Open Recommendations

The OIG recommends that the Executive Director for Operations identify and automate the appropriate data entry areas within the Decommissioning, Uranium Recovery, and Waste Programs module to promote accurate, complete, and standardized data entry.

The OIG recommends that the Executive Director for Operations update existing inspection data entry guidance to include how to document assist inspections and general license inspections.

The OIG recommends that the Executive Director for Operations review the existing guidance for each Web-Based Licensing System module and update it to reflect current data entry practices, as appropriate.

The OIG recommends that the Executive Director for Operations identify and implement strategies that improve the search functionality of the Web-Based Licensing System.

The OIG recommends that the Executive Director for Operations update the Web-Based Licensing System to make the search functionality consistent across all the modules.

Note: We did not make a formal recommendation for this report. However, we are claiming cost savings. The following is the language we used in the Tracking Sheet we submitted to the Agency. "In our 2022 review, we recommended SSA, “Improve Agency systems to automate benefit computations and reduce the need for manual processing.” Therefore, no recommendation in the current report.

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 veterans 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.

The Facility Director establishes a mental health executive council that operates in accordance with Veterans Health Administration requirements.

The Facility Director ensures development and implementation of a multi-year recovery transformation plan.

The Associate Chief of Staff for Behavioral Health ensures a minimum of four hours of recovery-oriented, interdisciplinary programming on weekdays and weekends on the inpatient mental health units.

The Facility Director ensures inpatient mental health units are in good repair and the environment reflects recovery-oriented principles.