Open Recommendations

The Facility Director identifies and addresses barriers to communal room access for veterans on the inpatient unit.

The Facility Director ensures accurate reporting of inpatient mental health beds and implements processes to monitor.

The Facility Director formalizes processes to monitor and track compliance with state involuntary commitment requirements.

The Facility Director ensures staff document veterans legal commitment status in the electronic health record and monitors for compliance.

The Chief of Staff ensures documentation of discussions between prescribers and veterans on the risks and benefits of newly prescribed medications and monitors for compliance.

The Chief of Staff ensures discharge instructions for veterans include appointment locations written in easy-to-understand language.

The Chief of Staff ensures discharge instructions for veterans include the purpose for each medication listed and are free of medical abbreviations.

The Chief of Staff directs staff to complete and document the Columbia-Suicide Severity Rating Scale within 24 hours before veterans discharge and monitors for compliance.

The Chief of Staff directs staff to complete suicide prevention safety plans and provide copies of the plans to veterans or caregivers and monitors for compliance.

The Chief of Staff directs staff to address ways to make veterans environments safer from potentially lethal means, beyond firearms and opioids, in safety plans and monitors for compliance.

The Under Secretary for Health identifies barriers to, and ensures documentation of, discussions specific to making the environment safer from identified lethal means in veterans safety plans.

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

The Facility Director ensures compliance with Veterans Health Administration requirements for the Interdisciplinary Safety Inspection Team, including recording of meeting minutes, membership, and attendance, and monitors for compliance.

The Facility Director implements processes to ensure the Interdisciplinary Safety Inspection Team applies Mental Health Environment of Care Checklist standards on the inpatient mental health unit and monitors for compliance.

The Facility Director directs inpatient unit staff and Interdisciplinary Safety Inspection Team members to comply with Mental Health Environment of Care Checklist training requirements and monitors for compliance.

Some or all of the recommendation is not publicly available due to concerns with information protected under the Freedom of Information Act.

Implement a process to verify all change requests are closed and reviewed when all change activities have been completed.

Validate all critical and high incident tickets are resolved within required timeframes.

Update policy to identify when an after action report should be created and verify completion of all after action reports.

The Railroad Retirement Board's Bureau of Fiscal Operations should continue working with the
Department of Treasury to determine the proper accounting treatment for contributions received by
Department of Labor on behalf of the RRB (i.e., contributions receivable) and provide supporting documentation
of the discussions and decisions made with the Department of Treasury for auditor review.

Revise NARA 161, NARA’s Internal Control Program , to establish a process to periodically evaluate whether the prior-year risk assessment remains valid and appropriate to address significant organizational or operational changes.

Document through a written formal memorandum any periodic risk evaluations and the decision whether or not to update the last prior-year assessment to reflect the current risk environment. This memorandum should include a clear justification and documentation of the evaluation performed and be reviewed and approved by the Management Control Oversight Council to ensure appropriate oversight and accountability.

Establish NARA policy for reviewing System and Organization Controls 1 Type 2 reports and evaluating complementary user entity controls. This policy related to control activities should be integrated into the agency’s internal control over financial reporting framework and include: a. Identification and Evaluation of CUECs b. Assignment of Responsibility c. Assessment of Control Effectiveness d. Documentation and Oversight

Establish a written formalized methodology for calculating materiality thresholds in accordance with Office of Management and Budget Circular A-123, Appendix A.

Ensure access request forms are resubmitted for the NARANet accounts noted in the audit finding.