All Reports

The Overton Brooks VA Medical Center Director evaluates the processes for the communication of abnormal radiology imaging results and ensures patients receive timely notification, per Veterans Health Administration and facility requirements.

The Overton Brooks VA Medical Center Director ensures oversee all clinical decisions and documentation made by residents and the oversight is reflected within the documentation.

The Overton Brooks VA Medical Center Director reviews the processes for assigning a provider surrogate and monitors compliance.

The Under Secretary for Health ensures that Veterans Integrated Service Network leaders provide adequate oversight to ensure adherence to the mental health residential rehabilitation treatment program access to care policy as required.

The Under Secretary for Health ensures the Office of Mental Health and Suicide Prevention develops, implements, and monitors action plans to meet Intensive Community Mental Health Recovery visit frequency requirements, to include program resource needs and the ongoing role for virtual care.

The Under Secretary for Health requires the Office of Mental Health and Suicide Prevention to develop a process for Intensive Community Mental Health Recovery programs to ensure veterans receiving low-intensity services do not represent greater than 20 percent of caseloads and to distinguish between veterans receiving high- and low-intensity services for accurate and effective program oversight.

The Under Secretary for Health identifies barriers and ensures healthcare systems develop, implement, and maintain contingency plans specific to Intensive Community Mental Health Recovery programs regarding veteran access to medications during emergencies, including long-acting injectable antipsychotic medications.

The Rocky Mountain Network Director reviews facility staff’s actions taken in response to the allegations and concerns related to the patients identified in this report to ensure Veterans Health Administration and facility requirements were met including Montana elder abuse reporting requirements, and takes actions, such as reporting, disciplinary actions, peer reviews, and consultation with the Office of General Counsel, as needed.

The Montana VA Healthcare System Director ensures that the rights of community living center patients to refuse treatments or procedures are acknowledged and documented according to Veterans Health Administration requirements, and staff are educated on and adhere to the rights, as needed.

The Montana VA Healthcare System Director reviews the nursing care provided to the identified patient with respect to quality of care, including adhering to the patient’s care plan, and reporting and documenting status changes, and takes actions as indicated.

The Montana VA Healthcare System Director reviews the physician’s care provided to the identified patient with respect to quality of care, including documenting and reporting status changes and concerns, and takes actions as indicated.

The Montana VA Healthcare System Director reviews community living center screening and admission evaluation processes and ensures that the processes, including documentation of admissions decisions, roles, and responsibilities are established to meet the care needs of prospective patients, and are communicated with applicable staff, as needed.

The Montana VA Healthcare System Director ensures state licensing board processes related to the mistreatment incidents identified in this report are reviewed, deficiencies identified, and compliance processes completed.

The North Las Vegas Medical Center Director ensures a review is conducted of the primary care provider’s electronic health record documentation in order to determine if blood pressure entries other than 120/80 are false and takes action as necessary.

The North Las Vegas Medical Center Director ensures that any identified false blood pressures are amended in the electronic health record in accordance with Veterans Health Administration policy.

The VA Maryland Health Care System Director ensures that Emergency Department providers conduct comprehensive clinical assessments and address patients’ presenting complaints.

The VA Maryland Health Care System Director evaluates and strengthens the process to ensure that problem lists reflect current and active diagnoses, and takes action as necessary.

The Veterans Integrated Service Network Director reviews the supervision provided to the psychiatry trainee regarding the patient’s treatment, documentation, and document control, to include electronic health records and video recordings, and determines if standards were met, and takes action as indicated.

The Greater Los Angeles Healthcare System Director reviews the facility leader and staff responses, including those of the supervisor and patient advocate, to ensure the patient’s concerns were adequately addressed, and takes action as indicated.

The Under Secretary for Health conducts a review to assess the possible scope of current and former VA psychiatry residents being in possession of patients’ personal health information, to include video recorded treatment sessions and consent forms, and consults with the appropriate organizational leaders such as the Office of General Counsel on the required disposition of the recordings and forms, and takes action as needed.

The Greater Los Angeles Healthcare System Director ensures records control schedules, including one for video recordings, are completed for the Mental Health Department as required by Veterans Health Administration policy.

The Greater Los Angeles Healthcare System Director reviews processes related to the utilization of video recordings, in consultation with appropriate staff, to ensure compliance with Veterans Health Administration requirements.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Ensure vulnerabilities are remediated within established time frames.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Assign accessibility coordinators, publicize their names, and conduct a self-evaluation of policies as outlined in VA accessibility requirements.

Coordinate a process to ensure veterans with visual impairments are informed of the availability of accommodations, regardless of their level of disability.