OpenClosed - ImplementedClosed - Not Implemented
No. 1 to Veterans Health Administration (VHA)
The District Director determines reasons clinical quality review remediation plans were not completed, ensures completion, and monitors compliance.
No. 2 to Veterans Health Administration (VHA)
The District Director determines reasons administrative quality review remediation plans were not completed, ensures completion, and monitors compliance.
No. 3 to Veterans Health Administration (VHA)
The District Director evaluates the process for resolution of administrative quality review deficiencies and initiates action as necessary.
No. 4 to Veterans Health Administration (VHA)
The District Director determines reasons why critical incident quality reviews (currently known as morbidity and mortality reviews) for serious suicide attempts were not completed, ensures completion, and monitors compliance.
No. 5 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. 6 to Veterans Health Administration (VHA)
The District Director ensures lethality risk assessments are completed on the first clinical visit and monitors compliance across all zone vet centers.
No. 7 to Veterans Health Administration (VHA)
The District Director, in collaboration with Readjustment Counseling Service Central Office evaluates the limitations of current tools and tracking methods including why completion dates are not available in RCSnet and ensures compliance with standards for timely completion of intake assessments, military histories, and lethality risk assessments.
No. 8 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. 9 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. 10 to Veterans Health Administration (VHA)
The District Director confirms clinical staff make timely notification to the suicide prevention coordinator at the support Veterans Affairs medical facility for clients with significant safety risks and monitors compliance across all zone vet centers.
No. 11 to Veterans Health Administration (VHA)
The District Director ensures clinical staff consult with the Vet Center Director, external clinical consultant, or VA suicide prevention coordinator following a client’s lethality status change as required, and monitors compliance across all zone vet centers.
No. 12 to Veterans Health Administration (VHA)
The District Director ensures clinical staff complete crisis reports as required and monitors compliance across all zone vet centers.
No. 13 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 Central Oregon Vet Center and takes actions as indicated to ensure compliance with Readjustment Counseling Service requirements.
No. 14 to Veterans Health Administration (VHA)
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 at the Bellingham Vet Center, takes action to ensure requirements are met, and monitors compliance.
No. 15 to Veterans Health Administration (VHA)
The District Director determines reasons the Bellingham Vet Center did not have a written crisis plan, ensures requirements related to crisis plans are met and monitors compliance.
No. 16 to Veterans Health Administration (VHA)
The District Director determines reasons for noncompliance with the appointment of a clinical liaison at the Tacoma Vet Center, ensures assignment of a liaison, and monitors compliance.
No. 17 to Veterans Health Administration (VHA)
The District Director determines reasons a process for completing and tracking four hours of external clinical consultation per month did not occur at the Bellingham, Central Oregon, Tacoma, and Wasilla Vet Centers, ensures Vet Center Directors implement processes, and monitors compliance.
No. 18 to Veterans Health Administration (VHA)
The District Director determines reasons for noncompliance with staff supervision provided by vet center directors at the Bellingham, Central Oregon, Tacoma, and Wasilla Vet Centers, ensures staff supervision occurs as required, and monitors compliance.
No. 19 to Veterans Health Administration (VHA)
The District Director verifies and determines reasons for noncompliance with monthly RCSnet chart audits at the Bellingham, Central Oregon, Tacoma, and Wasilla Vet Centers, ensures chart audits are completed as required, and monitors compliance.
No. 20 to Veterans Health Administration (VHA)
The District Director determines reasons employees at the Bellingham, Central Oregon, Tacoma, and Wasilla Vet Centers did not complete required trainings, ensures all staff complete mandatory trainings, and monitors compliance.
No. 21 to Veterans Health Administration (VHA)
The District Director evaluates and determines reasons for noncompliance with a presentable exterior at the Wasilla Vet Center and ensures all exterior grounds are in good repair.
No. 22 to Veterans Health Administration (VHA)
The District Director evaluates and determines reasons for noncompliance with tactile (braille) signage at the Bellingham, Central Oregon, Tacoma, and Wasilla Vet Centers and ensures all exit doors are compliant with Architectural Barriers Act requirements.
No. 23 to Veterans Health Administration (VHA)
The District Director reviews reasons for noncompliance with securing confidential and sensitive information at the Bellingham and Tacoma Vet Centers and ensures all vet center employees safely and securely store protected health information.