Open Recommendations

The Facility Director ensures veterans’ privacy in restraint rooms on the inpatient mental health units.

The Associate Chief of Staff for Behavioral Health develops written guidance to ensure staff and veterans’ safety during outdoor breaks.

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

The Chief of Staff ensures the completion of comprehensive inpatient mental health treatment plans 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 mental health treatment coordinators are included in care coordination.

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 listed medication in easy-to-understand language.

The Chief of Staff ensures discharge instructions for veterans include an explanation when both trade and generic names are used for the same medication.

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

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

The Facility Director ensures staff comply with timely completion of VA S.A.V.E. training requirements and monitors for compliance.

The Facility Director ensures the Interdisciplinary Safety Inspection Team adheres to Veterans Health Administration requirements, including recording meeting minutes and including all required members, and monitors for compliance.

The Facility Director implements processes to ensure Interdisciplinary Safety Inspection Team staff accurately identify and document safety hazards within the Patient Safety Assessment Tool and monitors for compliance.

The Facility Director ensures staff address identified Mental Health Environment of Care Checklist deficiencies in accordance with Veterans Health Administration guidelines and monitors for compliance.

The Facility Director ensures Interdisciplinary Safety Inspection Team members comply with Mental Health Environment of Care Checklist training requirements and monitors for compliance.

Update the Sponsored Projects Handbook in these ways: a. Implement controls related to residual funds on fixed price projects to address excessive balances; and b. Ensure that the financial review, record, and reconciliation procedures provide sufficient guidance for units to meet minimum standards of documentation.

Implement mandatory training and track attendance for unit PIs, unit Fund Managers, and others identified by OSP as involved in the sponsored project program that: a. Covers key responsibilities including but not limited to project identification and initiation, financial management (payroll and non-payroll), reporting, and closeout; and b. Provides examples of how to document financial reviews, unit expenditure records, and quarterly reconciliations in accordance with the updated Sponsored Projects Handbook.

Incorporate key internal processes in written policies and procedures concerning OSP: (1) reviewing project activities and balances; (2) monitoring sponsored projects; and (3) using checklists.

Determine and document the allowability of the questioned $157,850 for payroll costs and $74,382 for non-payroll costs charged to Project 505247 and resolve any costs determined to be disallowed with the sponsor.

Determine and document the allowability of the questioned $81,924 for payroll costs charged to Project 505223 and resolve any costs determined to be disallowed with the sponsor.

Develop and implement written unit timekeeping procedures in compliance with Smithsonian policies.

Determine and document the allowability of the questioned $24,260 for non-payroll costs charged to Project 786172 and resolve any costs determined to be disallowed with the sponsor.

Determine and document the allowability of the questioned $118,238 from catering costs charged to government-funded projects and resolve any costs determined to be disallowed with the sponsor(s).

Develop and implement procedures to monitor the following: a. The timeliness and compliance of units' project expenditure reviews, records, and reconciliations with the updated Sponsored Projects Handbook; and b. The timely submission of reports to sponsors.