review of SIUNet records to ensure that inaccurate and duplicate data is removed and/or corrected.

Review the supervisory reporting structure for Polygraph Examiners to ensure examiners can independently carry out the duties and functions of the position.

Review its rehire policies and procedures to ensure that the DEA has clear and consistent practices when rehiring former employees for its four core series positions.

Implement controls to ensure that the polygraph Report of Investigation is being prepared accurately and properly reviewed by the Polygraph Unit.