All Reports

The VA Nebraska—Western Iowa Health Care System Director ensures the installation of night lighting changes to accommodate patient comfort and facility staff’s 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 staff’s 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 unit’s acuity level and staffing needs.

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 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 Under Secretary for Health clarifies the requirements for suicide risk and intervention training for audiologists and delineates responsibility for ensuring training is completed as required.

The Under Secretary for Health evaluates the definition of healthcare provider for the purposes of suicide risk and intervention training.

The Under Secretary for Health evaluates the accuracy of suicide risk and intervention training assignment, consistent with Veterans Health Administration policy, for all healthcare providers.

The Under Secretary for Health ensures audiology staff complete suicide risk identification screening as required.

The Under Secretary for Health evaluates oversight of and barriers to mental health integration in audiology services and takes action as appropriate.

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.

The Associate Chief of Staff, Mental Health ensures compliance with Veterans Health Administration requirements for a full-time local recovery coordinator.

The Associate Chief of Staff, Mental Health ensures the implementation of written processes for staff training, education, and recovery-oriented services. 

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 written 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.

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 2’s documentation in Patient 2’s 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.

The District Director ensures district leaders follow the Readjustment Counseling Service policy requirements to provide oversight of morbidity and mortality review panel member assignments and report completion.

The District Director identifies reasons for noncompliance with documentation requirements of high-risk client contacts and outcomes in RCSNet and the High Risk Suicide Flag SharePoint site, ensures requirements are met, and monitors compliance.

The Readjustment Counseling Service Chief Officer considers developing an additional written policy for High Risk Suicide Flag SharePoint disposition and related RCSNet documentation.

The Under Secretary for Health ensures that VA homeless program staff consistently document, in patients’ electronic health records, the clinical information from the Homeless Operations Management and Evaluation System.

The Under Secretary for Health makes certain that a suicide risk screening is completed with patients during intake into VA homeless programs, consistent with Veterans Health Administration policy.

The Under Secretary for Health ensures that staff complete suicide risk screening in response to danger of self-harm identified in the Homeless Operations Management and Evaluation System.

The Under Secretary for Health makes certain that homeless program staff provide and document care coordination to address patients’ mental health and substance use disorder treatment needs as identified in the Homeless Operations Management and Evaluation System.

District leaders and the Kansas City Vet Center Director determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.

District leaders and the Des Moines, Sioux City, and Kansas City Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.

District leaders and the Des Moines, Sioux City, Kansas City, and Rapid City Vet Center Directors determine reasons for noncompliance with having an annual risk and vulnerability assessment completed by VA police or local law enforcement, ensure completion, and monitor compliance.

District leaders and the Kansas City Vet Center Director determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.

District leaders and the Kansas City and Rapid City Vet Center Directors determine reasons for noncompliance with having an emergency and crisis plan that includes required components, ensure completion, and monitor compliance.

District leaders and the Detroit, Escanaba, and Cincinnati Vet Center Directors collaborate with the supporting VA medical facility to determine reasons for noncompliance with staff participation on the mental health executive council, take action as indicated, and monitor compliance.

District leaders and the Fort Wayne, Escanaba, and Cincinnati Vet Center Directors determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented, and monitor compliance.

District leaders and the Detroit and Escanaba Vet Center Directors determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.

District leaders and the Fort Wayne, Detroit, Escanaba, and Cincinnati Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.

District leaders and the Escanaba Vet Center Director determine reasons for noncompliance with annual fire or safety inspections, ensure completion, and monitor compliance.

District leaders and the Fort Wayne, Detroit, and Escanaba Vet Center Directors determine reasons for noncompliance with having an annual risk and vulnerability assessment completed by VA police or local law enforcement, ensure completion, and monitor compliance.

District leaders and the Cincinnati Vet Center Director determine reasons for noncompliance with annual automated external defibrillator servicing by VA medical center biomedical engineering, ensure completion, and monitor compliance.

District leaders and the Detroit and Escanaba Vet Center Directors determine reasons for noncompliance with having a current emergency and crisis plan that includes required components, ensure completion, and monitor compliance.

The Readjustment Counseling Service Chief Officer reviews the administrative site visit protocol and Veterans Health Administration requirements related to inconsistencies in frequency for risk and vulnerability assessments and updates the administrative site visit protocol as indicated.

The Readjustment Counseling Service Chief Officer reviews the administrative site visit protocol and Veterans Health Administration requirements related to automated external defibrillator annual servicing and updates the administrative site visit protocol as indicated.

The District 5 Director conducts a full review of care provided to the client by the Everett Vet Center Director and counselor, consults with Human Resources and General Counsel Offices, and takes action as needed.

The District 5 Director ensures vet center leaders and staff are knowledgeable about applicable state laws pertaining to duty to warn.

The District 5 Director makes certain that the Everett Vet Center Director and staff adhere to requirements for consultation with support facility external consultants and suicide prevention coordinators when indicated, and monitors compliance.

The Chief Officer, Readjustment Counseling Service provides written guidance to clarify crisis reporting criteria and monitoring responsibilities.

The Chief Officer, Readjustment Counseling Service establishes written policy that clarifies clinical record documentation requirements regarding entry dates; non-visit progress note completion time frames; and progress note deletion and addition, and monitors compliance.

The Chief Officer, Readjustment Counseling Service establishes written guidance regarding time requirements for the completion of risk assessment documentation in clients’ clinical records.

The District 5 Director ensures readjustment counselors’ compliance with updating and reviewing safety plans as required by Readjustment Counseling Service policy.

The Chief Officer, Readjustment Counseling Service ensures that vet center directors are issued the correct position description and are performing duties within the identified scope of work.

The District 5 Director conducts a review of the care provided to complex clients by the Everett Vet Center Director since March 2021 and addresses identified clinical needs.

The Facility Director establishes a mental health executive council that operates in accordance with Veterans Health Administration requirements.

The Facility Director ensures development and implementation of a multi-year recovery transformation plan.

The Associate Chief of Staff for Behavioral Health ensures a minimum of four hours of recovery-oriented, interdisciplinary programming on weekdays and weekends on the inpatient mental health units.

The Facility Director ensures inpatient mental health units are in good repair and the environment reflects recovery-oriented principles.

The Facility Director ensures veterans’ privacy in restraint rooms on the inpatient mental health units.

The Associate Chief of Staff for Behavioral Health develops written guidance to ensure staff and veterans’ safety during outdoor breaks.

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

The Chief of Staff ensures the completion of comprehensive inpatient mental health treatment plans 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 mental health treatment coordinators are included in care coordination.

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 listed medication in easy-to-understand language.

The Chief of Staff ensures discharge instructions for veterans include an explanation when both trade and generic names are used for the same medication.

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

The Chief of Staff ensures safety plans address ways to make the veteran’s environment safer from potentially lethal means and monitors for compliance.

The Facility Director ensures staff comply with timely completion of VA S.A.V.E. training requirements and monitors for compliance.

The Facility Director ensures the Interdisciplinary Safety Inspection Team adheres to Veterans Health Administration requirements, including recording meeting minutes and including all required members, and monitors for compliance.

The Facility Director implements processes to ensure Interdisciplinary Safety Inspection Team staff accurately identify and document safety hazards within the Patient Safety Assessment Tool and monitors for compliance.

The Facility Director ensures staff address identified Mental Health Environment of Care Checklist deficiencies in accordance with Veterans Health Administration guidelines and monitors for compliance.

The Facility Director ensures Interdisciplinary Safety Inspection Team members comply with Mental Health Environment of Care Checklist training requirements and monitors for compliance.

The Facility Director ensures the mental health executive council operates in accordance with VHA requirements.

The Chief of Mental Health identifies barriers and implements processes to provide a minimum of four hours of recovery-oriented, interdisciplinary programming on weekends on the inpatient mental health unit and monitors for compliance.

The Facility Director develops and implements processes to monitor and track compliance with involuntary commitment requirements. 

The Chief of Staff ensures timely documentation of informed consent discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications and monitors for compliance.

The Chief of Staff ensures discharge instructions for veterans are written in easy-to-understand language and include the purpose for each medication. 

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

The Chief of Staff directs staff to complete or review safety plans with veterans prior to discharge and monitors for compliance. 

The Chief of Staff directs staff to address ways to make the veteran’s environment safer from potentially lethal means in safety plans and monitors for compliance. 

The Facility Director directs staff to comply with Lethal Means Safety training and monitors for compliance. 

The Facility Director directs staff to comply with Skills Training for Evaluation and Management of Suicide training and monitors for compliance. 

The Facility Director directs staff to comply with VA S.A.V.E. training and monitors for compliance. 

The Facility Director ensures Interdisciplinary Safety Inspection Team requirements are met and monitors for compliance. 

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

The Facility Director uses VHA guidelines to develop a facility-specific policy for the use of restraint chairs. 

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

District leaders and the Evanston, La Crosse, and Milwaukee Vet Center Directors collaborate with the support VA medical facility to determine reasons for noncompliance with staff participation on the mental health executive council, take action as indicated, and monitor compliance.

District leaders and the Evanston, Gary Area, La Crosse, and Milwaukee Vet Center Directors determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented, and monitor compliance.

District leaders and the Gary Area Vet Center Director determine reasons for noncompliance with Vet Center Director review of 10 percent of active client records monthly for each counselor’s caseload, ensure completion, and monitor compliance.

District leaders and the Gary Area, La Crosse, and Milwaukee Vet Center Directors determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.

District leaders and the Evanston, Gary Area, and Milwaukee Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.

District leaders and the La Crosse Vet Center Director determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.

District leaders determine reasons why the closing of the Milwaukee Vet Center resulted in multiple communication failures, and ensure all clients are notified of the new location, the Vet Center Call Center has accurate information, and websites include correct location and phone number information.

The Readjustment Counseling Service Chief Officer considers developing written guidance for vet center closure and temporary relocation processes including oversight responsibilities.

The Under Secretary for Health clarifies Veterans Integrated Service Network staffing requirements, including mandatory and discretionary positions.

The Under Secretary for Health ensures the use of the standardized Veterans Integrated Service Network core organizational chart to promote clarity of the Chief Mental Health Officer position and reporting structure.

The Under Secretary for Health considers standardization of the Veterans Integrated Service Network Chief Mental Health Officer functional statement to reflect role responsibilities.

The Under Secretary for Health ensures the alignment of the Veterans Integrated Service Network Chief Mental Health Officer performance plan with the functional statement.

The Under Secretary for Health defines the Veterans Integrated Service Network Chief Mental Health Officer role authority to enhance governance efficiency and effectiveness of mental health services.

The VA Central Western Massachusetts Healthcare System Director establishes a mental health executive council that operates in accordance with VHA requirements.

The VA Central Western Massachusetts Healthcare System Director ensures staff consistently solicit and incorporate veteran feedback into process improvements.

The VA Central Western Massachusetts Healthcare System Chief of Mental Health develops written guidance to ensure staff and veteran safety during outdoor breaks.

The VA Central Western Massachusetts Healthcare System Director ensures the development of written processes for the admission of veterans on an involuntary hold and monitors and tracks compliance with involuntary commitment requirements.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures timely documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures discharge instructions for veterans include follow-up appointment location and contact information in easy-to-understand language.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures discharge instructions include the purpose for each medication listed and are written in easy-to-understand language.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures staff complete the Columbia-Suicide Severity Rating Scale within 24 hours before discharge and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures staff address ways to make veterans’ environments safer from potentially lethal means in safety plans and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Director ensures staff comply with Skills Training for Evaluation and Management of Suicide requirements and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Director establishes an interdisciplinary safety inspection team in alignment with Veterans Health Administration requirements and ensures ongoing compliance.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures that the sally port inpatient unit doors are synchronized and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Director uses VHA guidelines to develop facility-specific policy for the use of restraint chairs.

The VA Central Western Massachusetts Healthcare System Director ensures alignment between physical restraint policies and practices.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures mental health leaders update inpatient unit furniture to meet safety requirements and implements processes to reduce associated safety risks.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures compliance with VHA requirements for Mental Health Environment of Care Checklist training completion.

The VA Northern Indiana Healthcare System Director evaluates the system clinic cancellation policy and Chief of Staff notification of urgent clinic cancellations and takes action as appropriate.

The VA Northern Indiana Healthcare System Director reviews short-notice clinical cancellations for social work mental health clinics, including the provider’s clinic, to evaluate patient impact and take actions as appropriate.

The District Director, in conjunction with the Deputy District Director, develops a contingency coverage plan to ensure oversight during periods of vet center director vacancies.

The District Director monitors district leaders’ compliance with completion of morbidity and mortality reviews for client deaths by suicide, including timeliness, as required.

The District Director ensures district leaders are aware of the Readjustment Counseling Service policy requirements to provide oversight of morbidity and mortality review completion, including panel member assignments, participation of affected vet center staff, report completion, reporting of completion delays, and information dissemination.

The District Director determines reasons vet center counselors did not complete safety plan components for clients assessed at intermediate or high suicide risk level in either acute, chronic, or both categories; ensures completion of safety plans for all active clients assessed at intermediate or high suicide risk levels; and monitors compliance across all zone vet centers.

The District Director determines reasons staff did not document providing safety plans to clients, ensures all active clients assessed at intermediate or high suicide risk levels receives a safety plan, and monitors compliance across all zone vet centers.

The Under Secretary for Health ensures that required suicide risk and intervention training includes suicide risk identification screening and evaluation requirements, procedures, and instruction.

The Under Secretary for Health considers establishing benchmarks for suicide risk screening and evaluation that reflect the clinical importance of suicide risk identification requirements and takes action as warranted.

The Under Secretary for Health ensures monitoring of adherence to suicide risk identification screening and evaluation setting-specific requirements.

The Under Secretary for Health ensures actions taken to address barriers to completing suicide risk screening and evaluation are effective to increase adherence to annual and setting-specific requirements in all clinical settings.

The Under Secretary for Health ensures non-mental health clinical specialty leaders are aware of and adherent to the suicide risk identification screening and evaluation requirements.

The Under Secretary for Health ensures clearly identified responsibilities for suicide risk identification screening and evaluation adherence monitoring and oversight.