All Reports

The District Director determines reasons clinical quality review remediation plans at the four selected vet centers did not include documentation of deficiency resolution and the time frame of resolution, takes indicated actions to ensure completion, and monitors compliance.

The District Director determines reasons for lack of evidence that clinical quality review deficiencies were resolved at the Cleveland, Columbus, and Toledo Vet Centers, takes indicated actions to ensure completion, and monitors compliance.

The District Director determines reasons for lack of evidence for administrative quality review deficiency resolution for the Cleveland, Columbus, and South Bend Vet Centers, takes indicated actions to ensure completion, and monitors compliance

The District Director determines reasons administrative quality review remediation plans did not include documentation of deficiency resolution and the time frame of resolution for the Columbus and South Bend Vet Centers, takes indicated actions to ensure completion, and monitors compliance.

The Readjustment Counseling Service Chief Officer defines “serious suicide attempt” and establishes criteria for when a morbidity and mortality review is required as well as a standardized process for completing the review.

The District Director ensures the intake portion of the psychosocial assessment is completed and monitors compliance across all zone vet centers.

The District Director ensures suicide risk assessments are completed on the first clinical visit and monitors compliance across all zone vet centers.

The District Director ensures clinical staff consult and coordinate care with the support VA medical facility for shared clients flagged as high risk for suicide and monitors compliance across all zone vet centers.

The District Director 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 ensures clinical staff consult with the vet center director, external clinical consultant, associate district director for counseling, or support VA medical facility mental health provider to include the suicide prevention coordinator following a client’s suicide risk assessment as required, and monitors compliance across all zone vet centers.

The District Director determines reasons for noncompliance with High Risk Suicide Flag SharePoint site requirements and the tracking of continuity of care for clients with a high risk-suicide flag or clients with an increased predictive risk for suicide at the Columbus, South Bend, and Toledo Vet Centers, takes action to ensure requirements are met, and monitors compliance.

The District Director determines reasons a process for completing and tracking four hours of external clinical consultation per month did not occur at Cleveland, Columbus, South Bend, and Toledo Vet Centers, ensures vet center directors implement processes, and monitors compliance.

The District Director determines reasons staff at the Cleveland, Columbus, South Bend, and Toledo Vet Centers did not complete required trainings, ensures all staff complete mandatory trainings, and monitors compliance.

The Midwest District 3 Director ensures the South Bend Vet Center Director and counselors complete suicide risk assessments and assign risk levels based on client risk factors, reevaluate levels when risk factors change, and monitors staff’ compliance.

The Midwest District 3 Director ensures the South Bend Vet Center Director and counselors consistently mitigate clients’ risk for suicide, as appropriate, by developing personalized safety plans, seeking clinical consultation, increasing client contact efforts, and completing crisis reports, and monitors compliance.

The Midwest District 3 Director ensures that when clients are transferred from one counselor to another, relevant clinical information is communicated, applicable safety measures are in place, services are not disrupted, and when possible, a joint session with the outgoing and incoming counselor is held with the client.

Ensure vulnerabilities are remediated within established time frames.

Develop and approve a system security plan and an authorization to operate for the special-purpose system.

Verify that access control lists have been applied to network segments that contain medical systems.

Validate that appropriate physical and environmental security measures are implemented and functioning as intended.

The Richard L. Roudebush VA Medical Center Director ensures that staff conduct and document focused professional practice evaluations as required by Veterans Health Administration.

The Richard L. Roudebush VA Medical Center Director ensures timely completion of factfinding reviews to promptly identify and address system vulnerabilities.

The VISN 7 Director ensures that ordering providers communicate normal mammography results to patients within 14 calendar days.

The District Director determines reasons clinical quality review remediation plans did not include documentation of deficiency resolution and the time frame for resolution for the Fargo, Omaha, and Sioux Falls Vet Centers, takes indicated actions to ensure completion, and monitors compliance.

The District Director determines reasons for lack of evidence that clinical quality review deficiencies were resolved at the Columbia, Fargo, Omaha, and Sioux Falls Vet Centers, takes indicated actions to ensure completion, and monitors compliance.

The Readjustment Counseling Service Chief Officer defines “serious suicide attempt” and establishes criteria for when a morbidity and mortality review is required as well as a standardized process for completing the review.

The District Director ensures the intake portion of the psychosocial assessment is completed and monitors compliance across all zone vet centers.

The District Director ensures suicide risk assessments are completed on the first clinical visit and monitors compliance across all zone vet centers.

The District Director ensures clinical staff consult and coordinate care with the support VA medical facility for shared clients flagged as high risk for suicide and monitors compliance across all zone vet centers.

The District Director verifies clinical staff follow confidentiality requirements when consulting and coordinating care with the support VA medical facility for shared clients at high risk for suicide and monitors compliance across all zone vet centers.

The District Director ensures clinical staff complete safety plans for clients that are assessed at intermediate or high, acute or chronic, risk level as required and monitors compliance across all zone vet centers.

The District Director ensures clinical staff consult with the vet center director, external clinical consultant, associate district director for counseling, or support VA medical facility mental health provider to include the suicide prevention coordinator following a client’s suicide risk assessment as required, and monitors compliance across all zone vet centers.

The System Director evaluates and determines any additional reasons for noncompliance and ensures the Patient Safety Manager conducts a root cause analysis or includes the patient safety event in an aggregate review for all events assigned an actual or potential safety assessment code score of three.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs define Focused Professional Practice Evaluation criteria in advance.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers with similar training and privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs’ determinations to continue current privileges are based on Ongoing Professional Practice Evaluation activities.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Medical Executive Committee’s decision to recommend continuation of privileges is based on Ongoing Professional Practice Evaluation results.

Work with the Centers for Medicare and Medicaid Services to establish a data sharing agreement with VA to limit potential duplicate claim payments.

The Under Secretary for Health ensures compliance with suicide risk and lethal means safety training requirements.

The Under Secretary for Health evaluates the efficacy of the May 2022 Veterans Integrated Service Network and Office of Mental Health and Suicide Prevention oversight structure for suicide risk training and considers inclusion of an oversight structure for lethal means safety training compliance.

The Under Secretary for Health evaluates the adequacy of the one-time lethal means safety training requirement and takes action as appropriate.

The Under Secretary for Health ensures clinician completion of comprehensive suicide risk evaluations including the discussion and documentation of firearms access and safe storage as required, and monitors compliance.

The Under Secretary for Health evaluates staff’s perceived barriers to completion of the suicide risk identification strategy and takes action as appropriate.

Monitor facility follow-up rates by type of care and on a month-over-month basis, establish monitoring metrics, and assist facilities if they fall below these metrics.

Evaluate and update, as appropriate, whether activities that occurred before cancellation and notations of “No Action Other Reason” should be tracked as follow-up.