Open Recommendations

The Under Secretary for Health considers written guidance regarding risk for violence assessment use in units identified as a high-risk workplace that can be used to temporarily change a unit’s acuity level and staffing needs.

The VA Nebraska"Western Iowa Health Care System Director evaluates the root cause analysis processes regarding reporting of action items and outcome measures in accordance with Veterans Health Administration requirements, takes action as needed, and monitors compliance.

The VA Nebraska"Western Iowa Health Care System Director evaluates processes requesting and reporting changes to authorized and operating beds on the inpatient mental health unit, takes action as needed, and monitors compliance.

The VA Midwest Health Care Network Director strengthens processes to ensure adequate oversight and adherence to Veterans Health Administration requirements pertaining to changes to authorized and operating inpatient mental health unit beds.

The VA Nebraska"Western Iowa Health Care System Director reviews and ensures consistent application of facility nursing leaders use of risk for violence assessment on the inpatient mental health unit, and monitors for compliance.

The VA Nebraska"Western Iowa Health Care System Director ensures the installation of night lighting changes to accommodate patient comfort and facility staffs ability to safely conduct rounding in applicable inpatient mental health unit patient rooms.

The VA Nebraska"Western Iowa Health Care System Director ensures establishment and implementation of guidance related to the facility inpatient mental health unit staffs use and security of handheld flashlights to ensure appropriate education and training of handheld flashlights usage and storage.

The VA Nebraska"Western Iowa Health Care System Director establishes and ensures implementation of a patient safety observation rounds standard operating procedure consistent with Veterans Health Administration requirements.

The VA Nebraska"Western Iowa Health Care System Director reviews facility Mental Health Environment of Care Checklist processes related to development of mitigation plans as required by the Veterans Health Administration, and monitors compliance.

The VA Nebraska"Western Iowa Health Care System Director ensures compliance with Veterans Health Administration staffing requirements for areas identified as high-risk, such as the inpatient mental health unit, and monitors compliance.

The Under Secretary for Health evaluates the Veterans Health Administration written guidance for high-risk workplace staffing and determines if clarification is needed.

The VA Nebraska"Western Iowa Health Care System Director ensures staff that may provide coverage on the inpatient mental health unit receive applicable Prevention and Management of Disruptive Behavior training for high-risk units.

The VA Nebraska"Western Iowa Health Care System Director strengthens processes to ensure that supervisors are made aware of staff members that have not completed the applicable Prevention and Management of Disruptive Behavior training for high-risk units, to include the hands-on component, and monitors compliance.

The Under Secretary for Health considers written guidance regarding risk for violence assessment use in units identified as a high-risk workplace that can be used to temporarily change a units acuity level and staffing needs.

Require the Maryland GOCPP to develop and implement adequate controls to ensure required grant-related records are retained in accordance with DOJ and state guidelines.

Require the Maryland GOCPP to strengthen its annual state certification reporting practices to improve reporting accuracy.

Require the Maryland GOCPP to develop and implement controls to ensure adequate oversight and improve the accuracy of performance reporting.

Work with the Maryland GOCPP to strengthen procedures for its secondary review of payments and implement enhanced accounting controls to help mitigate the risk of duplicate payments.

Remedy $80,550 in duplicate victim compensation payments.

Remedy $66,653 in unallowable questioned costs associated with victim compensation payments.

Remedy the $4,400 in unsupported questioned cost associated with a victim compensation payment.

Ensure the Maryland GOCPP updates its CICB Manual to: (1) require that the supporting files for claims contain written justification for any deviation from the CICB's policy on processing decisions, and (2) reflect the applicable and accurate statutory award limits established by the state of Maryland.

Update policies, and procedures related to monitoring and oversight of internal controls related to journal entries, to ensure internal consistency with, and clear definition of, those journal entries that are processed by the service provider; and to define the required documentation to be maintained to evidence CPSC reviews of journal entries.

ML - 1: Design and implement a control to identify, analyze, and respond to risks related to the validity of open obligations.

ML - 2: Establish procedures and recurring communication with the appropriate stakeholders to assist in the identification and de-obligation of stale undelivered orders.