Open Recommendations

We recommend that Treasury's Office of Capital Access disallow the questioned cost amount of $20,850 and instruct Moreno Valley to repay that amount to the Federal Government.

The Medical Center Director ensures each service develops a workflow for the communication of test results.

The Medical Center Director ensures quality management staff report deficiencies identified from the External Peer Review Program to executive leaders, and staff take corrective actions as needed.

The Medical Center Director ensures the facility has a written policy for communication of test results.

The Chief of Staff and Associate Director of Patient Care Services ensure leaders in each service develop written service-level workflows that outline the process for staff to communicate test results to providers and patients.

The Veterans Integrated Service Network Director ensures executive leaders implement a process to monitor actions related to Veterans Health Administration policy changes.

The Medical Center Director ensures the Chief of Staff and Associate Director of Patient Care Services review performance metrics for test result communications and take action for identified deficiencies.

The Medical Center Director ensures executive leaders attend Quality and Patient Safety Council meetings.

The Executive Medical Center Director ensures clinical staff can open all doors to shared bathrooms.

The Executive Medical Center Director ensures staff keep exterior doors closed to minimize risk to wandering patients.

The Executive Medical Center Director ensures each service has workflows to communicate test results.

The Facility Director ensures the Mental Health Executive Council operates in accordance with Veterans Health Administration requirements.

The Chief of Mental Health ensures compliance with Veterans Health Administration requirements for a full-time local recovery coordinator.

The Chief of Mental Health ensures a minimum of four hours of recovery-oriented, interdisciplinary programming on weekdays and weekends on the inpatient mental health unit.

The Facility Director considers consulting with the Office of Mental Health to clarify guidelines for design elements such as artwork on the inpatient unit.

The Facility Director considers alternatives to outdoor access for the inpatient unit, such as those identified in VA’s Design Guide for Inpatient Mental Health & Residential Rehabilitation Treatment Program Facilities.

The Facility Director develops and implements written processes to monitor and track compliance with state laws for involuntary hospitalization and consults with the Office of General Counsel to ensure processes are consistent with applicable laws.

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

The Chief of Staff ensures veterans’ discharge instructions are written in easy-to-understand language and include the follow-up mental health appointment location, the purpose of each medication, and how the medication is supposed to be taken.

The Facility Director ensures the Interdisciplinary Safety Inspection Team adheres to Veterans Health Administration requirements, including recording membership and attendance for Mental Health Environment of Care Checklist inspections.

The Veterans Integrated Service Network Director implements processes to ensure the Veterans Integrated Service Network Mental Health Environment of Care Checklist Oversight Team provides facility guidance consistent with Veterans Health Administration requirements.

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

Develop and implement a process to monitor and verify that all mail containers have accurate labels at the Shreveport Processing and Distribution Center and Package Support Annex.

Properly reconcile the Surface Visibility scanners in Ethos and at the facility and take measurable actions to retrieve all lost scanners at the Shreveport Processing and Distribution Center.

Implement controls to monitor and secure Surface Visibility scanners, including a sign out process at the Shreveport Processing and Distribution Center and Package Support Annex.