Mental Health Inspection of the VA Boston Healthcare System in Brockton, MA

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.