All Reports

The Under Secretary for Health ensures the third-party administrator and community care breast imaging providers are informed of the expectations and processes for provision of breast images to the referring VA facility, addresses any barriers identified, and follows up to ensure compliance.

The VA Eastern Colorado Health Care System Director ensures that facility community care staff comply with Veterans Health Administration requirements for requesting medical records, including images, from community providers and documentation of the receipt of medical records, including images, and follows up to ensure compliance.

The VA Eastern Colorado Health Care System Director reviews processes, to ensure community care images are uploaded timely; assesses identified barriers, including staffing; and follows up to ensure compliance.

The Under Secretary for Health reviews limitations of current VA image sharing technologies, considers implementation of technologies to support timely sharing of images with community providers, and takes action as warranted.

The VA Eastern Colorado Health Care System Director reviews facility policy and standard operating procedures to ensure sufficient guidance and resources for compliance with Veterans Health Administration requirements for breast cancer screening, follow-up, and care coordination, and takes action as warranted.

The VA Eastern Colorado Health Care System Director assesses the scope of the lack of tracking of breast cancer screening and follow-up for patients with a BIRADS 0, 3, 4, 5, or 6 from at least February 2024 forward to ensure all patients receive appropriate notification and timely follow-up of findings, and takes action as indicated.

The VA Eastern Colorado Health Care System Director ensures credentialing and privileging staff complete primary source verification of credentials, and monitors for compliance.

The VA Eastern Colorado Health Care System Director makes certain that clinical service chiefs follow processes for review of supporting documentation during the credentialing and privileging process, and follows up to ensure compliance.

The VA Eastern Colorado Health Care System Director ensures that the radiology service chief initiates focused professional practice evaluations timely, as required, and monitors for compliance.

The Under Secretary for Health ensures alcohol use screening performance monitoring to demonstrate sustained improvement of required alcohol use screening.

The Under Secretary for Health reviews the clinical implications and considers implementing sex-specific thresholds to prompt the delivery of brief intervention in response to alcohol use screening and takes action as appropriate.

The Facility Director ensures the Mental Health Executive Council includes veteran representation.

The Veterans Integrated Service Network Director provides oversight and monitoring of bed utilization.

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

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

The Chief of Staff ensures staff use the required admission note template to document legal commitment status.

The Chief of Staff ensures documentation of discussions between prescribers and veterans on the risks and benefits of newly prescribed central nervous system medications.

The Chief of Staff ensures discharge summaries are completed within two business days of discharge.

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 an explanation when both trade and generic names are used for the same medication.

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

The Facility Director directs nonclinical staff to complete VA S.A.V.E. training requirements.

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

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.

The Facility Director directs inpatient unit staff and Interdisciplinary Safety Inspection Team members to complete Mental Health Environment of Care Checklist training requirements.

The Facility Executive Director ensures the Mental Health Executive Council includes veteran representation.

The Facility Executive Director ensures staff complete the mental health nursing admission screen note, with veterans’ legal status, for admissions to the inpatient mental health unit and develops a plan to monitor for sustained compliance.

The Chief of Staff ensures documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications prior to administration and develops a plan to monitor for sustained compliance.

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

The Facility Executive Director ensures staff complete VA S.A.V.E. training and develops a plan to monitor for sustained compliance.

The Facility Executive Director ensures Interdisciplinary Safety Inspection Team members participate in Mental Health Environment of Care Checklist inspections and develops a plan to monitor for sustained compliance.

The Facility Executive Director ensures all required individuals complete Mental Health Environment of Care Checklist annual training and develops a plan to monitor for sustained compliance.

Strengthen and monitor the automation process to ensure that automated Dependency and Indemnity Compensation rating decisions and notifications fully comply with all legal requirements and procedural guidance.

Ensure the Pension and Fiduciary Service revises the quality review checklist for automated death benefits decisions so that those decisions undergo the same scrutiny as traditionally processed claims.

Consult with VA’s Office of General Counsel to determine whether the modernization plan submitted to Congress—regarding service-connected death benefit grants—complies with section 701(b) of the PACT Act and take appropriate corrective action if needed.

Take corrective action on the remaining three of seven instances that led to about $612,000 in improper payments.

Update requirements provided to the VA Hines Information Technology Center to ensure all foreign beneficiaries, including those with an address in the Philippines, are included in the annual end product generation.

Update the Veterans Benefits Administration’s Adjudication Procedures Manual to clarify and strengthen the actions claims processors should take to verify foreign beneficiaries are alive.

Ensure jurisdiction guidance for routine reviews for residents in the Philippines is clearly communicated to all regional offices.

Provide guidance to assist claims processors in verifying information in the Veterans Benefits Administration’s systems compared to the results from the Social Security Administration inquiry results.

Update the Adjudication Procedures Manual to require claims processors to upload the Social Security Administration inquiry results to beneficiaries’ records.

The VA Loma Linda Healthcare System Director ensures the Chief of Staff signs peer review designation memoranda within three days of determining a peer review is needed as outlined in Veterans Health Administration policy.

The VA Loma Linda Healthcare System Director ensures that focused professional practice evaluations for initial appointments and additional privileges are completed in accordance with Veterans Health Administration policy and monitors for compliance.

The VA Fayetteville Coastal Healthcare System Director confirms full implementation of the VA Community Care Oversight and Consult Management Council.

The Under Secretary for Health reviews practices and procedures for managing consults to identify and prioritize appointment scheduling for patients with serious health conditions (high‑priority consults), such as cancer, and provide direction to the field on the process to use to make this determination.

The VA Fayetteville Coastal Healthcare System Director directs the development and implementation of community care service standard operating procedures to address identification and management of high-priority consults, timeliness of consult processing, and care coordination that aligns with direction provided by Veterans Health Administration’s Integrated Veterans Care program.

The VA Fayetteville Coastal Healthcare System Director ensures staff are trained in all newly developed community care standard operating procedures and that adherence to policy and practice is monitored.

The VA Fayetteville Coastal Healthcare System Director confirms completion of a review of quality management processes to ensure quality management staff, when reviewing patient safety events, consider potential system issues and, if present, recommend they be addressed using other quality management reviews.

The VA Fayetteville Coastal Healthcare System Director ensures local processes are in place, including assigned roles and responsibilities, to manage Office of Inspector General case referrals in compliance with VA Directive 0701, Office of Inspector General Hotline Complaint Referrals.

The VA Fayetteville Coastal Healthcare System Director confirms reasonable efforts to conduct an institutional disclosure with the patient regarding circumstances that led to the delay in the diagnosis of and treatment for lung cancer are made and, if a disclosure is completed, that it is documented in the electronic health record.

The Under Secretary for Health assesses the electronic health record reviews completed by the system in response to the community care backlog to determine if a more comprehensive review is warranted with appropriate disclosure to patients placed at risk or harmed as a result of a delay in action on their community care consult, and takes action accordingly.

District leaders and the Prince George’s County Vet Center Director collaborate with the supporting VA medical facility to determine reasons for noncompliance with staff participation in the mental health executive council, take action as indicated, and monitor compliance.

District leaders and the Prince George’s County, Fayetteville, and Chesapeake 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 to complete consultation requirements, and monitor compliance.

District leaders and the Prince George’s County and Fayetteville Vet Center Directors determine reasons for noncompliance with employees completing select training in the required time frame, ensure completion, and monitor compliance.

District leaders and the Prince George’s County, Fayetteville, and Chesapeake 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 Prince George’s County and Chesapeake Vet Center Directors determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.

District leaders and the Prince George’s County Vet Center Director determine reasons for noncompliance with annual fire extinguisher servicing, ensure completion, and monitor compliance.

District leaders and the Fayetteville and Chesapeake Vet Center Directors determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.

District leaders and the Fayetteville 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 Chesapeake Vet Center Director determine reasons for noncompliance with having an emergency and crisis plan that includes required components, ensure completion, and monitor compliance.

District leaders and the Lancaster Vet Center Director determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented to complete consultation requirements, and monitor compliance.

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

District leaders and the Dubois, Lancaster, and White Oak 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 Buffalo Vet Center Director collaborate with the supporting VA medical facility to determine reasons for noncompliance with staff participation in the mental health executive council, take action as indicated, and monitor compliance.

District leaders and the Buffalo, Nassau, and Syracuse 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 to complete consultation requirements, and monitor compliance.

District leaders and the Buffalo, Nassau, and Syracuse Vet Center Directors determine reasons for noncompliance with employees completing select training in the required time frame, ensure completion, and monitor compliance.

District leaders and the Buffalo and Nassau 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 Syracuse Vet Center Director determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.

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

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

District leaders and the Syracuse 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 Nassau and Syracuse 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 determine reasons why there are discrepancies in the vet center address on VA and public-facing websites and ensure all websites include correct location information.

District leaders and the New Haven 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 New Haven, Sanford, and Providence 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 to complete consultation requirements, and monitor compliance.

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

District leaders and the New Haven, Sanford, and Providence Vet Center Directors determine reasons for noncompliance with employees completing select training in the required time frame, ensure completion, and monitor compliance.

District leaders and the New Haven, Sanford, and Providence 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 New Haven and Providence Vet Center Directors determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.

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

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

The Executive Medical Center Director ensures clinical staff can open all doors to shared bathrooms.

The Executive Medical Center Director ensures staff keep exterior doors closed to minimize risk to wandering patients.

The Executive Medical Center Director ensures staff store clean and dirty equipment and supplies separately.

The Executive Medical Center Director ensures each service has workflows to communicate test results.

Facility leaders ensure the community living center’s dementia unit shower room is clean and free from hazards, and that leaders conduct a risk assessment to determine the need for other safety measures.

The Medical Center Director ensures facility staff conduct a privacy assessment and take actions to protect patient information in the Emergency Department.

Facility leaders ensure all eyewash stations are clean and function properly.

The Medical Center Director ensures the facility has a written policy for communication of test results.

The Chief of Staff and Associate Director of Patient Care Services ensure leaders in each service develop written service-level workflows that outline the process for staff to communicate test results to providers and patients.

The Veterans Integrated Service Network Director ensures executive leaders implement a process to monitor actions related to Veterans Health Administration policy changes.

The Medical Center Director ensures the Chief of Staff and Associate Director of Patient Care Services review performance metrics for test result communications and take action for identified deficiencies.

The Medical Center Director ensures executive leaders attend Quality and Patient Safety Council meetings.

Executive leaders ensure staff properly store endoscopes.

The Medical Center Director ensures each service develops a workflow for the communication of test results.

The Medical Center Director ensures quality management staff report deficiencies identified from the External Peer Review Program to executive leaders, and staff take corrective actions as needed.

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

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

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

The Facility Director considers consulting with the Office of Mental Health to clarify guidelines for design elements such as artwork on the inpatient unit.

The Facility Director considers alternatives to outdoor access for the inpatient unit, such as those identified in VA’s Design Guide for Inpatient Mental Health & Residential Rehabilitation Treatment Program Facilities.

The Facility Director develops and implements written processes to monitor and track compliance with state laws for involuntary hospitalization and consults with the Office of General Counsel to ensure processes are consistent with applicable laws.

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

The Chief of Staff ensures veterans’ discharge instructions are written in easy-to-understand language and include the follow-up mental health appointment location, the purpose of each medication, and how the medication is supposed to be taken.

The Facility Director ensures the Interdisciplinary Safety Inspection Team adheres to Veterans Health Administration requirements, including recording membership and attendance for Mental Health Environment of Care Checklist inspections.

The Veterans Integrated Service Network Director implements processes to ensure the Veterans Integrated Service Network Mental Health Environment of Care Checklist Oversight Team provides facility guidance consistent with Veterans Health Administration requirements.

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