All Reports

The VA Loma Linda Healthcare System Director ensures the Chief of Staff signs peer review designation memoranda within three days of determining a peer review is needed as outlined in Veterans Health Administration policy.

The VA Loma Linda Healthcare System Director ensures that focused professional practice evaluations for initial appointments and additional privileges are completed in accordance with Veterans Health Administration policy and monitors for compliance.

The VA Fayetteville Coastal Healthcare System Director confirms full implementation of the VA Community Care Oversight and Consult Management Council.

The Under Secretary for Health reviews practices and procedures for managing consults to identify and prioritize appointment scheduling for patients with serious health conditions (high‑priority consults), such as cancer, and provide direction to the field on the process to use to make this determination.

The VA Fayetteville Coastal Healthcare System Director directs the development and implementation of community care service standard operating procedures to address identification and management of high-priority consults, timeliness of consult processing, and care coordination that aligns with direction provided by Veterans Health Administration’s Integrated Veterans Care program.

The VA Fayetteville Coastal Healthcare System Director ensures staff are trained in all newly developed community care standard operating procedures and that adherence to policy and practice is monitored.

The VA Fayetteville Coastal Healthcare System Director confirms completion of a review of quality management processes to ensure quality management staff, when reviewing patient safety events, consider potential system issues and, if present, recommend they be addressed using other quality management reviews.

The VA Fayetteville Coastal Healthcare System Director ensures local processes are in place, including assigned roles and responsibilities, to manage Office of Inspector General case referrals in compliance with VA Directive 0701, Office of Inspector General Hotline Complaint Referrals.

The VA Fayetteville Coastal Healthcare System Director confirms reasonable efforts to conduct an institutional disclosure with the patient regarding circumstances that led to the delay in the diagnosis of and treatment for lung cancer are made and, if a disclosure is completed, that it is documented in the electronic health record.

The Under Secretary for Health assesses the electronic health record reviews completed by the system in response to the community care backlog to determine if a more comprehensive review is warranted with appropriate disclosure to patients placed at risk or harmed as a result of a delay in action on their community care consult, and takes action accordingly.

The Richard L. Roudebush VA Medical Center Director establishes a process to ensure that changes impacting the availability of clinical services to patients are clearly communicated to all relevant staff members.

The Richard L. Roudebush VA Medical Center Director ensures that residents, fellows, and clinical service leaders understand and follow the requirement to document complete and pertinent information, including assessments and recommendations, in patients’ electronic health records.

The Richard L. Roudebush VA Medical Center Director educates providers on the requirements related to completing a clinical disclosure when an adverse event occurs, such as a delay in care.

The Richard L. Roudebush VA Medical Center Director ensures the episode of care related to the patient’s transfer is reviewed to determine whether an institutional disclosure is needed in accordance with Veterans Health Administration requirements, and takes action as warranted.

The Richard L. Roudebush VA Medical Center Director monitors to ensure that Joint Patient Safety Reporting system reports are included or rejected in accordance with Veterans Health Administration guidance.

The Richard L. Roudebush VA Medical Center Director ensures a comprehensive review of the patient’s care and transfer is completed to identify factors that contributed to the patient’s unnecessary transfer and takes action as warranted.

The Oklahoma City VA Health Care System Director, with Pathology and Laboratory Medicine Service leaders, conducts a comprehensive review of the quality of care for the four patients identified in this report, including determinations of cytopathology processing delays and assessment of patient harm, and takes action as warranted.

The Oklahoma City VA Health Care System Director ensures that routine non-gynecological turnaround time corrective actions are documented and monitored for effectiveness, as required by the Veterans Health Administration.

The Oklahoma City VA Health Care System Director conducts a comprehensive review of the quality of care provided by the Chief of Pathology and Laboratory Medicine Service, identifies deficiencies, and takes action as warranted. 

The Oklahoma City VA Health Care System Director reviews the Pathology and Laboratory Medicine Service event reporting requirements for variance events and ensures completion according to facility policy and Veterans Health Administration requirements.

The Oklahoma City VA Health Care System Director, in conjunction with the National Center for Patient Safety, evaluates patient safety event reporting processes within the Pathology and Laboratory Medicine Service, and ensures completion according to Veterans Health Administration requirements.

The Veterans Integrated Service Network Director develops and implements a plan to provide sustained support and oversight in a constructive manner to the VA Dublin Healthcare System leaders and programs.

The Veterans Integrated Service Network Director ensures that following Veterans Integrated Service Network site reviews with findings, Veterans Integrated Service Network staff review the associated VA Dublin Healthcare System action plans to confirm proposed actions adequately address findings, track action items through implementation, evaluate effectiveness to ensure resolution, and monitor for sustainment.

The Under Secretary for Health considers standardizing the Veterans Integrated Service Network Chief Medical Officer’s and Chief Nursing Officer’s role and responsibilities to include the authority to hold systems leaders accountable for resolving identified deficiencies.

The VA Nebraska—Western Iowa Health Care System Director ensures the installation of night lighting changes to accommodate patient comfort and facility staff’s ability to safely conduct rounding in applicable inpatient mental health unit patient rooms.

The VA Nebraska—Western Iowa Health Care System Director ensures establishment and implementation of guidance related to the facility inpatient mental health unit staff’s use and security of handheld flashlights to ensure appropriate education and training of handheld flashlights usage and storage.

The VA Nebraska—Western Iowa Health Care System Director establishes and ensures implementation of a patient safety observation rounds standard operating procedure consistent with Veterans Health Administration requirements.

The VA Nebraska—Western Iowa Health Care System Director reviews facility Mental Health Environment of Care Checklist processes related to development of mitigation plans as required by the Veterans Health Administration, and monitors compliance.

The VA Nebraska—Western Iowa Health Care System Director ensures compliance with Veterans Health Administration staffing requirements for areas identified as high-risk, such as the inpatient mental health unit, and monitors compliance.

The Under Secretary for Health evaluates the Veterans Health Administration written guidance for high-risk workplace staffing and determines if clarification is needed.

The VA Nebraska—Western Iowa Health Care System Director ensures staff that may provide coverage on the inpatient mental health unit receive applicable Prevention and Management of Disruptive Behavior training for high-risk units.

The VA Nebraska—Western Iowa Health Care System Director strengthens processes to ensure that supervisors are made aware of staff members that have not completed the applicable Prevention and Management of Disruptive Behavior training for high-risk units, to include the hands-on component, and monitors compliance.

The Under Secretary for Health considers written guidance regarding risk for violence assessment use in units identified as a high-risk workplace that can be used to temporarily change a unit’s acuity level and staffing needs.

The VA Nebraska—Western Iowa Health Care System Director reviews and ensures consistent application of facility nursing leaders’ use of risk for violence assessment on the inpatient mental health unit, and monitors for compliance.

The VA Nebraska—Western Iowa Health Care System Director evaluates the root cause analysis processes regarding reporting of action items and outcome measures in accordance with Veterans Health Administration requirements, takes action as needed, and monitors compliance.

The VA Nebraska—Western Iowa Health Care System Director evaluates processes requesting and reporting changes to authorized and operating beds on the inpatient mental health unit, takes action as needed, and monitors compliance.

The VA Midwest Health Care Network Director strengthens processes to ensure adequate oversight and adherence to Veterans Health Administration requirements pertaining to changes to authorized and operating inpatient mental health unit beds.

The New York/New Jersey VA Healthcare Network Director evaluates the circumstances that led to Network and Syracuse VA Medical Center leaders not following clinical restructuring requirements according to VHA Directive 1043.

The Syracuse VA Medical Center Director evaluates the implementation of high reliability organization principles when communicating changes to clinical operations that include stakeholders, service and section leaders, and staff input.

The Syracuse VA Medical Center Director evaluates facility contract processes and takes action to ensure leaders maintain adequate oversight of contracting milestones.

The Syracuse VA Medical Center Director evaluates the communication of established contingency plans and ensures alignment with high reliability organization principles.

The Syracuse VA Medical Center Director ensures the monitoring and evaluation of patient transfers according to Veterans Health Administration Directive 1094(1) and takes action as warranted.

The Syracuse VA Medical Center Director ensures annual procedural complexity designation infrastructure reviews are completed accurately and ensures administrative actions are performed as required.

The New York/New Jersey VA Healthcare Network Director evaluates fiscal year 2026 procedural complexity designation infrastructure reviews for all Veterans Integrated Service New York/New Jersey VA Health Care Network facilities and takes action to ensure reviews are accurate and deficiencies are addressed as required.

The Under Secretary for Health ensures a timeliness expectation for infrastructure waiver submissions pursuant to Veterans Health Administration Directive 1220(1).

The Marion VA Health Care System Director ensures a review is conducted of the care provided to the patient by the primary care provider and the neurologist, consults with Human Resources and General Counsel Offices, and takes action as warranted. 

The Marion VA Health Care System Director ensures primary care nursing staff’s adherence to facility fall prevention policy and monitors compliance.

The Marion VA Health Care System Director evaluates the facility fall prevention policy to consider expectations for mental health staff’s role in responding to patient reports of falls at home. 

The Marion VA Health Care System Director reviews processes to ensure primary care and specialty care staff are appropriately educated and trained on making referrals to and the services available through the facility’s Traumatic Brain Injury Polytrauma Clinic.

The Marion VA Health Care System Director ensures compliance with the primary care program facility policy concerning specialty consultation staff’s communication with a patient’s primary care provider regarding patient concerns.

The Marion VA Health Care System Director ensures compliance with the facility patient problem list standard operating procedure. 

The Marion VA Health Care System Director strengthens processes to ensure compliance with Veterans Health Administration timeliness standards for obtaining and scanning community care records.

The Marion VA Health Care System Director reviews facility care coordination practices between primary care providers and community care providers, identifies barriers to sharing patient treatment information to inform clinical decision-making, and takes action as warranted. 

The Marion VA Health Care System Director ensures community care staff adhere to requirements regarding completion of community care-care coordination plan notes and monitors compliance.

The Marion VA Health Care System Director conducts a review of the facility primary care scheduling processes to ensure compliance with Veterans Health Administration and facility policy on care coordination within Patient Aligned Care Teams. 

The Marion VA Health Care System Director ensures suicide prevention staff document high-risk flag inactivation within patients’ electronic health records and notify patients when a high-risk flag is activated or inactivated as required by the Veterans Health Administration, and monitors compliance.

The Marion VA Health Care System Director ensures mental health staff adhere to Veterans Health Administration requirements on safety planning during high risk for suicide patient record flag patient contacts.

The Marion VA Health Care System Director evaluates the care provided to the patient, determines if an institutional disclosure is warranted, and takes action as indicated.

The VA Detroit Healthcare System Director ensures pathology and laboratory medicine service leaders communicate feedback regarding staff-specific errors to facilitate staff learning and according to Veterans Health Administration high reliability organization guidance.

The VA Detroit Healthcare System Director evaluates the quality and patient safety service response to patient safety events, including tracking and monitoring of service level corrective action plans to ensure timely resolution of patient safety events, and takes action as necessary.

The VA Detroit Healthcare System Director verifies pathology and laboratory medicine service leaders demonstrate clear communication of the laboratory quality management technologist roles and responsibilities in accordance with Veterans Health Administration requirements.

The VA Detroit Healthcare System Director ensures the pathology and laboratory medicine service will sustain oversight of manual complete blood count with differential reads for accuracy via retrospective pathologist secondary reviews.

The VA Detroit Healthcare System Director makes certain that pathology and laboratory medicine service leaders track variance reporting and ensure completion of applicable corrective action in accordance with facility policy and Veterans Health Administration requirements.

The San Francisco Healthcare System Director confirms the Sierra Pacific Veterans Integrated Service Network Clinical Resource Hub sleep medicine licensed independent practitioners are privileged in accordance with policy and monitors for compliance.

The Sierra Pacific Veterans Integrated Service Network Director ensures Sierra Pacific Veterans Integrated Service Network leaders and San Francisco Healthcare System leaders are educated on Veterans Health Administration policies regarding actions required following licensed independent practitioners’ lapse in privileges.

The Sierra Pacific Veterans Integrated Service Network Director confirms the San Francisco Healthcare System and the Sierra Pacific Veterans Integrated Service Network Clinical Resource Hub leaders complete a review of clinical care rendered by physicians with lapsed privileges as required by the Veterans Health Administration directive.

The Under Secretary for Health ensures the Veterans Health Administration National Program Director, Sleep Medicine and the National Sleep Medicine Field Advisory Board review sleep medicine privileges and provide national guidance for sleep medicine physicians who seek other specialty privileges.

The San Francisco Healthcare System Director ensures that the Sierra Pacific Veterans Integrated Service Network Clinical Resource Hub director addresses sleep medicine physicians’ concern of potential for disruptions in sleep medicine services without dual privileges and notifies sites receiving Sierra Pacific Veterans Integrated Service Network Clinical Resource Hub services if sleep medicine privilege changes will disrupt services.

The Lexington VA Healthcare System Director ensures emergency department, mental health, and inpatient medical and nursing staff responsible for suicide risk assessment understand the need to evaluate patients for a personally owned insulin pump and remove the insulin pump prior to inpatient admission, when necessary and monitors for compliance.

The Lexington VA Healthcare System Director verifies the draft insulin pump policy is finalized, and Lexington VA Healthcare System emergency department, mental health, and inpatient medical and nursing staff are educated on the policy.

The Lexington VA Healthcare System Director ensures leaders and staff review the Lexington VA Healthcare System policy evaluation and approval procedure.

The Lexington VA Healthcare System Director verifies that patients receive discharge instructions, with a follow-up care plan when discharged from the Lexington VA Healthcare System emergency department.

The Lexington VA Healthcare System Director ensures a review of Psychiatrist 2’s documentation in Patient 2’s electronic health record and makes certain documentation is completed according to Veteran Health Administration policy, including that entries are accurate, succinct, without extensive copy and paste, and devoid of derogatory, critical, comments, and takes action as warranted.

The Lexington VA Healthcare System Director confirms that the patient safety managers understand and apply Veteran Health Administration guidance to accurately use safety assessment codes when scoring a patient safety event.

The Lexington VA Healthcare System Director verifies that root cause analyses are completed according to Veterans Health Administration policy including interviewing individuals knowledgeable about the event.

The Lexington VA Healthcare System Director ensures peer representation at the Peer Review Committee for psychiatry case reviews.

The VA Greater Los Angeles Healthcare System Director considers conducting peer reviews for the clinical staff involved in the patient’s care from day 30 through day 32, to identify opportunities to strengthen clinical practices and improve the quality of patient care.

The VA Greater Los Angeles Healthcare System Director ensures that inpatient nurses receive training on the National Early Warning Signs assessment related to the assessment’s administration, intervention, escalation, and documentation; establishes a process to monitor inpatient nurses’ adherence; and conducts audits to ensure improved and sustained compliance.

The VA Greater Los Angeles Healthcare System Director ensures nursing staff have knowledge of and timely access to the accurate names and contact numbers for patients’ on-call provider teams and the medical officer of the day, and addresses and closely monitors discrepancies as warranted.

The VA Greater Los Angeles Healthcare System Director reviews [Standard Operating Procedure] SOP-00-QM-100, Clinical and Administrative Escalation Process, May 28, 2025; ensures the procedure meets facility and service-line needs; and confirms information is disseminated to relevant leaders, providers, and nursing staff.

The VA Greater Los Angeles Healthcare System Director ensures nursing shift assessments electronic health record documentation is completed, timely, and at frequencies required by Veterans Health Administration’s nursing policies and procedures; takes corrective action as indicated; and establishes a process to monitor for improved and sustained compliance.

The VA Greater Los Angeles Healthcare System Director evaluates the circumstances surrounding the death of the patient to ensure completion of comprehensive quality review process(es) in alignment with Veterans Health Administration standards on patient safety and high reliability that identify root causes and provide actions that enhance patient safety and mitigate similar events.

The VA Greater Los Angeles Healthcare System Director confirms that facility staff made reasonable efforts to conduct an institutional disclosure with the patient’s family.

The VA New York Harbor Healthcare System Director reviews facility processes to ensure medical and psychosocial health care for residents who report abuse, and staff are educated on the requirements.

The VA New York Harbor Healthcare System Director ensures that community living center nursing leaders and factfinding investigators complete factfindings in accordance with Veterans Health Administration policy.

The VA New York Harbor Healthcare System Director reviews responses to other incidents of suspected abuse and ensures actions are completed for resolution, including notifications.

The VA New York Harbor Healthcare System Director ensures community living center staff are compliant with Veterans Health Administration Prevention and Management of Disruptive Behavior Program education and training requirements.

The VA New York Harbor Healthcare System Director ensures community living center nursing and clinical staffs’ electronic health records documentation meets requirements for timeliness, accuracy, and completion, and takes action as needed.

The Under Secretary for Health ensures that VHA abuse policy addresses compliance with federal statutes and regulations, including 42 C.F.R. § 483.12, and outlines suspected elder abuse processes to notify leaders, interdisciplinary care team members, VA Police, patients’ families or designees, and state regulatory agencies; and identifies roles and responsibilities of reviewing officials for investigative reviews.

The VA New York Harbor Healthcare System Director ensures system abuse policies include required elements to comply with Veterans Health Administration, state, and federal regulations, including 42 C.F.R. § 483.12; and clearly outlines processes for leaders and staff when responding to suspected abuse related to reporting (for example, to interdisciplinary care team members, VA Police, family or designee, and state regulatory agencies); and conducting factfinding investigations.

The VA Fayetteville Coastal Healthcare System Director reviews the endocrine consult management process and takes actions as needed to ensure compliance with current Veterans Health Administration directives and guidance.

The VA Fayetteville Coastal Healthcare System Director implements a strategy to review patients affected by delayed endocrine consults to evaluate whether harm occurred and the appropriateness of institutional disclosures.

The VA Fayetteville Coastal Healthcare System Director ensures a sustainable and effective service line agreement between endocrine and primary care services is developed and agreed upon by both services, and monitors implementation.

The VA Fayetteville Coastal Healthcare System Director confirms effective utilization of endocrine clinic appointments to ensure timely access to care.

The VA Fayetteville Coastal Healthcare System Director ensures a process is in place for monitoring and tracking clinic profile modification requests.

The VA Mid-Atlantic Health Care Network Director reviews the leadership performance of the chief of medicine related to communication and collaboration and takes action as necessary.

The VA Fayetteville Coastal Healthcare System Director evaluates communication gaps identified in this report between leaders of primary care and the Medicine Service and takes action to ensure consistency with Veterans Health Administration High Reliability Organization goals.

The Overton Brooks VA Medical Center Director conducts a comprehensive review of the patient’s hospitalization and takes action as indicated, including quality management improvement processes such as a peer review.

The Overton Brooks VA Medical Center Director ensures medical staff recognize the importance of obtaining hospitalized patients’ non-VA medical records and assesses the current processes for obtaining non-VA medical records, identifies any barriers to completion, and takes action as warranted.

The Overton Brooks VA Medical Center Director assesses the application of the one-to-one observation policy and practices at the facility, and takes action as warranted.

The Overton Brooks VA Medical Center Director reviews interim behavioral patient record flag processes to ensure implementation of safety strategies for staff and patients, and takes action as warranted.

The Overton Brooks VA Medical Center Director evaluates whether documentation of patient and patient-related behavioral events are reflected accurately in the electronic health record to facilitate continuity of care and communication among medical staff and takes action as necessary.

The VA Southern Nevada Healthcare System Director ensures that clinical service chiefs take action to address concerns substantiated in factfindings, and that all patient safety concerns identified in factfindings are reviewed and addressed.

The VA Southern Nevada Healthcare System Director evaluates the need for additional factfinders, and takes action as warranted.

The VA Southern Nevada Healthcare System Director ensures that clinical service chiefs take action timely when aware of patient safety concerns.

The VA Southern Nevada Healthcare System Director reviews the information outlined in this report, determines the need to initiate the state licensing board reporting process, and takes action as warranted.

The VA Southern Nevada Healthcare System Director requires clinical service chiefs and credentialing and privileging managers to receive education on the completion of provider exit review forms and that, when supervisory staff contact credentialing and privileging staff for initiation of the state licensing board reporting process, a process is in place to ensure the message is clear and received.

The VA Southern Nevada Healthcare System Director ensures that clinical service chiefs and staff are educated on the need and process for submitting Joint Patient Safety Reporting reports upon awareness of patient safety events in accordance with facility policy.

The VA Southern Nevada Healthcare System Director educates the Chief of Staff on the need to complete management reviews when warranted, ensures that a review occurs of the dental hygienist’s care of Patient C, and ensures disclosure is provided if warranted.

The VA Southern Nevada Healthcare System Director makes certain that the Chief of Staff utilizes high reliability organization principles and establishes a process for the communication of pervasive concerns regarding a provider’s care.

The VA Western New York Health Care System Executive Director ensures that community living center staff complete behavioral notes and conduct behavioral rounds, consistent with system policies regarding behavioral health and administration of antipsychotic medications, monitors for compliance, and takes action as indicated.

The VA Western New York Health Care System Executive Director evaluates community living center nursing staff compliance with system policies regarding the administration of medications, and nursing documentation related to medication refusals, medical provider notification, and residents’ nutritional intake, and takes action as required.

The VA Western New York Health Care System Executive Director reviews the system policy regarding the use of antipsychotic medications in the community living center and considers aligning system policy with Veterans Health Administration’s dementia system of care recommendation to document risk-benefit discussions for all residents receiving pharmacological interventions for dementia-related behaviors.

The VA Western New York Health Care System Executive Director makes certain community living center staff comply with the system policy on fingerstick blood sugar testing, including documenting results and notification to the resident’s provider, and monitors compliance, taking action as indicated.

The VA Western New York Health Care System Executive Director reviews Batavia community living center laboratory processes and takes action as necessary to ensure timely completion of orders.

The VA Western New York Health Care System Executive Director ensures community living center staff enter joint patient safety reports and disclosures, as Veterans Health Administration guides and requires, and in support of high reliability organization principles, and monitors compliance.

The VA Western New York Health Care System Executive Director makes certain the community living center quality assurance performance improvement procedures adhere to Veterans Health Administration requirements, including the use of data to track effectiveness of quality assurance activities, and supports improvement in community living center nursing care. 

The VA Western New York Health Care System Executive Director ensures completion of the chief geriatric physician’s focused professional practice evaluation for cause per Veterans Health Administration requirements.

The VA Western New York Health Care System Executive Director evaluates community living center medical provider staffing to ensure staffing meets patient care needs and takes action as necessary, including continued recruitment to fill vacancies.

The VA Western New York Health Care System Executive Director ensures review of education plans, education needs assessments, and completion of a system dementia education plan as well as initial and ongoing Staff Training in Assisted Living Residences-VA training, as expected, for all community living center nursing staff, and takes action as indicated.

The VA New Mexico Healthcare System Director ensures that social work staff are knowledgeable that 10-10EZR forms can be completed at any time to correct a patient’s financial information and documents are not required to verify financial information.

The VA New Mexico Healthcare System Director reviews the ineffective communication, collaboration, and utilization of available sources of information by social work staff and the enrollment and eligibility supervisor and ensures the ongoing assessment of barriers that could affect patients’ care.

The VA New Mexico Healthcare System Director identifies why postsurgical follow-up care was not coordinated for the patient and takes action as warranted.

The VA New Mexico Healthcare System Director educates emergency department providers on the expectation for identifying the eligibility of each patient who requires admission and the need to obtain Chief of Staff approval if an ineligible patient necessitates care at the facility.

The VA New Mexico Healthcare System Director ensures that inpatient providers are aware of the process to obtain Chief of Staff approval for an ineligible patient to continue care at the facility when clinically indicated.

The VA New Mexico Healthcare System Director reviews the process for note retractions and ensures providers and document specialists are trained on the process.

The VA New Mexico Healthcare System Director ensures that inpatient social workers, providers, transfer coordinators, and nurses are aware that ineligible patients can be transferred from the facility and provides education related to the processes required for approval and facilitation of the transfer.

The VA New Mexico Healthcare System Director monitors compliance with the requirement that discharge paperwork is provided to each patient who is discharged.

The VA New Mexico Healthcare System Director ensures that providers communicate relevant information to community healthcare providers as needed to ensure continuity of care.

The VA New Mexico Healthcare System Director evaluates that staff (inpatient social workers, providers, transfer coordinators, nurses, and the nursing officer of the day) are aware that ineligible patients can be transported from the facility and provides education related to the processes required for approval and facilitation of the transport.

The VA New Mexico Healthcare System Director educates staff on steps to take if attempts to escalate concerns to their supervisors are not adequately addressed.

The VA New Mexico Healthcare System Director reviews the facility’s root cause analysis process, ensures that staff directly involved in an adverse event do not participate in root cause analysis of an event, and considers if another root cause analysis should be completed on this event.

The VA New Mexico Healthcare System Director makes certain that leaders are aware when assigned as responsible for root cause analysis action items and adhere to action plan due dates.

The VA New Mexico Healthcare System Director takes action to ensure that leaders understand and effectively utilize high reliability organization principles noted in this report to identify and correct deficiencies.

The VA New Mexico Healthcare System Director monitors the podiatry residency program for compliance with VHA Directive 1400.01 postgraduate year 1 resident supervision requirements.

The District 5 Director conducts a full review of care provided to the client by the Everett Vet Center Director and counselor, consults with Human Resources and General Counsel Offices, and takes action as needed.

The District 5 Director ensures vet center leaders and staff are knowledgeable about applicable state laws pertaining to duty to warn.

The District 5 Director makes certain that the Everett Vet Center Director and staff adhere to requirements for consultation with support facility external consultants and suicide prevention coordinators when indicated, and monitors compliance.

The Chief Officer, Readjustment Counseling Service provides written guidance to clarify crisis reporting criteria and monitoring responsibilities.

The Chief Officer, Readjustment Counseling Service establishes written policy that clarifies clinical record documentation requirements regarding entry dates; non-visit progress note completion time frames; and progress note deletion and addition, and monitors compliance.

The Chief Officer, Readjustment Counseling Service establishes written guidance regarding time requirements for the completion of risk assessment documentation in clients’ clinical records.

The District 5 Director ensures readjustment counselors’ compliance with updating and reviewing safety plans as required by Readjustment Counseling Service policy.

The Chief Officer, Readjustment Counseling Service ensures that vet center directors are issued the correct position description and are performing duties within the identified scope of work.

The District 5 Director conducts a review of the care provided to complex clients by the Everett Vet Center Director since March 2021 and addresses identified clinical needs.