All Reports

Date Issued
|
Report Number
25-03462-12
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Topics:  Mental Health ● Patient Care Services Operations ● Suicide Prevention

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Under Secretary for Health considers specific VHA guidance related to the recognition of personally owned insulin pumps as a lethal means for patients with suicidal ideation and at risk for suicide in emergency departments and inpatient units to mitigate risk and improve patient safety.

Date Issued
|
Report Number
24-00392-240
|
Topics:  Mental Health ● Suicide Prevention

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/5/2026

The District Director ensures district leaders follow the Readjustment Counseling Service policy requirements to provide oversight of morbidity and mortality review panel member assignments and report completion.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The District Director identifies reasons for noncompliance with documentation requirements of high-risk client contacts and outcomes in RCSNet and the High Risk Suicide Flag SharePoint site, ensures requirements are met, and monitors compliance.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Readjustment Counseling Service Chief Officer considers developing an additional written policy for High Risk Suicide Flag SharePoint disposition and related RCSNet documentation.