Open Recommendations

Implement a mechanism designed to reasonably ensure that VA oversight staff take appropriate enforcement measures to address persistent or recurring deficiencies by a Grant and Per Diem grantee that pose risks to veteran care and safety.

Ensure grant agreements require the grantee to promptly disclose to VA any adverse health or safety conditions occurring at any facility where VA-funded participants are receiving service, including the occurrence of sentinel events affecting non-VA-funded participants on the grantees premises and any adverse health or safety inspection results or similar findings made concerning the grantees premises or operations by any non-VA oversight entity, such as a federal, state, county, or local regulator.

Ensure Grant and Per Diem participants residing at the Veterans Village of San Diego (VVSD) who are eligible for clinical drug treatment receive appropriate support to obtain those services despite the closure of VVSDs clinical treatment housing model.

The OIG recommends facility leaders assess storage locations that are outside of standard supply rooms and implement a process to ensure staff remove expired supplies.

The VA Central Western Massachusetts Healthcare System Director establishes a mental health executive council that operates in accordance with VHA requirements.

The VA Central Western Massachusetts Healthcare System Director ensures staff consistently solicit and incorporate veteran feedback into process improvements.

The VA Central Western Massachusetts Healthcare System Director ensures the development of written processes for the admission of veterans on an involuntary hold and monitors and tracks compliance with involuntary commitment requirements.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures discharge instructions for veterans include the follow-up appointment location and contact information in easy-to-understand language.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures that discharge instructions include the purpose for each medication listed and are written in easy-to-understand language.

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

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures that staff address ways to make veterans environments safer from potentially lethal means in safety plans and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Director ensures staff comply with Skills Training for Evaluation and Management of Suicide requirements and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures that the sally port inpatient unit doors are synchronized and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Director establishes an interdisciplinary safety inspection team that meets VHA requirements and ensures ongoing compliance.

The VA Central Western Massachusetts Healthcare System Director uses VHA guidelines to develop facility-specific policy for the use of restraint chairs.

The VA Central Western Massachusetts Healthcare System Director ensures alignment between use of physical restraint policies and practices.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures compliance with VHA requirements for Mental Health Environment of Care Checklist training completion.

Establish a Risk Management Committee and include key personnel and stakeholders from different CFTC Divisions.

Create the Governance Charter and hold regular meetings with the Risk Management Committee.

Update and finalize an ERM roadmap from 2020 which includes estimated and actual completion dates.

Develop Annual Risk Analysis Reports and distribute to the various divisions.

Implement an Enterprise Governance, Risk and Compliance (eGRC) Tool which will help aggregate risks across the enterprise and map them to strategic objectives.

Enhance ERM communication channels and hold regular meetings between the ERM team and departments.

Increase CFTC leadership support and conduct regular briefings and workshops, and actively participate in ERM activities.

Foster a collaborative environment by appointing ERM liaisons within each division.