OpenClosed - ImplementedClosed - Not Implemented
No. 1 to Veterans Health Administration (VHA)
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 Center City, Huntington, Northeast, and Scranton Vet Centers; takes indicated actions to ensure completion; and monitors compliance.
No. 2 to Veterans Health Administration (VHA)
The District Director determines reasons for lack of evidence that clinical quality review deficiencies were resolved at the Center City, Huntington, Northeast, and Scranton Vet Centers; takes indicated actions to ensure completion; and monitors compliance.
No. 3 to Veterans Health Administration (VHA)
The District Director determines reasons administrative quality review remediation plans were not completed at the Beckley and Bucks County Vet Centers, ensures completion, and monitors compliance.
No. 4 to Veterans Health Administration (VHA)
The District Director determines the reasons administrative quality review remediation plans do not include the Deputy District Director’s approval and date of approval as required, and ensures compliance.
No. 5 to Veterans Health Administration (VHA)
The District Director determines reasons administrative quality review remediation plans did not include documentation of deficiency resolution and the time frame for resolution for the Center City, Huntington, Northeast, and Scranton Vet Centers; takes indicated actions to ensure completion; and monitors compliance.
No. 6 to Veterans Health Administration (VHA)
The District Director determines reasons for lack of evidence for administrative quality review deficiency resolution for the Center City, Huntington, Northeast, and Scranton Vet Centers; takes indicated actions to ensure completion; and monitors compliance.
No. 7 to Veterans Health Administration (VHA)
The District Director ensures completion of a morbidity and mortality review for the death by homicide, and ensures all future morbidity and mortality reviews are completed as required.
No. 8 to Veterans Health Administration (VHA)
The District Director ensures the intake portion of the psychosocial assessment is completed, and monitors compliance across all zone vet centers.
No. 9 to Veterans Health Administration (VHA)
The District Director ensures suicide risk assessments are completed on the first clinical visit, and monitors compliance across all zone vet centers.
No. 10 to Veterans Health Administration (VHA)
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.
No. 11 to Veterans Health Administration (VHA)
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.
No. 12 to Veterans Health Administration (VHA)
The District Director confirms clinical staff make timely notification to the suicide prevention coordinator at the support VA medical facility for clients with significant safety risks, and monitors compliance across all zone vet centers.
No. 13 to Veterans Health Administration (VHA)
The District Director ensures clinical staff complete safety plans for clients that 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.
No. 14 to Veterans Health Administration (VHA)
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 following a client’s suicide risk assessment as required, and monitors compliance across all zone vet centers.
No. 15 to Veterans Health Administration (VHA)
The District Director, in collaboration with the support VA medical facility clinical or administrative liaisons, determines the reasons for noncompliance with staff participation on the mental health council for the Center City, Huntington, Northeast, and Scranton Vet Centers, and takes actions as indicated to ensure compliance with Readjustment Counseling Service requirements.
No. 16 to Veterans Health Administration (VHA)
The District Director determines the reasons for noncompliance with critical event plans with desktop reference at the Center City and Northeast Philadelphia Vet Centers, and takes actions as indicated to ensure compliance with Readjustment Counseling Service requirements.
No. 17 to Veterans Health Administration (VHA)
The District Director determines reasons for noncompliance with the appointment of a clinical liaison at the Scranton Vet Center, ensures assignment of a mental health professional as liaison, and monitors compliance.
No. 18 to Veterans Health Administration (VHA)
The District Director determines reasons for noncompliance with a process for completing and tracking four hours of external clinical consultation per month at the Center City, Scranton, and Northeast Vet Centers; ensures Vet Center Directors implement processes; and monitors compliance.
No. 19 to Veterans Health Administration (VHA)
The District Director determines reasons for noncompliance with staff supervision provided by vet center directors at the Center City, Huntington, Northeast, and Scranton Vet Centers; ensures staff supervision occurs as required; and monitors compliance.
No. 20 to Veterans Health Administration (VHA)
The District Director verifies and determines reasons for noncompliance with monthly chart audits at the Center City, Huntington, Northeast, and Scranton Vet Centers; ensures chart audits are completed as required; and monitors compliance.
No. 21 to Veterans Health Administration (VHA)
The District Director determines reasons employees at the Center City, Huntington, Northeast, and Scranton Vet Centers did not complete required trainings; ensures all staff complete mandatory trainings; and monitors compliance.
No. 22 to Veterans Health Administration (VHA)
The District Director evaluates and determines reasons for noncompliance with tactile (braille) signage at the Center City, Huntington, and Northeast Vet Centers, and ensures all exit doors are compliant with Architectural Barriers Act Standards.
No. 23 to Veterans Health Administration (VHA)
The District Director reviews reasons for noncompliance with securing confidential and sensitive information at the Center City Vet Center, and ensures all vet center employees safely and securely store protected health information.
No. 24 to Veterans Health Administration (VHA)
The District Director reviews reasons for noncompliance with having a current and comprehensive emergency and crisis plan at the Center City and Northeast Vet Centers, ensures completion of a current and comprehensive emergency and crisis plan, and monitor’s compliance.