Open Recommendations

The Facility Director ensures regular communication between mental health and executive leaders regarding staffing needs and mental health processes.

The Facility Director ensures the Mental Health Executive Council operates in accordance with Veterans Health Administration requirements.

The Chief of Mental Health ensures a full-time, dedicated local recovery coordinator is integrated into the inpatient mental health unit to support recovery-oriented care.

The Chief of Mental Health ensures mental health leaders develop and implement written processes for staff training, education, and recovery-oriented services.

The Chief of Mental Health ensures staff provide a minimum of four hours of recovery-oriented, interdisciplinary mental health programming on weekdays and weekends.

The Facility Director ensures veterans’ privacy in the communal shower room on the inpatient mental health unit.

The Facility Director ensures clinicians document veterans’ capacity to consent to admission to the inpatient mental health unit.

The Veterans Integrated Service Network Director ensures facilities’ involuntary hold and hospitalization processes align with applicable state laws and develops processes for ongoing oversight.

The Facility Director consults with District Counsel to establish written involuntary hold and hospitalization processes that align with West Virginia State laws and monitors compliance.

The Facility Director develops and implements written care coordination processes for veterans involuntarily admitted to non-VA healthcare facilities.

The Chief of Staff ensures providers document discussions with veterans on the risks and benefits of newly prescribed medications and monitors for compliance.

The Chief of Staff ensures veterans’ discharge instructions are written in easy-to-understand language and include the follow-up appointment location, the purpose of each medication, and an explanation when both trade and generic names are used for the same medication.

The Facility Director ensures staff comply with suicide prevention training requirements and monitors for compliance.

The Facility Director ensures Interdisciplinary Safety Inspection Team members participate in Mental Health Environment of Care Checklist inspections and document membership and attendance.

The Facility Director ensures the Interdisciplinary Safety Inspection Team accurately identifies, documents, and addresses safety hazards within the Patient Safety Assessment Tool and monitors for compliance.

The Facility Director directs staff to comply with Mental Health Environment of Care Checklist training requirements and monitors for compliance.

Implement written policies and training to ensure that all employees who work on multiple activities record their time in a way that supports the distribution of the employee’s salary or wages among specific activities or cost objectives.

The Commission should determine the risks associated with non-standard adjustments in its financial reporting process and develop and document appropriate controls to review and validate those non-standard transaction outputs on the aging reports created by their service provider. At a minimum, the Commission should:

• Establish a dollar value threshold to review all balances without identifying contract and vendor fields, recorded on the monthly aging reports provided to the Office of the Chief Financial Officer and the OIG and
• Review and verify all material non-standard adjustment transactions (JVs, SVs, RVs, and BB transactions) recorded without identifying contract and vendor…

Develop new or modify existing MOU supplemental schedules to include a framework for multicycle project budgets with specific illustrative criteria describing which projects should be categorized as multicycle, as well as roles and responsibilities for
a. developing and approving the currency budget’s multicycle projects, including which costs may be conditionally approved and how to receive full approval.
b. reviewing to ensure multicycle projects’ quarterly funding requests are justified and subsequently advancing funds.
c. annually reconciling the prior year’s advances to expenses and adjusting future advances as appropriate.

Update and implement the Accountable Property Handbook to address returning IT assets that requires a secure chain of custody process, including IT assets subject to litigation holds.

Update the offboarding procedures to include instructions to employees to ensure exiting employees return their IT assets in accordance with the updated Accountable Property Handbook.

Improve the IT asset accountability process going forward to include historical IT asset tracking by employee and by addressing and implementing data access procedures for returned cell phones on litigation holds.

In coordination with OCFO and the OCIO, develop and implement a plan with defined milestones and timelines to resolve data discrepancies between Maximo and Odyssey and ensure property data are complete, accurate, and properly reconciled with the F/A module. As part of this plan, clarify roles, responsibilities, and coordination mechanisms between offices to ensure sustained accountability for property management and reconciliation activities.

Assess and, where feasible, enhance Maximo’s configuration to automate key property management controls. This assessment should include a cost–benefit analysis to determine viable improvements and identify compensating controls if system enhancements are not practical, to ensure consistent and accurate property data entry and reconciliation.

Finalize and issue updates to property management policies and procedures, including the DFMH, MS 511, and related guidance, to reflect the implementation of Maximo as the agency’s property management system and ensure alignment with current processes and controls.