All Reports

Comprehensive Healthcare Inspection of the VA Western New York Healthcare System in Buffalo
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21-00290-116
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2022
The Director evaluates and determines the reasons for noncompliance and makes certain that leaders accurately identify and report adverse events as sentinel events when criteria are met.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that the Peer Review Committee recommends improvement actions for Level 3 peer reviews.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2022
The Director evaluates and determines any additional reasons for noncompliance and makes certain that required members attend Surgical Work Group meetings.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2022
The Chief of Staff and Associate Director for Patient/Nursing Services evaluate and determine any additional reasons for noncompliance and make certain that staff monitor and evaluate all transfers as part of VHA’s Quality Management Program.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2022
The Chief of Staff and Associate Director for Patient/Nursing Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2023
The Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete the required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2022
The Director evaluates and determines any additional reasons for noncompliance and makes certain that Employee Threat Assessment Team members complete the required training.
Inspection of Information Technology Security at the VA Financial Services Center
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21-01221-24
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Topics:  Information Technology and Security

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 7/20/2022
The Financial Services Center director implements measures to maintain an accurate system inventory.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 7/20/2022
The Financial Services Center director implements a more effective patch and vulnerability management program that can accurately identify vulnerabilities and enforce patch application.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 10/11/2022
The Financial Services Center director implements systems and information integrity procedures that detail how policies are applied to local systems, and create a mechanism for informing employees of new or updated policies and procedures.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 7/20/2022
The Financial Services Center director, in conjunction with the system owner, develops and implements capabilities for all systems to generate audit logs and collect and forward audit events to the Cybersecurity Operations Center for review, analysis, and reporting.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2022
The Financial Services Center director continues to upgrade the video surveillance system and ensure new capabilities provide full surveillance and video retention to improve monitoring and incident response.
Comprehensive Healthcare Inspection of Veterans Integrated Service Network 6: VA Mid-Atlantic Health Care Network in Durham, North Carolina
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21-00237-114
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Topics:  Medical Staff Privileging Credentialing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2022
The Chief Medical Officer evaluates and determines any additional reasons for noncompliance and makes certain to review the credentials files and approve the VA appointments of physicians who had potentially disqualifying licensure actions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/31/2023
The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that the Veterans Integrated Service Network’s Emergency Management Committee meets at least quarterly.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2022
The Network Director evaluates and determines any additional reasons for noncompliance and ensures the Emergency Manager completes an annual review of the collective Veterans Integrated Service Network-wide strengths, weaknesses, priorities, and requirements for improvement.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2022
The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the Lead Women Veterans Program Manager completes annual site visits at each facility within the Veterans Integrated Service Network.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2022
The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that the Lead Women Veterans Program Manager completes assessments to identify staff’s women’s health education gaps and develops or adapts educational programs, materials, or resources where gaps are identified.
Financial Efficiency Review of the Durham VA Health Care System in North Carolina
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21-02458-94
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Topics:  Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/2/2023
Ensure finance office staff are made aware of policy requirements and reviews are conducted on all inactive open obligations as required by VA Financial Policy, vol. 2, chap. 5, “Obligations Policy.”
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
Ensure quarterly purchase card audits are performed as required by the Veterans Health Administration’s standard operating procedure, “Internal Audits—Purchase Cards and Convenience Checks.”
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/7/2022
Establish controls to confirm approving officials and purchase cardholders review their purchases and make sure contracting is used when it is in the best interest of the government.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/7/2022
Require purchase cardholders to submit a request for ratification for any unauthorized commitments identified.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/7/2022
Develop measures to confirm that completed VA Form 0242 submissions are accurate and updated for all cardholders.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/7/2022
Ensure cardholders comply with record retention requirements as stated in VA’s Financial Policy, vol. 16, “Charge Card Programs.”
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
Establish controls to make certain that budget or accounting staff review the salary cost data each pay period and promptly address cost center corrections with human resources staff as needed.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
Ensure service chiefs and supervisors review labor mapping for accuracy and completeness.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/7/2022
Develop and implement a plan to increase inventory turnover closer to the VHA recommended level.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/7/2022
Develop and implement a plan to complete facility based inventory audits of noncontrolled drug line items in compliance with VHA policy.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 308,000.00
Comprehensive Healthcare Inspection Summary Report: Evaluation of Medical Staff Privileging in Veterans Health Administration Facilities, Fiscal Year 2020
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21-01503-112
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Topics:  Medical Staff Privileging Credentialing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/12/2023
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures service chiefs include the minimum specialty criteria for focused professional practice evaluations of gastroenterology, pathology, nuclear medicine, and radiation oncology practitioners.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2024

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that service chiefs include service-specific criteria in ongoing professional practice evaluations.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2024

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures executive committees of the medical staff recommend continuing licensed independent practitioners’ privileges based on professional practice evaluation results.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2024

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that provider exit review forms are completed within seven business days of licensed healthcare professionals’ departure from a medical facility.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2024

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that provider exit review forms are signed by the service chief, the chief of staff, and the medical facility director if the licensed healthcare professional failed to meet the generally-accepted standards of care.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures credentialing and privileging managers initiate the state licensing board reporting process within the required time frame when licensed healthcare professionals fail to meet generally-accepted standards of care.
Improved Governance Would Help Patient Advocates Better Manage Veterans’ Healthcare Complaints
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21-00510-105
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Topics:  Healthcare Infrastructure

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2024

Review and update, as appropriate, program policy to formally align with the Office of Patient Advocacy’s program expectations, including when complaints must be entered into a patient advocate tracking system and the responsibilities of patient advocate supervisors.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2023
Implement controls that require facility patient advocate supervisors and Veterans Integrated Service Network patient advocate coordinators to perform regular, documented reviews of records in the patient advocate tracking system to monitor that the required information is entered properly.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2024

Provide guidance to medical facility directors to ensure they fulfill their required Patient Advocacy Program management duties, including timely complaint resolution and trending complaint data.

Comprehensive Healthcare Inspection of the W.G. (Bill) Hefner VA Medical Center in Salisbury, North Carolina
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21-00282-111
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/17/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures leaders conduct institutional disclosures for all sentinel events.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Medical Center Director determines the reasons for noncompliance and ensures the Systems Redesign Manager participates on the Veterans Integrated Service Network Systems Redesign Review Advisory Group.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/17/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members regularly attend Surgical Workgroup meetings.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/6/2023

The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete all required prevention and management of disruptive behavior training.

VA’s Compliance with the VA Transparency & Trust Act of 2021
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22-00879-118
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Topics:  Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 4/6/2023
Consult with appropriate VA financial and legal officials to determine whether the use of CARES Act funds for the Beaufort National Shrine project violates the Purpose Statute and, if a violation occurred, take the steps necessary to remedy the violation.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 4/6/2023
Determine the obligations to sustain essential information technology investments, update the obligation schedule as necessary, provide an updated spend plan to Congress, and include this information in future biweekly updates.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 3,600,000.00
Medication Management Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, Washington
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21-00656-110
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Topics:  Electronic Health Records Modernization (EHRM) ● Patient Safety

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No. 1
Not Implemented Recommendation Image, X character'
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 4/9/2024

The Deputy Secretary ensures that substantiated and unresolved allegations discussed in this report are reviewed and addressed.

No. 2
Not Implemented Recommendation Image, X character'
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 9/28/2022

The Deputy Secretary ensures medication management issues related to the new electronic health record that are identified subsequent to this inspection be reported to the Office of Inspector General for further analysis.

Care Coordination Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, Washington
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21-00781-109
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Topics:  Electronic Health Records Modernization (EHRM) ● Patient Safety ● Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 10/2/2023

The Deputy Secretary ensures that substantiated and unresolved allegations noted in this report are reviewed and addressed.

Ticket Process Concerns and Underlying Factors Contributing to Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, Washington
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21-00781-108
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Topics:  Electronic Health Records Modernization (EHRM) ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 10/3/2023

The Deputy Secretary completes an evaluation of the new electronic health record problem resolution processes and takes action as warranted.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 10/19/2022

The Deputy Secretary completes an evaluation of the underlying factors of substantiated allegations identified in this report and takes action as warranted.

No. 3
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

The Deputy Secretary ensures the electronic health record modernization deployment schedule reflects resolution of the allegations and concerns discussed in this report.

Comprehensive Healthcare Inspection of the Salem VA Medical Center in Virginia
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21-00281-100
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2023
The Chief of Staff and Associate Director–Patient/Nursing Services evaluate and determine any additional reasons for noncompliance and ensure that staff monitor and evaluate inter-facility patient transfers as part of VHA’s Quality Management Program.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/19/2023

The Chief of Staff and Associate Director–Patient/Nursing Services evaluate and determine any additional reasons for noncompliance and ensure that all required members attend Disruptive Behavior Committee meetings.

Review of Allegations of Improper Maintenance at VA’s Houston National Cemetery
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21-03325-86
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Topics:  Maintenance and Construction

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 3/10/2022
Revise the equipment policy to include provisions and timelines to resume routine activities, such as required preventive maintenance checks, which could be affected by natural disasters or emergencies, such as the COVID 19 pandemic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 9/26/2022
Provide an action plan and timeline to repair the headstones or sod in the 65 gravesites the team identified.
Public Disability Benefits Questionnaires Reinstated but Controls Could Be Strengthened
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21-02750-63

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/11/2022
Revise the Veterans Benefits Administration’s adjudication procedures manual to clarify and communicate steps that claims processors must take to ensure all certification elements on the publicly available disability benefits questionnaires are provided and are authentic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/11/2022
Update the Veterans Benefits Administration’s adjudication procedures manual to clarify the intent of guidance involving authenticity, face value, and validation of publicly available disability benefits questionnaires to ensure claims processors evaluate the questionnaires in accordance with evidentiary principles
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/26/2022
Implement actions to facilitate claims processors’ understanding of the need to document the evaluation of evidence within benefits entitlement decisions when using publicly available disability benefits questionnaires.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/21/2022
Amend the Veterans Benefits Administration’s adjudication procedures manual to define valid rationale to ensure medical opinions are well supported when deciding entitlement to benefits.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/30/2024

Correct all processing errors on cases identified by the review team and report the results to the Office of Inspector General.

Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 88,700.00
Comprehensive Healthcare Inspection of the Hunter Holmes McGuire VA Medical Center in Richmond, Virginia
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21-00280-89
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Topics:  Patient Safety ● Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/26/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Systems Redesign and Improvement Coordinator tracks facility-level improvement capabilities and projects.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2023
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete a final peer review within 120 calendar days from the date it is determined that a peer review is needed, or the Medical Center Director approves an extension request in writing.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the Peer Review Committee recommends improvement actions for Level 3 peer reviews.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/26/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that the Surgical Work Group reviews surgical deaths.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff monitor and evaluate inter-facility transfers.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2023
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure transferring providers complete all required elements of the VA Inter-Facility Transfer Form or a facility-defined equivalent prior to patient transfers.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2023
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that staff send pertinent medical records, including an active patient medication list, to the receiving facility during inter-facility transfers.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/26/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2023
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work area.
Comprehensive Healthcare Inspection of the James J. Peters VA Medical Center in Bronx, New York
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21-00289-90
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/3/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Peer Review Committee submits a quarterly summary analysis for review by the Medical Executive Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/3/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members attend Facility Surgical Workgroup meetings.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/3/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Facility Surgical Workgroup reviews surgical deaths and evaluates critical surgical events as required.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/1/2022
The Chief of Staff and Nurse Executive (ADPCS/Chief Nurse Executive) evaluate and determine any additional reasons for noncompliance and ensure all required members attend Disruptive Behavior Committee meetings.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2023
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Facilities, Fiscal Year 2020
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21-01506-76
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Topics:  Suicide Prevention

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2023
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility providers conduct four follow-up visits, either face-to-face or telephonic with documented patient preference, within the required time frame.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2023
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures providers collaborate with suicide prevention coordinators when follow-up contact is unsuccessful for high-risk patients.
No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that employees complete initial suicide risk and intervention training within 90 days of hire and annual suicide prevention refresher training.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2023
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that all facility suicide prevention coordinators complete at least five outreach activities per facility each month.
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