All Reports

The VA Southern Nevada Healthcare System Director develops a process consistent with Veterans Health Administration Directive 1004.01(3) to ensure patients are informed, prior to voluntary admission to the inpatient mental health unit, that the unit is locked and provides services to patients with mental health disorders.

The VA Southern Nevada Healthcare System Director ensures staff are educated following development of the informed consent process for voluntary admission to the inpatient mental health unit.

The VA Southern Nevada Healthcare System Director confirms that medical center policy 116-22-10 adheres to Nevada state law relevant to admission to mental health units and is approved in accordance with Veterans Health Administration policies.

The VA Southern Nevada Healthcare System Director confirms that medical center policy 116-22-10 includes the responsible owners’ oversight and guidance responsibilities as required by Veterans Health Administration Directive 0999(1).

The VA Southern Nevada Healthcare System Director ensures staff education regarding changes to the medical center policy 116-22-10.

The VA Southern Nevada Healthcare System Director ensures that any facility policies involving state law addressing voluntary or involuntary mental health commitments be reviewed by the Office of General Counsel.

The VA Southern Nevada Healthcare System Director develops a process to ensure facility policies adhere to the Veterans Health Administration Directive 0999(1), medical center policy standardized template.

The Ann Arbor VA Medical Center Director conducts a full review of the patient’s spring to fall 2017 mental health care to identify quality of care improvement opportunities related to inpatient psychiatrist 2’s medical decision-making, staff’s pre-discharge outpatient care planning, and outpatient staff’s collaboration in providing treatment and engagement efforts including the mental health treatment coordinator assignment and role, and takes actions as warranted.

The Battle Creek VA Medical Center Director ensures staff awareness and access to eligibility verification procedures.

The Battle Creek VA Medical Center Director expedites the full implementation of the Transfer and Admission Coordination Office including a centralized phone number and monitors compliance with the standardized checklist.

The Battle Creek VA Medical Center Director expedites the completion and implementation of the interfacility transfers standard operating procedure and monitors compliance.

The Battle Creek VA Medical Center Director ensures the mental health residential rehabilitation treatment program standard operating procedure is aligned with Veterans Health Administration requirements regarding referral and monitors compliance.

The Veterans Integrated Service Network Director evaluates the efficacy of the Interagency Resolution Council and identification of clearly defined objectives and processes to monitor progress and address identified barriers.

The VA Houston Health Care System Director evaluates the efficiency of evidence-based psychotherapy consult management procedures; identifies barriers to timely appointment scheduling, including scheduling processes and staffing needs; and takes action as warranted.

The VA Houston Health Care System Director ensures that administrative support staff document scheduling efforts in patients’ electronic health records, as required by the Veterans Health Administration.

The VA Houston Health Care System Director ensures that staff document offering VA-issued devices for participation in virtual mental health appointments in patients’ electronic health records.

The VA Houston Health Care System Director conducts a review of providers’ lethal means safety assessment and planning with the patient, identifies barriers to effective lethal means safety discussions, and takes action as warranted.

The Under Secretary for Health clarifies the expectations and requirements for homeless program staff’s completion of suicide risk assessments and updates or reviews of safety plans for high risk for suicide patients.

The Sheridan VA Medical Center Director ensures completion of warm handoffs and Comprehensive Suicide Risk Evaluations within 24 hours for patients on the medical unit that screen positive on the Columbia-Suicide Severity Rating Scale.

The Sheridan VA Medical Center Director ensures that psychiatry or medical officer of the day staff reassess suicidal patients prior to changing a one-to-one observation status order.

The Sheridan VA Medical Center Director ensures that inpatient notes are completed and authenticated by providers as soon as possible, but always within 24 hours, in accordance with facility policy.

The Sheridan VA Medical Center Director ensures that staff follow facility policies for removing belongings and environmental risks for suicidal patients on one-to-one observation status on the medical unit.

The Overton Brooks VA Medical Center Director ensures the suicide prevention team utilizes information from Medora and the required Veterans Health Administration screening and evaluation tools when assessing patients’ suicide risk in response to Veterans Crisis Line requests, and monitors for compliance.

The Overton Brooks VA Medical Center Director ensures the suicide prevention team follows national requirements for documenting each contact attempt in a patient’s electronic health record when responding to Veterans Crisis Line requests, and monitors for compliance.

The Overton Brooks VA Medical Center Director ensures the suicide prevention program manager documents clinical case reviews of suicide prevention staff members’ Veterans Crisis Line request responses and addresses identified deficiencies as required by the Veterans Health Administration.

The Overton Brooks VA Medical Center Director monitors intensive care unit one-to-one observation staff assignments for compliance with facility policy, and takes action as appropriate.

The Overton Brooks VA Medical Center Director ensures the provision of mental health appointments for patients with a high risk for suicide patient record flag as required by Veterans Health Administration policy, and monitors for compliance.

The Overton Brooks VA Medical Center Director ensures that suicide prevention staff consult with patients’ treatment teams prior to inactivation of high risk for suicide patient record flags, and monitors for compliance.

The Overton Brooks VA Medical Center Director ensures timely completion of behavioral health autopsy program chart reviews and family interview contact forms, and monitors for compliance.

The Veterans Integrated Service Network Director takes steps to ensure that suicide prevention positions are posted and continues to identify additional recruitment opportunities for suicide prevention positions, as indicated.

The El Paso VA Health Care System Director ensures Behavioral Health Service policies and guidance are in alignment with federal laws and Texas and New Mexico state laws specific to the system’s emergency detention orders, and educates behavioral health licensed independent practitioners on the policies, as needed.

The Executive Director ensures staff complete root cause analyses for sentinel events.

The Chief of Staff ensures service chiefs initiate Focused Professional Practice Evaluations for newly appointed licensed independent practitioners.

The Chief of Staff ensures service chiefs regularly complete Ongoing Professional Practice Evaluations for licensed independent practitioners.

The Chief of Staff ensures service chiefs consider specialty-specific data during licensed independent practitioners’ Ongoing Professional Practice Evaluations.

The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations.

The Chief of Staff ensures the Healthcare Delivery Council or an appropriately identified executive committee of the medical staff reviews professional practice evaluation results.

The Veterans Integrated Service Network Chief Medical Officer oversees the healthcare system’s privileging processes.

The Executive Director ensures staff follow the manufacturer’s recommendations for testing over-the-door alarms for sleeping rooms in the Acute Psychiatric Unit.

The Executive Director ensures staff test panic alarms in the Acute Psychiatric Unit and document VA police response times.

The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation the same calendar day, when logistically feasible and clinically appropriate, for all ambulatory care patients with a positive suicide risk screen.

The Chief of Staff ensures clinical staff notify the suicide prevention team when patients report suicidal behaviors during the Comprehensive Suicide Risk Evaluation.

The Chief of Staff ensures the suicide prevention coordinators conduct, track, and report a minimum of five suicide prevention outreach activities each month.

The Chief of Staff ensures service chiefs recommend continued privileges for licensed independent practitioners based on Ongoing Professional Practice Evaluation activities, and the Medical Executive Committee recommends them based on evaluation results.

The Deputy Medical Center Director ensures staff post biohazard signs in applicable areas.

The Associate Director ensures staff keep patient care areas safe and clean.

The Assistant Director ensures staff document VA police response times for panic alarm testing in the inpatient mental health unit.

The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in all ambulatory care settings.

The Chief of Staff ensures service chiefs regularly complete Ongoing Professional Practice Evaluations for licensed independent practitioners.

The Chief of Staff ensures the Clinical Executive Board reviews professional practice evaluation data for licensed independent practitioners.

The Chief of Staff ensures service chiefs include service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.

The Medical Center Director ensures staff follow the manufacturer’s recommendations for testing over-the-door alarms on mental health inpatient unit sleeping room doors.

The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation the same calendar day, when logistically feasible and clinically appropriate, for all ambulatory care patients with a positive suicide risk screen.

The Chief of Staff ensures suicide prevention coordinators conduct, track, and report a minimum of five suicide prevention outreach activities each month.

The Chief of Staff ensures clinical staff notify the suicide prevention team when patients report suicidal behaviors during the Comprehensive Suicide Risk Evaluation.

The Chief of Staff ensures practitioners from other facilities with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations for solo licensed independent practitioners.

The Medical Center Director ensures staff conduct environment of care inspections in non-patient care areas at least once per fiscal year.

The Medical Center Director ensures providers complete the Comprehensive Suicide Risk Evaluation the same day as a patient’s positive suicide risk screen in ambulatory care settings.

The Medical Center Director ensures leaders conduct institutional disclosures for all applicable sentinel events.

The Medical Center Director ensures staff complete environment of care inspections in patient and non-patient care areas at the required frequency.

The Medical Center Director ensures staff cover electrical receptacles in the Inpatient Mental Health Unit common area with metal plates.

The Medical Center Director ensures providers complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.

The Medical Center Director ensures clinical staff notify the suicide prevention team when patients report suicidal behaviors during Comprehensive Suicide Risk Evaluations.

The Chief of Staff ensures service chiefs incorporate service-specific criteria in professional practice evaluations.

The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in ambulatory care settings.

The Chief of Staff ensures service chiefs document professional practice evaluation results in practitioners’ profiles, and the Medical Executive Committee reviews service chiefs’ recommendations along with clinical competence information when making privileging recommendations to the Director.

The Associate Director ensures staff keep patient care areas safe and clean.

The Director ensures staff regularly test panic alarms in the mental health inpatient unit and document VA police response times.

The Director ensures staff maintain a safe environment in the mental health inpatient unit.

The Director ensures staff maintain a safe environment in the Emergency Department for mental health patients.

The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation the same calendar day, when logistically feasible and clinically appropriate, for all ambulatory care patients with a positive suicide risk screen.

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

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

The Readjustment Counseling Service Chief Officer ensures the High Risk Suicide Flag SharePoint site functions as intended and includes accurate data.

The District Director and zone leaders identify reasons for noncompliance, ensure Readjustment Counseling Service policy confidentiality requirements are followed when collaborating care with the support VA medical facility for shared clients at high risk for suicide, and monitor compliance across all zone vet centers.

The District Director identifies reasons for noncompliance with consultation requirements for clients who are assessed at intermediate or high suicide risk level in either acute, chronic, or both categories; ensures consultation requirements are met; and monitors compliance.

The District Director identifies reasons for noncompliance; ensures clinical staff complete safety plans for clients who are assessed at intermediate or high suicide risk level in either acute, chronic, or both categories as required; and monitors compliance across all zone vet centers.

The District Director identifies reasons for noncompliance, ensures clients are provided a copy of their completed safety plan as required, and monitors compliance across all zone vet centers.

District leaders and the Ft. Lauderdale, Ft. Myers, Gainesville, Lakeland, Naples, and San Juan Vet Center Directors, collaborate with the support VA medical facility clinical liaison to determine the reasons for noncompliance, take action as indicated, and monitor to ensure compliance with staff participation on the mental health executive council.

District leaders and the Lakeland Vet Center Director, determine reasons for noncompliance with High Risk Suicide Flag SharePoint site requirements and the tracking of continuity of care for at-risk clients, take action to ensure requirements are met, and monitor compliance.

District leaders and the Lakeland Vet Center Director determine reasons for noncompliance and ensure assignment of a liaison.

District leaders and the Lakeland Vet Center Director determine reasons for noncompliance and ensure assignment of an external clinical consultant.

District leaders and the Ft. Lauderdale, Ft. Myers, Gainesville, Naples, and San Juan Vet Center Directors determine reasons for noncompliance, ensure a process is implemented for completing and tracking four hours of external clinical consultation per month, and monitor compliance.

District leaders and the Ft. Lauderdale, Gainesville, and Lakeland Vet Center Directors determine reasons for noncompliance with monthly active counseling records, ensure chart audits are completed as required, and monitor compliance.

District leaders and the Ft. Lauderdale, Ft. Myers, Gainesville, Lakeland, and San Juan Vet Center Directors determine reasons for noncompliance, develop processes to ensure all staff complete mandatory trainings, and monitor compliance.

District leaders and the Gainesville and Lakeland Vet Center Directors determine reasons for noncompliance and ensure outreach plans are completed.

District leaders and the Ft Lauderdale, Ft. Myers, Naples, and San Juan Vet Center Directors determine reasons for noncompliance and ensure outreach plans include all required strategic components.

District leaders and the Ft. Myers, Naples, and San Juan Vet Center Directors determine reasons for noncompliance, ensure outreach activities are tailored to the cultural demographics of the vet center’s veteran service area, and monitor compliance.

District leaders and the Gainesville Vet Center Director determine reasons for noncompliance, ensure completion of fire and/or safety inspections, and monitor compliance.

District leaders and the Gainesville Vet Center Director determine reasons for noncompliance, ensure the risk and vulnerability assessment is completed by VA police or local law enforcement, and monitor compliance.

District leaders and the Gainesville and Naples Vet Center Director determine reasons for noncompliance, ensure automated external defibrillators are serviced annually, and monitor compliance.

District leaders and the Ft. Lauderdale and Naples Vet Center Directors determine reasons for noncompliance, ensure fire extinguishers are inspected monthly, and monitor compliance.

District leaders and the Ft. Myers Vet Center Director determine reasons for noncompliance, ensure automated external defibrillators are inspected monthly, and monitor compliance.

District leaders, and the Naples Vet Center Director, determine reasons for noncompliance and ensure evacuation plans are posted in a communal area.

District leaders and the Ft. Lauderdale, Ft. Myers, Lakeland, and Naples Vet Center Directors determine reasons for noncompliance, ensure completion of a current and comprehensive emergency and crisis plan, and monitor compliance.

District leaders and the Marietta, Bay County, and Savannah Vet Center Directors collaborate with the support VA medical facility clinical liaisons to determine the reasons for noncompliance, take action as indicated, and monitor to ensure compliance with staff participation on the mental health executive council.

District leaders and the Marietta and Charleston Vet Center Directors determine reasons for noncompliance, ensure a process is implemented for completing and tracking four hours of external clinical consultation per month, and monitor compliance.

District leaders and the Augusta, Johnson City, Marietta, Charleston, Bay County, and Savannah Vet Center Directors determine reasons for noncompliance, develop processes to ensure all staff complete mandatory trainings, and monitor compliance.

District leaders and the Charleston Vet Center Director determine reasons for noncompliance and ensure outreach plans are completed.

District leaders and the Augusta, Johnson City, Marietta, Bay County, and Savannah Vet Center Directors determine reasons for noncompliance and ensure outreach plans include all required strategic components.

District leaders and the Augusta, Johnson City, and Savanah Vet Center Directors determine reasons for noncompliance, ensure outreach activities are tailored to the cultural demographics of the vet center’s veteran service area, and monitor compliance.

District leaders and the Augusta Vet Center Director determine reasons for noncompliance, ensure the risk and vulnerability assessment is completed by VA police or local law enforcement, and monitor compliance.

District leaders and the Augusta Vet Center Director determine reasons for noncompliance, ensure fire extinguishers are serviced annually and monitor compliance.

District leaders and the Augusta, Johnson City, Charleston, and Bay County Vet Center Directors determine reasons for noncompliance, ensure fire extinguishers are inspected monthly, and monitor compliance.

The District Director and zone leaders, in conjunction with the Augusta Vet Center Director, determine reasons for noncompliance and ensure vet center obtains an automated external defibrillator.

District leaders and the Charleston Vet Center Director determine reasons for noncompliance, ensure automated external defibrillators are inspected monthly, and monitors compliance.

District leaders and the Charleston and Bay County Vet Center Directors determine reasons for noncompliance, ensure completion of a current and comprehensive emergency and crisis plan, and monitor compliance.

District leaders and the Charleston Vet Center Director determine reasons for noncompliance, and ensures ancillary staff have a desktop reference sheet to address mental health crisis situations.

The Veterans Integrated Service Network Director ensures the Veterans Integrated Service Network Chief Medical Officer oversees the hospital’s privileging process.

The Hospital Director ensures staff conduct environment of care inspections in non patient care areas at least once per fiscal year.

The Hospital Director ensures the suicide prevention team conducts a minimum of five outreach activities per month.

The Hospital Director ensures the suicide prevention coordinators report suicide related events monthly to mental health leaders and quality management staff.

The Hospital Director ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in all ambulatory care settings.

The Medical Center Director ensures the Suicide Prevention Coordinator conducts at least five outreach activities each month.

The Chief of Staff ensures the Peer Review Committee recommends improvement actions for all peer reviews.

The Director ensures staff conduct environment of care inspections in patient care areas at least twice per fiscal year.

The Associate Director ensures staff maintain all medical equipment in accordance with manufacturers’ recommendations or use an alternative maintenance program that does not reduce the safety of the equipment.

The Chief of Staff ensures medications transported by the pneumatic tube system are only accessible by approved individuals.

The Associate Director ensures Environmental Management Services staff keep areas used by patients clean and orderly.

The Director ensures staff check over-the-door alarms in mental health inpatient units with corridor doors to patient sleeping rooms according to the manufacturer’s guidelines.

The Director ensures all entrances into mental health inpatient units have a sally port.

The Director ensures providers complete the Comprehensive Suicide Risk Evaluation the same day as a patient’s positive suicide risk screen in ambulatory care settings.

The Medical Center Director ensures staff document VA police response times to panic alarm testing in the Inpatient Psychiatry Unit

The Medical Center Director ensures staff follow the manufacturer’s guidelines for checking over-the-door alarms for patient sleeping rooms in the Inpatient Psychiatry Unit.

The Medical Center Director ensures the Suicide Prevention Coordinator reports suicide-related events to mental health leaders and quality management staff at least monthly

The Medical Center Director ensures providers complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.