All Reports

The Director takes appropriate actions to maintain a clean environment to reduce the risk of infection, in accordance with Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Director takes appropriate actions so staff change privacy curtains to reduce the risk of infection and supervisors monitor compliance, in accordance with the facility’s Infection Prevention and Control Manual.

The Director takes appropriate action so staff update the facility policy for communicating test results and develop service-level workflows that describe team members’ roles in the process, as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Veterans Integrated Service Network Director and facility Director take appropriate action for the surveillance system to be fully operational.

The Director takes appropriate actions to secure portable liquid nitrogen tanks and store the tanks according to the National Fire Protection Association’s Compressed Gases and Cryogenic Fluids Code, NFPA 55 requirements.

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.

Develop and implement procedures to maintain stock within the required thresholds as outlined in Veterans Health Administration Directive 1761.

Ensure all relevant supply chain staff receive appropriate and recurring training and require supervisors to perform ongoing monitoring—including periodic inventory reviews and root‑cause analyses—to strengthen controls over VA supplies.

Develop and implement, in collaboration with the Veterans Integrated Service Network, local procedures that require custodial officers to notify supply chain staff when equipment is relocated, and establish protocols to validate and update equipment location and ensure equipment items are properly tagged.

Ensure expendable supplies labeled expired are, in fact, expired and appropriate documentation is completed before turning the supplies in.

Address the physical security issues discussed in this report and provide recurring training on proper physical security controls and procedures to individuals with authorized access to the primary inventory point and warehouses.

Evaluate contractor performance under the contracts awarded for inventory management systems in the Augusta VA Health Care System and take appropriate action to ensure performance in accordance with the contract and to recover funds.

Ensure supply chain management staff effectively address deficiencies identified during Veterans Integrated Service Network quality control reviews.

Confer with the VA Office of General Counsel to determine whether VA should assert a claim to recover the $11.2 million paid for services not received

Evaluate and take any needed actions to make sure policies and procedures require appropriate officials to accurately ascertain information security requirements for contracts that involve sensitive information prior to award.

Create and mandate standardized due process letters for clear and unmistakable errors and severance of service connection, drafted in compliance with 38 C.F.R. § 3.103.

Update procedures to require an enhanced level of review for all final decisions associated with proposed adverse actions resulting from clear and unmistakable errors so that decisions are compliant with 38 C.F.R. § 3.105 and the M21-1 Adjudication Procedures Manual.

Develop an automated report that periodically identifies proposed adverse actions without a final decision and applicable pending end product, and ensure identified cases are reviewed and resolved as appropriate, to maintain compliance with the M21-1 Adjudication Procedures Manual and the M21-4 Manual.

Correct all errors identified by this review as appropriate, so claim processing actions are compliant with 38 C.F.R. § 3.103 and 3.105, the M21-1 Adjudication Procedures Manual, and the M21-4 Manual.

The Wm. Jennings Bryan Dorn VA Medical Center Director ensures that all patients admitted to the intensive care unit receive access to continuous critical care, particularly after hours, and clearly defines the role and responsibilities of the on-site intensivist and TeleCritical Care in the care of surgical intensive care unit admissions.

The Wm. Jennings Bryan Dorn VA Medical Center Director ensures that in the absence of patient-specific orders for vital sign parameters that warrant provider notification, intensive care unit nurses adhere to facility policy for provider notification parameters.

The Wm. Jennings Bryan Dorn VA Medical Center Director reviews VHA Directive 1155(1), Treatment of Acute Ischemic Stroke, August 22, 2025, and ensures the facility is in full compliance with current stroke center designation requirements, including protocols for inpatient stroke response, diagnostic imaging, consultation, and transfer processes.

The Wm. Jennings Bryan Dorn VA Medical Center Director clarifies the qualifications for provider coverage in the intensive care unit and ensures all intensive care unit providers are appropriately privileged to deliver care in the intensive care unit prior to providing care.

The Wm. Jennings Bryan Dorn VA Medical Center Director determines whether providers delivered patient care in the intensive care unit without approved, current, facility‑specific privileges and, if so, completes required reviews and assessments in accordance with VHA requirements.

The Wm. Jennings Bryan Dorn VA Medical Center Director creates a process ensuring contract ICU physicians covering in the intensive care unit have access to the electronic health record for documentation and order writing from the start of their tour.

The Wm. Jennings Bryan Dorn VA Medical Center Director reviews this patient’s case and any associated quality management reviews, and if gaps are identified, develops an action plan to ensure quality management processes are completed in accordance with relevant VHA quality management directives.

Facility leaders take appropriate actions so staff develop a written workflow for each service that is consistent with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director takes appropriate actions so fire doors close completely and latch, as required by National Fire Protection Association 80 Standard for Fire Doors and Other Opening Protectives.

The Director takes appropriate actions so staff update the facility policy on test result communications to meet the requirements of Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director for Patient Care Services/Nurse Executive take appropriate actions so staff develop, for each service, written workflows consistent with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director takes appropriate actions for the Chief of Staff to review Patient Centered Management Module data and address efficiency, capacity, and staffing needs, in accordance with Veterans Health Administration Directive 1406(3), Patient Centered Management Module (PCMM) for Primary Care.

The Director develops workflows for all services that communicate test results to patients and includes the process for assigning designees (surrogates) for providers who order tests in the facility’s policy, as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Northport VA Medical Center Director considers reviewing the inclusion of psychotherapy extended-care caseload metrics into performance measures such as Focused Professional Practice Evaluations for Cause, and takes action as warranted.

The Northport VA Medical Center Director considers a strategy to review patients terminated from individual psychotherapy while the psychotherapist was on a Focused Professional Practice Evaluation for Cause, determines whether any harm occurred, and takes action as warranted.

The District Director monitors district leaders’ compliance with completion of morbidity and mortality reviews for client deaths by suicide, including timeliness, as required.

The District Director ensures district leaders are aware of the Readjustment Counseling Service policy requirements to provide oversight of morbidity and mortality review completion, including all review components, the appropriateness of recommendations, and reporting delays to the Deputy Chief Officer.

The Readjustment Counseling Service Chief Officer ensures morbidity and mortality review lessons learned are distributed nationally across Readjustment Counseling Service to support suicide prevention efforts.

The District Director identifies reasons for noncompliance with HRSF SharePoint-related RCSNet documentation requirements, ensures requirements are met, and monitors compliance.

The Readjustment Counseling Service Chief Officer ensures implementation of a planned solution to address the high risk suicide flag SharePoint site malfunction and ensures data accuracy and functionality as intended.

Implement comprehensive national policy on how staff should process enrollment applications that are missing information—including a firm and clear requirement that they enter incomplete applications in the Veterans Health Administration Enrollment System.

Coordinate with the Veterans Benefits Administration to identify opportunities to further streamline enrolling veterans in both administrations.

Define and implement guidelines for applications received at community-based outpatient clinics to make certain that they are processed consistently and promptly across the Veterans Health Administration.

Ensure the Health Eligibility Center regularly evaluates medical center enrollment practices.

Establish and implement procedures to make sure enrollment staff adhere to requirements in reviewing the records of veterans who may qualify for higher‑priority groups.

Standardize how Veterans Integrated Service Networks assess whether medical facilities are complying with Veterans Health Administration enrollment policies.

Determine whether enrollment coordinators nationwide should employ the Health Eligibility Center’s audit tool, and if so, direct that its use is required.

Define in policy how medical facility enrollment coordinators should conduct oversight.