Open Recommendations

Address all building maintenance, safety, and security issues identified during site visits.

Develop processes and requirements for routinely collecting excess and underutilized space data across its property portfolio and include accountability mechanisms for ensuring this data is collected on a regular basis.

Develop processes to periodically assess and verify the accuracy of excess and underutilized space data and update in the designated system of record.

Develop and implement a comprehensive strategy for managing excess and underutilized space, which would include processes for identifying space at properties throughout the network, centralized tracking and reporting, and corrective action plans (such as for renting, disposing, or repurposing).

Verify that all rooms and spaces reported in the Real Asset Management Program Out-leasing module are properly coded.

Reconcile property space data across all modules within the property management system to verify consistency and accuracy of the data.

The Lexington VA Healthcare System Director ensures emergency department, mental health, and inpatient medical and nursing staff responsible for suicide risk assessment understand the need to evaluate patients for a personally owned insulin pump and remove the insulin pump prior to inpatient admission, when necessary and monitors for compliance.

The Lexington VA Healthcare System Director verifies the draft insulin pump policy is finalized, and Lexington VA Healthcare System emergency department, mental health, and inpatient medical and nursing staff are educated on the policy.

The Lexington VA Healthcare System Director ensures leaders and staff review the Lexington VA Healthcare System policy evaluation and approval procedure.

The Lexington VA Healthcare System Director verifies that patients receive discharge instructions, with a follow-up care plan when discharged from the Lexington VA Healthcare System emergency department.

The Lexington VA Healthcare System Director ensures a review of Psychiatrist 2s documentation in Patient 2s electronic health record and makes certain documentation is completed according to Veteran Health Administration policy, including that entries are accurate, succinct, without extensive copy and paste, and devoid of derogatory, critical, comments, and takes action as warranted.

The Lexington VA Healthcare System Director confirms that the patient safety managers understand and apply Veteran Health Administration guidance to accurately use safety assessment codes when scoring a patient safety event.

The Lexington VA Healthcare System Director verifies that root cause analyses are completed according to Veterans Health Administration policy including interviewing individuals knowledgeable about the event.

The Lexington VA Healthcare System Director ensures peer representation at the Peer Review Committee for psychiatry case reviews.

The Under Secretary for Health considers specific VHA guidance related to the recognition of personally owned insulin pumps as a lethal means for patients with suicidal ideation and at risk for suicide in emergency departments and inpatient units to mitigate risk and improve patient safety.

We recommend that the Deputy Secretary of Commerce direct the Department’s Chief Information Officer to update and implement VDP reporting and resolution standard operating procedures to ensure that vulnerability remediation is comprehensive across impacted systems.

We recommend that the Deputy Secretary of Commerce direct the Department’s Chief Information Officer to work with bureaus to establish and implement an automated solution to coordinate communication between the contractor and bureaus and to prompt action on delayed vulnerability remediation based on impact level.

The Associate Director ensures staff make feminine hygiene products available in public womens and unisex restrooms.

The Medical Center Director ensures staff implement processes to secure medications from unauthorized access.

The Associate Director ensures staff make feminine hygiene products available in public womens and unisex restrooms.

The Executive Director ensures staff address environment of care deficiencies within 14 days or have an action plan, as required.

The Executive Director ensures staff perform preventive maintenance on medical equipment in accordance with manufacturers recommendations.

The Executive Director ensures staff evaluate the best place to store cleaning supplies, staff store them there, and leaders monitor compliance.

The Executive Director ensures staff remove expired medical supplies and patient food items from patient care areas.

The Executive Director ensures doors in patient care areas have signs to indicate what is stored inside.