All Reports

The Associate Chief of Staff, Mental Health develops and implements written processes to ensure treatment planning on the inpatient mental health unit aligns with Veterans Health Administration Directive 1160.01, Uniform Mental Health Services in VHA Medical Points of Service requirements. 

The Associate Chief of Staff, Mental Health requires a minimum of four hours of recovery-oriented, interdisciplinary programming on weekends on the inpatient mental health unit, in alignment with Veterans Health Administration Directive 1160.06(1), Inpatient Mental Health Services.

The Facility Director ensures implementation of a recovery-oriented environment on the inpatient mental health unit, consistent with Veterans Health Administration’s Design Guide for Inpatient Mental Health & Residential Rehabilitation Treatment Program Facilities.

The Facility Director develops and implements a written standard operating procedure for the use of video monitoring on the inpatient mental health unit, as required by Veterans Health Administration Office of Mental Health Standard Operating Procedure 1160.06.1, “Standard Operating Procedure for Maintaining Safety and Security on Inpatient Mental Health Units under VHA [Veterans Health Administration] Directive 1160.06.”

The Chief of Staff ensures that only healthcare staff have access to video monitoring in treatment areas and that video equipment is used for monitoring, not recording, in accordance with Veterans Health Administration Directive 1078, Privacy of Persons Regarding Photographs, Digital Images and Video or Audio Recordings.

The Facility Director posts signage to notify veterans of video monitoring on the inpatient mental health unit, as required Veterans Health Administration Directive 1078, Privacy of Persons Regarding Photographs, Digital Images and Video or Audio Recordings.

The Facility Director develops and implements written processes to ensure compliance with state involuntary commitment requirements in Veterans Health Administration Directive 1160.06(1), Inpatient Mental Health Services.

The Chief of Staff requires documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications prior to administrationand develops a plan to monitor for sustained compliance, in accordance with Veterans Health Administration Directive 1004.01(3), Informed Consent for Clinical Treatments and Procedures.

The Chief of Staff ensures discharge instructions include appointment locations in easy-to-understand language, consistent with Veterans Health Administration’s “Clinic Profile Management Business Rules.”

The Facility Director requires all Interdisciplinary Safety Inspection Team members attend biannual inspections and record attendance consistent with Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Units Treating Suicidal Patients.  

The Facility Director directs the Interdisciplinary Safety Inspection Team to provide biannual inspection attendance to the Comprehensive Environment of Care Committee, as required by Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Units Treating Suicidal Patients.

The Facility Director ensures staff complete appeals within the required time frame in accordance with Veterans Health Administration Office of Mental Health Standard Operating Procedure 1167.1, “Standard Operating Procedure for Submission of MHEOCC [Mental Health Environment of Care Checklist] Inspections and Appeals Under VHA [Veterans Health Administration] Directive 1167.”

The Facility Director directs staff to complete the required Mental Health Environment of Care Checklist training as required by Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Units Treating Suicidal Patients.

The Facility Director develops and implements clearly defined written processes for providing mental health care to veterans on medical units.

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

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 include the appointment location in easy-to-understand language.

The Chief of Staff ensures discharge instructions are free of medical abbreviations and includes the purpose for each listed medication and develops a plan to monitor for sustained compliance.

The Chief of Staff directs staff to complete or review veterans’ suicide prevention safety plans prior to discharge from the acute inpatient mental health unit and develops a plan to monitor for sustained compliance.

The Facility Director ensures the Interdisciplinary Safety Inspection Team adheres to Veterans Health Administration requirements, including attendance at environment of care inspections, record of required members’ attendance at inspections in meeting minutes, and develops a plan to monitor for sustained compliance.

The Facility Director directs staff to complete the required Mental Health Environment of Care Checklist training.

The Healthcare System Director ensures the Mental Health Executive Council includes ongoing veteran representation, in accordance with Veterans Health Administration Directive 1160.01, Uniform Mental Health Services in VHA [Veterans Health Administration] Medical Points of Service.

The Associate Chief of Service, Mental Health ensures the local recovery coordinator serves in a full-time capacity, in accordance with Veterans Health Administration requirements Directive 1163, Psychosocial Rehabilitation and Recovery Services. 

The Healthcare System Director ensures the physical environment on the inpatient mental health unit reflects recovery-oriented principles according to Veterans Affairs’ Design Guide for Inpatient Mental Health & Residential Rehabilitation Treatment Program Facilities.

The Chief of Staff ensures compliance with Veterans Health Administration Directive 1004.01(3), Informed Consent for Clinical Treatments and Procedures requirements related to 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 include the follow-up mental health appointment location information in easy-to-understand language, in accordance with Veterans Health Administration’s “Clinic Profile Management Business Rules,” and develops a plan to monitor for sustained compliance.

The Chief of Staff ensures discharge instructions include the purpose for each listed medication, consistent with Veterans Health Administration Directive 1345, Medication Reconciliation, and develops a plan to monitor for sustained compliance.

The Chief of Staff ensures staff provide a copy of the suicide prevention safety plan to veterans upon discharge from the inpatient unit, in accordance with Veterans Health Administration Office of Mental Health and Suicide Prevention Standard Operating Procedure 1160.06.2, “Standard Operating Procedure for Core Clinical Processes on Inpatient Mental Health Units under VHA [Veterans Health Administration] Directive 1160.06,” and develops a plan to monitor for sustained compliance.

The Healthcare System Director instructs the Interdisciplinary Safety Inspection Team to record and report attendance of inspections to the Environment of Care Committee, as required by Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Mental Health Units Treating Suicidal Patients, and develops a plan to monitor for sustained compliance.

The Healthcare System Director develops and implements a plan to monitor Mental Health Environment of Care Checklist training completion for sustained compliance, consistent with Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Mental Health Units Treating Suicidal Patients.

The Healthcare System Director ensures that Mental Health Environment of Care Checklist training completion attestation is accurately documented, in accordance with Veterans Health Administration Office of Mental Health Standard Operating Procedure 1167.2, “Standard Operating Procedure for Submission of MHEOCC [Mental Health Environment of Care Checklist] Attestations Under VHA [Veterans Health Administration] Directive 1167,” and develops a plan to monitor for sustained compliance.

The Healthcare System Director ensures the Mental Health Executive Council includes veteran representation, in accordance with Veterans Health Administration Directive 1160.01, Uniform Mental Health Services in VHA [Veterans Health Administration] Medical Points of Service.

The Chief of Mental Health ensures staff develop and implement a local standard operating procedure for staff education and training on recovery-oriented care, consistent with Veterans Health Administration Directive 1160.06(1), Inpatient Mental Health Services.

The Chief of Mental Health ensures the local recovery coordinator conducts reviews of inpatient training material to maintain a recovery-oriented approach, in accordance with Veterans Health Administration Directive 1163, Psychosocial Rehabilitation and Recovery Services.

The Chief of Mental Health considers consultation with the Office of Mental Health to ensure facility policy aligns with Veterans Health Administration Directive 1160.06(1), Inpatient Mental Health Services, on veterans’ access to personal clothing on the inpatient units.

The Chief of Mental Health ensures a minimum of four daily hours of recovery-oriented, interdisciplinary programming on the inpatient mental health units, consistent with Veterans Health Administration Directive 1160.06(1), Inpatient Mental Health Services, and develops a plan to monitor for sustained compliance.

The Healthcare System Director develops and implements written processes to ensure compliance with involuntary commitment requirements, in accordance with Veterans Health Administration Directive 1160.06(1), Inpatient Mental Health Services.

The Chief of Staff ensures compliance with Veterans Health Administration Directive 1004.01(3), Informed Consent for Clinical Treatments and Procedures, requirements related to 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 include the appointment location in easy-to-understand language, consistent with Veterans Health Administration’s “Clinic Profile Management Business Rules.”

In accordance with Veterans Health Administration Directive 1345, Medication Reconciliation, and Veterans Health Administration Health Information Management’s Health Record Documentation Program Guide Version 1.3, the Chief of Staff ensures discharge instructions include the purpose and dosing information for each listed medication in easy-to-understand language and develops a plan to monitor for sustained compliance.

The Chief of Staff directs staff to complete the Columbia-Suicide Severity Rating Scale within 24 hours before veterans’ discharge, consistent with Department of Veterans Affairs (VA) Suicide Risk Identification Strategy Minimum Requirements by Setting, and develops a plan to monitor for sustained compliance.

The Chief of Staff directs staff to complete or review veterans’ suicide prevention safety plans prior to discharge from the inpatient mental health units, in accordance with Veterans Health Administration Office of Mental Health and Suicide Prevention Standard Operating Procedure 1160.06.2, “Standard Operating Procedure for Core Clinical Processes on Inpatient Mental Health Units under VHA [Veterans Health Administration] Directive 1160.06,” and develops a plan to monitor for sustained compliance.

The Healthcare System Director directs staff to complete required suicide prevention training, according to the “Office of Suicide Prevention Suicide Prevention Mandatory Training Dashboard FAQ [Frequently Asked Questions],” and develops a plan to monitor for sustained compliance.

The Healthcare System Director instructs the Interdisciplinary Safety Inspection Team to adhere to Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Mental Health Units Treating Suicidal Patients, requirements related to attendance at inspections and record of attendance in meeting minutes, and develops a plan to monitor for sustained compliance.

The Healthcare System Director implements processes to ensure Interdisciplinary Safety Inspection Team staff accurately identify and document safety hazards, in accordance with Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Mental Health Units Treating Suicidal Patients.

The Healthcare System Director directs inpatient staff and Interdisciplinary Safety Inspection Team members to complete Mental Health Environment of Care Checklist training requirements, consistent with Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Mental Health Units Treating Suicidal Patients, and develops a plan to monitor for sustained compliance.

The Healthcare System Director ensures that Mental Health Environment of Care Checklist training completion is documented in attestations, in accordance with Veterans Health Administration Office of Mental Health Standard Operating Procedure 1167.2, “Standard Operating Procedure for Submission of MHEOCC [Mental Health Environment of Care Checklist] Attestations Under VHA Directive 1167,” and develops a plan to monitor for sustained compliance.

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.

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

The Associate Chief of Staff, Mental Health ensures the development and implementation of written processes for staff training, education, and recovery-oriented services.

The Associate Chief of Staff, 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 discharge instructions for veterans include appointment locations in easy-to-understand language.

The Facility Director directs staff to comply with VA S.A.V.E. training requirements and monitors for compliance.

The Facility Director directs inpatient unit staff, volunteers, and Interdisciplinary Safety Inspection Team members to comply with Mental Health Environment of Care Checklist training requirements and monitors for compliance.

The Facility Director establishes a mental health executive council that operates in accordance with Veterans Health Administration requirements.

The Facility Director ensures development and implementation of a multi-year recovery transformation plan.

The Associate Chief of Staff for Behavioral Health ensures a minimum of four hours of recovery-oriented, interdisciplinary programming on weekdays and weekends on the inpatient mental health units.

The Facility Director ensures inpatient mental health units are in good repair and the environment reflects recovery-oriented principles.

The Facility Director ensures veterans’ privacy in restraint rooms on the inpatient mental health units.

The Associate Chief of Staff for Behavioral Health develops written guidance to ensure staff and veterans’ safety during outdoor breaks.

The Facility Director formalizes processes to monitor and track compliance with state involuntary commitment laws.

The Chief of Staff ensures the completion of comprehensive inpatient mental health treatment plans and monitors for compliance.

The Chief of Staff ensures documentation of discussions between prescribers and veterans on the risks and benefits of newly prescribed medications and monitors for compliance.

The Chief of Staff ensures mental health treatment coordinators are included in care coordination.

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 the purpose for each listed medication 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 ensures staff complete the Columbia-Suicide Severity Rating Scale within 24 hours before discharge and monitors for compliance.

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

The Facility Director ensures staff comply with timely completion of VA S.A.V.E. training requirements and monitors for compliance.

The Facility Director ensures the Interdisciplinary Safety Inspection Team adheres to Veterans Health Administration requirements, including recording meeting minutes and including all required members, and monitors for compliance.

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

The Facility Director ensures staff address identified Mental Health Environment of Care Checklist deficiencies in accordance with Veterans Health Administration guidelines and monitors for compliance.

The Facility Director ensures Interdisciplinary Safety Inspection Team members comply with Mental Health Environment of Care Checklist training requirements and monitors for compliance.

The Facility Director ensures the mental health executive council operates in accordance with VHA requirements.

The Chief of Mental Health identifies barriers and implements processes to provide a minimum of four hours of recovery-oriented, interdisciplinary programming on weekends on the inpatient mental health unit and monitors for compliance.

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

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

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

The Chief of Staff directs staff to complete the Columbia-Suicide Severity Rating Scale within 24 hours before discharge and monitors for compliance.

The Chief of Staff directs staff to complete or review safety plans with veterans prior to discharge and monitors for compliance. 

The Chief of Staff directs staff to address ways to make the veteran’s environment safer from potentially lethal means in safety plans and monitors for compliance. 

The Facility Director directs staff to comply with Lethal Means Safety training and monitors for compliance. 

The Facility Director directs staff to comply with Skills Training for Evaluation and Management of Suicide training and monitors for compliance. 

The Facility Director directs staff to comply with VA S.A.V.E. training and monitors for compliance. 

The Facility Director ensures Interdisciplinary Safety Inspection Team requirements are met and monitors for compliance. 

The Facility Director implements processes to ensure the Interdisciplinary Safety Inspection Team applies Mental Health Environment of Care Checklist standards to all sections on the inpatient mental health unit and monitors for compliance. 

The Facility Director uses VHA guidelines to develop a facility-specific policy for the use of restraint chairs. 

The Facility Director directs staff to comply with Mental Health Environment of Care Checklist training requirements and monitors for compliance. 

The VA Central Western Massachusetts Healthcare System Director establishes a mental health executive council that operates in accordance with VHA requirements.

The VA Central Western Massachusetts Healthcare System Director ensures staff consistently solicit and incorporate veteran feedback into process improvements.

The VA Central Western Massachusetts Healthcare System Chief of Mental Health develops written guidance to ensure staff and veteran safety during outdoor breaks.

The VA Central Western Massachusetts Healthcare System Director ensures the development of written processes for the admission of veterans on an involuntary hold and monitors and tracks compliance with involuntary commitment requirements.

The VA Central Western Massachusetts Healthcare 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 compliance.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures discharge instructions for veterans include follow-up appointment location and contact information in easy-to-understand language.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures discharge instructions include the purpose for each medication listed and are written in easy-to-understand language.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures staff complete the Columbia-Suicide Severity Rating Scale within 24 hours before discharge and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures staff address ways to make veterans’ environments safer from potentially lethal means in safety plans and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Director ensures staff comply with Skills Training for Evaluation and Management of Suicide requirements and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Director establishes an interdisciplinary safety inspection team in alignment with Veterans Health Administration requirements and ensures ongoing compliance.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures that the sally port inpatient unit doors are synchronized and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Director uses VHA guidelines to develop facility-specific policy for the use of restraint chairs.

The VA Central Western Massachusetts Healthcare System Director ensures alignment between physical restraint policies and practices.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures mental health leaders update inpatient unit furniture to meet safety requirements and implements processes to reduce associated safety risks.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures compliance with VHA requirements for Mental Health Environment of Care Checklist training completion.

The Lieutenant Colonel Charles S. Kettles VA Medical Center Director ensures that service chiefs responsible for required invasive procedure infrastructure services ensure the completion of the annual review of infrastructure and that existing infrastructure is accurately reported.

The VA Healthcare System Serving Ohio, Indiana, and Michigan Network Director ensures that requirements and processes for invasive procedure complexity infrastructure waiver requests are clearly communicated to facility leaders.

The VA Healthcare System Serving Ohio, Indiana, and Michigan Network Director reviews the process for tracking invasive procedure complexity infrastructure waiver requests, and takes actions as needed to avoid delays in review and submission.

The Under Secretary for Health ensures that guidance provided to Veterans Integrated Service Network and facility leaders regarding the invasive procedure complexity infrastructure waiver request process is clear and consistent with Veterans Health Administration Directive 1220(1).

The Lieutenant Colonel Charles S. Kettles VA Medical Center Director confirms that acute and emergent patient transfer times related to waived infrastructure requirements are tracked and monitored, identifies trends or adverse patient outcomes, and takes actions as warranted.

The Lieutenant Colonel Charles S. Kettles VA Medical Center Director directs the chief of surgery, or designee, to attend blood utilization review committee meetings per facility requirements, and ensures compliance.

The Lieutenant Colonel Charles S. Kettles VA Medical Center Director reviews the care provided to patient B to confirm compliance with Veterans Health Administration Directive 1004.08, determines if an institutional disclosure is warranted, and takes action as required.

The Under Secretary for Health reviews Veterans Health Administration Directive 1400.01 to confirm that the supervision of PGY-1 surgery residents and guidance provided to Veterans Health Administration facilities aligns with Veterans Health Administration policy and Accreditation Council for Graduate Medical Education program requirements.

The Lieutenant Colonel Charles S. Kettles VA Medical Center Director ensures that operative documentation is completed per facility policy, reviews the methodology for monitoring operative documentation compliance, and takes action as necessary.

The Lieutenant Colonel Charles S. Kettles VA Medical Center Director reviews and monitors staff and health professional trainee compliance with the rules of behavior as it applies to authorized access to all VA computer programs including clinical applications.

The Under Secretary for Health evaluates the process for granting authorized access to VA computer systems for health profession trainees and takes steps to ensure access is provided by the start of trainee rotations at VA facilities.

The VA Healthcare System Serving Ohio, Indiana, and Michigan Network Director ensures the corrective actions developed by facility leaders to address surgical intensive care unit patient safety concerns are completed and evaluated for effectiveness.

The VA Montana Healthcare System Director reviews Community Living Center physician coverage to identify barriers and gaps, determines options for resolution, and completes and executes a coverage plan to ensure residents’ care and staff’s needs are met when the physician is not available for extended periods.

The VA Montana Healthcare System Director reviews Community Living Center physical therapy staffing to identify barriers and gaps, determines options for resolution, and completes and executes a hiring plan to ensure residents’ care and staff’s needs are met.

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

The Hampton VA Medical Center Director conducts focused clinical care reviews in accordance with Veterans Health Administration requirements, and monitors for compliance.

The Hampton VA Medical Center Director ensures that summary suspensions are conducted in accordance with Veterans Health Administration policy, and monitors for compliance.

The Hampton VA Medical Center Director confirms that proposed reduction or revocation of privileges complies with Veterans Health Administration policies and procedures, and monitors for compliance.

The Hampton VA Medical Center Director complies with Veterans Health Administration requirements when reporting licensed independent practitioners to state licensing boards.

The Hampton VA Medical Center Director completes a review of Medical Executive Committee meeting minutes and ensures recommendations made for focused professional practice evaluations for cause for licensed independent practitioners have been completed according to Veterans Health Administration requirements.

The Hampton VA Medical Center Director ensures that, when providers are transitioned from an initial focused professional practice evaluation to an ongoing professional practice evaluation, the transition is reported and documented as required by Veterans Health Administration policy, and monitors for compliance.

The Hampton VA Medical Center Director ensures that ongoing professional practice evaluations include documentation of all conclusionary outcomes required by Veterans Health Administration policy.

The Hampton VA Medical Center Director ensures surgical staff have an understanding of Veterans Health Administration Joint Patient Safety Reporting submissions and tracks submissions specific to Surgical Service, and monitors for compliance.

The Hampton VA Medical Center Director completes a comprehensive review of surgical morbidity and mortality conferences and ensures facility policy and practice is in alignment with Veterans Health Administration policy and, as necessary, consults with Veterans Health Administration’s National Surgery Office and Veterans Integrated Service Network leaders, and monitors for compliance.

The Hampton VA Medical Center Director ensures that the chief of surgery has a process to identify potential cases for peer review and communicates those cases to the appropriate program staff.

The Mid-Atlantic Veterans Integrated Service Network Director confirms the Hampton VA Medical Center Director ensures that management reviews and peer reviews, if both indicated for the same incident of care, are conducted in accordance with Veterans Health Administration policy, and are not conducted concurrently.

The Hampton VA Medical Center Director considers seeking guidance from the Office of General Counsel to determine the appropriate time frame for ensuring all required elements for previously completed institutional disclosures have been met.

The Under Secretary for Health makes certain the Veterans Health Administration complies with requirements that all acute sexual assault victim-survivors are offered prophylaxis for sexually transmitted infection when clinically indicated and monitors compliance.

The Under Secretary for Health verifies compliance with Veterans Health Administration requirements that all acute sexual assault victim-survivors are offered prophylaxis for pregnancy when clinically indicated and monitors compliance.

The Under Secretary for Health ensures all sexual assault victim-survivors are offered mental health resources, either directly through Veterans Health Administration or through the community and monitors compliance.

The Under Secretary for Health ensures compliance with Veterans Health Administration requirements for documentation of signature informed consent for forensic examinations conducted by staff at Veterans Health Administration facilities and monitors compliance.

The Under Secretary for Health coordinates with VA Office of Security and Law Enforcement to provide direction that facility policy or guidance include facility and jurisdiction-specific information necessary for frontline staff to act in accordance with jurisdiction and Veterans Health Administration requirements for VA police responding to sexual assaults.

The Under Secretary for Health ensures Veterans Health Administration’s policy specifies the required elements to include in Veterans Health Administration facilities’ policies or guidance on acute sexual assault, including jurisdiction-specific requirements, and considers an online national policy with an appendix containing each facility’s supplemental information.

The Under Secretary for Health makes certain that facility level management of acute sexual assault policy or guidance is updated to incorporate information on facility-specific resources and jurisdictional requirements as warranted, and educates staff as needed.

The Under Secretary for Health ensures that VA Police Chiefs review facility policy and guidance for police responding to sexual assaults and update to incorporate information on facility-specific resources and processes, including jurisdictional requirements, as warranted, and educates facility police officers as needed.

The Under Secretary for Health collaborates with the region 2 third-party administrator to ensure that community care providers submit documentation of care to the Veterans Health Administration including treatments provided specific to opioid risk mitigation (urine drug screening, prescription drug monitoring program checks) and all prescriptions, to include urgently/emergently prescribed opioids and utine/maintenance opioid prescriptions.

The VA Eastern Kansas Health Care System Director ensures system providers document evidence of Opioid Safety Initiative risk-mitigation strategies for patients who are on long-term opioids, as required by Veterans Health Administration policy.

The Under Secretary for Health develops and implements action requiring community care network providers to document evidence of application of Opioid Safety Initiative risk mitigation strategies when treating a veteran to whom they have rescribed opioids, and monitor compliance as part of their Community Provider Opioid Prescribing Practice reviews.

The Under Secretary for Health develops and implements action requiring community care network providers to conduct and document completion of state prescription drug monitoring program queries consistent with VHA policy, prior to prescribing controlled substances, regardless of whether the prescriptions are urgent, emergent, routine or maintenance prescriptions and monitor compliance as part of their Community Provider Opioid Prescribing Practice reviews.

The Under Secretary for Health considers issuing formal guidance to all Veterans Health Administration pharmacy staff regarding best practices for conducting state prescription drug monitoring program queries upon receipt of controlled substance prescriptions from community care network providers.

The Under Secretary for Health develops and implements a process to oversee compliance of VHA’s medication reconciliation process for patients receiving care in the community who are prescribed opioids to include recording of the prescriptions in the non-VA medication section of the medication profile.

The Under Secretary for Health considers options and implements a process for including non VA medications prescribed by community care providers in the data populating the opioid safety tools.

The VA Eastern Kansas Health Care System Director ensures that medications known to system staff are entered into the patient’s medication profile in the electronic health record.

The VA Heartland Network Director ensures the Veterans Integrated Service Network Community Care Oversight Council conducts oversight of community care network providers’ opioid prescribing practices and reports results through the Opioid Prescribing Community Providers’ SharePoint site.

The VA Heartland Network Director confirms that the VA Eastern Kansas Health Care System has a local process outlining expectations, roles, and responsibilities for completing reviews of community care network provider’s opioid prescribing practices and that the process is shared with system staff, initiated, and monitored.

The VA Eastern Kansas Health Care System Director continues efforts to recruit and hire staff to fill vacant pain management positions.

The Under Secretary for Health consults with the Office for Integrated Veteran Care to determine the value of including a review of community care network provider documentation for evidence of prescription drug monitoring program queries as a required element in VA’s Guidance for Community Provider Opioid Prescribing Practices Review.

The VA Eastern Kansas Health Care System Director ensures system staff and leaders are educated on the processes to report patient safety concerns involving community care network providers.