Open Recommendations

The VA Western New York Health Care System Executive Director ensures completion of the chief geriatric physician’s focused professional practice evaluation for cause per Veterans Health Administration requirements.

The VA Western New York Health Care System Executive Director evaluates community living center medical provider staffing to ensure staffing meets patient care needs and takes action as necessary, including continued recruitment to fill vacancies.

The VA Western New York Health Care System Executive Director ensures review of education plans, education needs assessments, and completion of a system dementia education plan as well as initial and ongoing Staff Training in Assisted Living Residences-VA training, as expected, for all community living center nursing staff, and takes action as indicated.

Increase the oversight role of the CPMO to address deficiencies in the execution of SRBs and
provide SRB members an independent avenue to communicate and address issues during and
after the SRBs

Update the SRB Handbook to reflect current policy, processes, and practices

Evaluate whether the preference for using civil servants is necessary for all disciplines. If not
necessary, consider promoting the use of contractors for board membership in disciplines
where the pool of civil servant expertise may be limited

Evaluate the potential for developing a more formalized pipeline and recruitment process for
SRB participants that could include maintaining a skills database of past members

Review existing conflict of interest policy and processes and consider:
a. clarifying terminology and developing definitions to aid Agency personnel in
consistently identifying which affiliation types are included in existing categories and
the review process used for each, and/or
b. expanding the number of affiliation categories to account for, at a minimum,
international partner agencies

Establish a process for verifying that mission directorates are conducting the required conflict
of interest reviews timely and implement record retention policies regarding SRB conflict of
interest review documents

Verify that contracts used to engage SRB members through contractors adhere to the conflict
of interest processes established in the SRB Handbook

Determine whether there is a need for individual mission directorate guidance for SRB
execution or if individualized mission directorate tailoring can be more effectively accomplished
in the ToR. If mission directorate guidance is determined to be needed, update them
accordingly and establish a frequency for their review and updating

Develop a formal, role-based training program with a focus on first time members in SRB roles

Determine the optimal method(s) and frequency required to keep an SRB appropriately
engaged and informed of program and project status between life-cycle reviews and implement
an applicable procedure in the SRB Handbook or other policy or guidance

Identify obstacles that inhibit programs and projects from providing timely information to SRBs
and implement solutions so that timelines agreed to for data deliverables are met

Implement a process for mission directorates to facilitate the collection and sharing of lessons
learned and document that process in the SRB Handbook

We recommend that the Grantee establish policies and procedures for the timely submission of progress reports in accordance with the Uniform Guidance and ARC grant agreement requirements.

We recommend that BIE ensure that Riverside Indian School has a fully functioning fire detection alarm system.

We recommend that BIE develop and implement a plan to resolve deficiencies identified in annual safety and health inspections with prescribed abatement timelines.

We recommend that BIE develop guidance to ensure that safety and health reports and associated work orders include detailed location information so BIE staff can easily find the deficiencies.

We recommend that BIE require Riverside Indian School to ensure that all components of the emergency management program are fully implemented and emergency management plans and continuity of operations plans are submitted as required.

We recommend that BIE develop a strategy to monitor future catastrophic deficiencies until corrected, and if a deficiency cannot be fixed within the abatement period, identify and implement mitigating measures.

We recommend that BIE provide Riverside Indian School's facilities and maintenance staff with access and training on BIE's facility management system, with emphasis on the importance of accurate and complete recordkeeping.

We recommend that BIE ensure that all safety and health deficiency work orders have the correct status either in an open status awaiting correction or as closed confirming that BIE has corrected the deficiency.

We recommend that BIE require Riverside Indian School to develop and implement a security plan as required by DOI policy.

We recommend that BIE require Riverside Indian School to train the school's collateral duty safety officer on the position's roles and responsibilities in advising management on issues related to the development and implementation of a safety and health program in accordance with Indian Affairs policy.