All Reports

District leaders and the Kauai Vet Center Director determine reasons for noncompliance with assigning a licensed mental health professional as a clinical liaison, ensure a process is implemented, and monitor compliance.

District leaders and the Corona, Temecula, Kauai, and Western Oahu 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 Western Oahu 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 Corona, Temecula, Kauai, and Western Oahu 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 Western Oahu Vet Center Director determine reasons for noncompliance with completion of a current written outreach plan, ensure completion, and monitor compliance.

The District Director and zone leaders, in conjunction with the Corona, Temecula, and Kauai 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 Western Oahu Vet Center Director determine reasons for noncompliance with fire or safety annual inspection, ensure completion, and monitor compliance.

District leaders and the Corona, Temecula, and Western Oahu 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 Temecula and Western Oahu Vet Center Directors determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.

District leaders and the Temecula Vet Center Director determine reasons for noncompliance with annual fire extinguisher servicing, ensure completion, and monitor compliance.

District leaders and the Corona, Temecula, and Kauai Vet Center Directors determine reasons for noncompliance with having an automated external defibrillator located on-site and ensure compliance with the requirement.

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

District leaders and the Kauai and Western Oahu Vet Center Directors determine reasons for noncompliance with having an updated emergency and crisis plan that includes required components, ensure completion, and monitor compliance.

District leaders and the Western Oahu Vet Center Director determine reasons for noncompliance with a desktop reference sheet outlining steps for ancillary office staff to follow in case of a suicidal or homicidal client, ensure completion, and monitor compliance.

District leaders and the Phoenix and West Valley Vet Center Director 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 Antelope Valley, Phoenix, and West Valley 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 West Valley 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 Antelope Valley 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 Antelope Valley, Phoenix, Santa Fe, and West Valley 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 Santa Fe Vet Center Director 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 Antelope Valley Vet Center Director determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.

District leaders and the Antelope Valley and Santa Fe Vet Center Directors determine reasons for noncompliance with having an automated external defibrillator located on-site and ensure compliance with the requirement.

District leaders and the Phoenix and Santa Fe 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 Santa Fe Vet Center Director determine reasons for noncompliance with a desktop reference sheet outlining steps for ancillary office staff to follow in case of a suicidal or homicidal client, ensure completion, and monitor compliance.

The VA Tuscaloosa Healthcare System Director conducts a full review of care provided to the patient by clinical staff, consults with Human Resources and General Counsel Offices, and takes action as needed.

The VA Tuscaloosa Healthcare System Director strengthens processes to ensure that providers provide patient education about applicable boxed warnings when prescribing psychiatric medication, and monitors compliance.

The VA Tuscaloosa Healthcare System Director ensures mental health staff conduct suicide risk screenings and assessments as required by the Veterans Health Administration, and monitors compliance.

The VA Tuscaloosa Healthcare System Director evaluates outpatient mental health clinic scheduling procedures; identifies barriers to timely appointment scheduling, including staffing levels; and takes action as warranted.

The VA Tuscaloosa Healthcare System Director strengthens processes to ensure adequate lethal means assessment and lethal means safety counseling with patients.

The VA Tuscaloosa Healthcare System Director reviews posttraumatic stress disorder clinic processes to consult with a patient’s prescriber following worsening of a patient’s mental health symptoms.

The VA Tuscaloosa Healthcare System Director ensures posttraumatic stress disorder clinic consult and documentation procedures align with Veterans Health Administration requirements.

The VA Tuscaloosa Healthcare System Director conducts a review of the supervisory oversight of the social worker and other clinicians in the posttraumatic stress disorder clinic to ensure the identification and follow-up of clinical concerns for patients with complex mental health needs.

The VA Tuscaloosa Healthcare System Director strengthens processes to ensure adherence to Veterans Health Administration and facility traumatic brain injury screening and consult requirements, and monitors compliance.

The VA Tuscaloosa Healthcare System Director evaluates the root cause analysis processes regarding reporting of incomplete action items in accordance with Veterans Health Administration requirements, takes action as needed, and monitors compliance.

The VA Tuscaloosa Healthcare System Director evaluates the Peer Review Committee processes on addressing identified system issues in accordance with Veterans Health Administration requirements, takes action as needed, and monitors compliance.

The Under Secretary for Health considers establishing written guidance regarding the Behavioral Health Autopsy Program family interview process, including suicide prevention program staff’s consultation, to ensure that the decision to not outreach a family member is based on the best interest of the family.

The VA Tuscaloosa Healthcare System Director ensures compliance with the Behavioral Health Autopsy Program including completion of the Family Interview Tool-Contact Form.

The VA Tuscaloosa Healthcare System Director evaluates the care provided to the patient, determines if an institutional disclosure is warranted, and takes action as indicated.

The VA Augusta Health Care System Director ensures that the Mental Health Executive Council includes veteran representation.

The Veterans Integrated Service Network Director implements processes to strengthen oversight and monitoring of bed utilization.

The VA Augusta Health Care System Associate Director for Patient Care Services ensures that inpatient mental health unit staffing supports authorized bed capacity.

The VA Augusta Health Care System Director develops and implements processes to incorporate veteran input for process improvements.

The VA Augusta Health Care System Chief of Mental Health develops processes to ensure integration of the Local Recovery Coordinator into the inpatient mental health unit to support recovery-oriented care.

The VA Augusta Health Care System Chief of Mental Health ensures a minimum of four hours of recovery-oriented, interdisciplinary programming on weekends on the inpatient mental health unit.

The VA Augusta Health Care System Director ensures continued implementation of a recovery-oriented environment on the inpatient mental health unit.

The VA Augusta Health Care System Director ensures accurate reporting of inpatient operating beds and implements processes to monitor.

The VA Augusta Health Care System Director identifies and addresses barriers to admission for veterans on involuntary holds for mental health treatment.

The VA Augusta Health Care System Director ensures alignment between involuntary commitment policies and practices, consistency with state laws, and implementation of monitoring processes.

The VA Augusta Health Care System Chief of Staff ensures assignment of ongoing responsibilities for monitoring timely documentation of the change in veterans’ voluntary or involuntary legal status, consistent with VHA policy and state laws.

The VA Augusta Health Care 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 improvement.

The VA Augusta Health Care System Director ensures the development and implementation of clearly defined written processes for transition of care when veterans are discharged from the inpatient mental health unit.

The VA Augusta Health Care System Chief of Staff ensures discharge summaries are completed within two business days of discharge and monitors for compliance.

The VA Augusta Health Care System Chief of Staff ensures discharge instructions for veterans include appointment location and contact information in easy-to-understand language.

The VA Augusta Health Care System Director ensures that medications listed in discharge instructions include the purpose for each medication and are written in easy-to-understand language.

The VA Augusta Health Care System Chief of Staff identifies barriers to completing the Columbia-Suicide Severity Risk Scale Screener within 24 hours prior to discharge, implements processes, and monitors to ensure compliance.

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

The VA Augusta Health Care System Director ensures staff comply with lethal means safety training and suicide risk training requirements and monitors for compliance.

The VA Augusta Health Care System Director ensures compliance with VHA requirements for the Interdisciplinary Safety Inspection Team, including environment of care subcommittee structure, and Mental Health Environment of Care Checklist training completion.

The VA Augusta Health Care System Chief of Staff ensures mental health leaders update inpatient unit toilets to meet safety requirements and implement processes to reduce associated safety risks.

The VA North Florida/South Georgia Health System Director consults with the Office of General Counsel to ensure system and service line policies and practices related to voluntary and involuntary admissions under the Baker Act provide clear guidance and are consistent with Florida state law as allowed by federal law and Veterans Health Administration regulations.

The VA North Florida/South Georgia Health System Director ensures that providers document their rationales for initiating involuntary examinations under the Baker Act within a patient’s electronic health record and monitors compliance.

The VA North Florida/South Georgia Health System Director verifies that a process is in place to provide patients who are admitted for an involuntary examination under the Baker Act with written information on their rights and monitors compliance.

The VA North Florida/South Georgia Health System Director confirms that mental health staff document offering evidence-based therapies during treatment planning with patients diagnosed with posttraumatic stress disorder, as required by Veterans Health Administration policy, and monitors compliance.

The VA North Florida/South Georgia Health System Director ensures that all licensed mental health staff receive annual training on the Baker Act and tracks compliance.

The VA North Florida/South Georgia Health System Director determines if there is a need for non-mental health providers in the emergency department to complete Baker Act training and takes action as warranted.

The VA North Florida/South Georgia Health System Director, in consultation with Veterans Health Administration’s Senior Security Officer, ensures system police, emergency department, and mental health staff follow VA policy specific to assisting staff in the prevention of patient elopements prior to an involuntary mental health evaluation and tracks compliance.

The VA North Florida/South Georgia Health System Director develops a process to provide oversight of compliance with all elements required by state law for use of the Baker Act as permitted by federal law and Veterans Health Administration policy.

The VA North Florida/South Georgia Health System Director, in consultation with the Office of General Counsel, determines whether Baker Act reporting by the system is required and provides clear guidance for applicable reporting processes.

The VA North Florida/South Georgia Health System Director develops a process to ensure system policies adhere to Veterans Health Administration Directive 0999(1), medical center policy standardized template as it pertains to assignment of oversight responsibilities.

The VA North Florida/South Georgia Health System Director directs a review of current patient advocate processes for follow-up and resolution with complainants, updates the process as warranted, and monitors compliance.

The VA North Florida/South Georgia Health System Director considers having the patient advocate process for tracking and monitoring trends capture complaints specific to involuntary admissions for leaders’ awareness and follow-up.

District leaders and the Jackson and Corpus Christi 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 Fort Worth Vet Center Director determine reasons for noncompliance with Readjustment Counseling Service documentation standards, ensure completion, and monitor compliance.

District leaders and the Fayetteville, New Orleans, Jackson, Corpus Christi, Fort Worth, and San Antonio Northeast 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 Jackson and San Antonio Northeast Vet Center Directors determine reasons for noncompliance with Vet Center Directors review of 10 percent of active client records monthly for each counselor’s caseload, ensure completion, and monitor compliance.

District leaders and the Fayetteville, New Orleans, Jackson, Corpus Christi, Fort Worth, and San Antonio Northeast 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 Fayetteville, New Orleans, Jackson, Corpus Christi, Fort Worth, and San Antonio Northeast 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 Fayetteville Vet Center Director 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 New Orleans Vet Center Director determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.

District leaders and the New Orleans, Jackson, and Corpus Christi Vet Center Directors determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.

District leaders and the Fayetteville and Fort Worth 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 Fayetteville, Corpus Christi, Fort Worth, and San Antonio Northeast Vet Center Directors determine reasons for noncompliance with a desktop reference sheet outlining steps for ancillary office staff to follow in case of a suicidal or homicidal client, ensure completion, and monitor compliance.

District leaders and the Fort Collins, Kalispell, Abilene, Salt Lake City, and Cheyenne 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 Fort Collins, Tulsa, Abilene, Salt Lake City, and Cheyenne 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 Fort Collins, Abilene, and Salt Lake City Vet Centers Directors determine reasons for noncompliance with Vet Center Directors review of 10 percent of active client records monthly for each counselor’s caseload, ensure completion, and monitor compliance.

District leaders and the Fort Collins, Kalispell, Tulsa, Abilene, Salt Lake City, and Cheyenne 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 Collins, Kalispell, Tulsa, Abilene, Salt Lake City, and Cheyenne 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 Cheyenne Vet Center Director determine reasons for noncompliance with completion of an annual fire or safety inspection, ensure completion, and monitor compliance.

District leaders and the Abilene and Cheyenne 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 Fort Collins and Kalispell Vet Center Directors determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.

District leaders and the Salt Lake City Vet Center Director determine reasons for noncompliance with annual fire extinguisher servicing, ensure completion, and monitor compliance.

District leaders and the Fort Collins, Kalispell, Abilene, Salt Lake City, and Cheyenne Vet Center Directors determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.

District leaders and the Salt Lake City 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 Cheyenne Vet Center Director determine reasons for noncompliance with building evacuation plans posted in a communal area for staff and visitors, ensure completion, and monitor compliance.

District leaders and the Fort Collins Vet Center Director determine reasons for noncompliance with a desktop reference sheet outlining steps for ancillary office staff to follow in case of a suicidal or homicidal client, ensure completion, and monitor compliance.

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 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 assesses 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 that a safety plan was provided to all active clients assessed at intermediate or high suicide risk levels, and monitors compliance across all zone vet centers

The Veterans Crisis Line Director determines the optimal ratio of supervisors to frontline staff needed, makes the best efforts to ensure the ratio is maintained, and takes action as warranted.

The Veterans Crisis Line Director ensures supervisors and staff are aware of postvention resources and monitors for compliance.

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 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.