Open Recommendations

Assess where the company and its partners’ expectations of the company’s role differ. Based on this assessment, take steps to clarify the company’s role, as appropriate.

Work with GDC to ensure that the company has adequate, ongoing visibility into project risks on the construction packages it is not leading.

Identify and document all relevant internal stakeholders and their related HTP support activities, and assign accountable departments and individuals for each activity identified.

Finalize the HTP internal document management system and related guidance consistent with Capital Delivery procedures.

Verify that Ein Dor Museum corrects the two instances of material noncompliance detailed on pages 22 to 23 of the audit report.

Verify that EcoPeace Middle East Environmental NGO Forum corrects the two material weaknesses in internal control detailed on pages 17 to 19 of the audit report.

Verify that EcoPeace Middle East Environmental NGO Forum corrects the two instances of material noncompliance detailed on pages 23 to 25 of the audit report.

Executive leaders ensure staff post safety risk assessment permits for all construction projects.

Executive leaders ensure staff install privacy curtains in all exam rooms.

Executive leaders ensure staff install handrails on both sides of the hallway in the Community Living Center.

Executive leaders ensure staff follow the facility’s policy for communication of abnormal test results to patients.

The Associate Director for Operations ensures staff keep patient care areas clean and clean storage areas free of dirty items and equipment.

The Chief of Staff ensures the facility has workflows for all services to identify team members roles in the test result communication process.

Facility leaders assess how staff monitor video laryngoscope supplies to ensure theyare readily available, and staff remove supplies when they expire.

Facility leaders ensure staff develop service-level workflows for the communicationof test results per the VHA directive.

Document and fully implement the Departmentwide process for monthly monitoring of compliance with in-person work requirements.

Ensure medical facilities establish and implement clear written Homeless Screening Clinical Reminder policies that define the roles and responsibilities of staff involved in the referral, follow-up, and monitoring processes.

Ensure medical facility staff involved in the Homeless Screening Clinical Reminder process are aware of and trained on written local policies and procedures for making referrals, conducting follow-up, and monitoring.

Develop and implement a review process to determine whether medical facility staff followed local Homeless Screening Clinical Reminder policies whenever a veteran does not receive a follow-up encounter within 30 days of a positive screening and correct any identified deficiencies.

Ensure all medical facilities have a reliable report that accurately lists veterans who screened positive and accepted referrals as well as the status of follow-up actions.

We recommend that the Commissioner of the Public Buildings Service coordinate with the tenant agency at the Oroville LPOE range to assess the target retrieval system operation and determine a corrective action plan to address any issues identified.

We recommend that the Commissioner of the Public Buildings Service develop and issue a comprehensive policy that, at a minimum, establishes roles and responsibilities for the operation and maintenance of the indoor firing ranges; document retention requirements; and comprehensive inspection and cleaning procedures.

Work with the Federal Highway Administration, Federal Motor Carrier Safety Administration, National Highway Traffic Safety Administration, and the NRSS Action Team to develop requirements and procedures for measuring the success of individual priority actions in achieving program outcomes.

The VA Detroit Healthcare System Director ensures pathology and laboratory medicine service leaders communicate feedback regarding staff-specific errors to facilitate staff learning and according to Veterans Health Administration high reliability organization guidance.

The VA Detroit Healthcare System Director evaluates the quality and patient safety service response to patient safety events, including tracking and monitoring of service level corrective action plans to ensure timely resolution of patient safety events, and takes action as necessary.