Open Recommendations

The Chief of Staff ensures veterans’ discharge instructions are written in easy-to-understand language and include the purpose of each medication.

The Facility Executive Director ensures staff complete VA S.A.V.E. training and develops a plan to monitor for sustained compliance.

The Facility Executive Director ensures Interdisciplinary Safety Inspection Team members participate in Mental Health Environment of Care Checklist inspections and develops a plan to monitor for sustained compliance.

The Facility Executive Director ensures all required individuals complete Mental Health Environment of Care Checklist annual training and develops a plan to monitor for sustained compliance.

The Facility Executive Director ensures the Mental Health Executive Council includes veteran representation.

The Facility Executive Director ensures staff complete the mental health nursing admission screen note, with veterans legal status, for admissions to the inpatient mental health unit and develops a plan to monitor for sustained compliance.

The Chief of Staff ensures documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications prior to administration and develops a plan to monitor for sustained compliance.

The Chief of Staff ensures veterans discharge instructions are written in easy-to-understand language and include the purpose of each medication.

The Facility Executive Director ensures staff complete VA S.A.V.E. training and develops a plan to monitor for sustained compliance.

The Facility Executive Director ensures Interdisciplinary Safety Inspection Team members participate in Mental Health Environment of Care Checklist inspections and develops a plan to monitor for sustained compliance.

The Facility Executive Director ensures all required individuals complete Mental Health Environment of Care Checklist annual training and develops a plan to monitor for sustained compliance.

The Facility Director ensures the Mental Health Executive Council includes veteran representation.

The Veterans Integrated Service Network Director provides oversight and monitoring of bed utilization.

The Chief of Mental Health ensures a minimum of four hours of recovery-oriented, interdisciplinary programming on weekends on the inpatient mental health unit.

The Facility Director develops and implements written processes to monitor and track compliance with state involuntary commitment requirements.

The Chief of Staff ensures staff use the required admission note template to document legal commitment status.

The Chief of Staff ensures documentation of discussions between prescribers and veterans on the risks and benefits of newly prescribed central nervous system medications.

The Chief of Staff ensures discharge summaries are completed within two business days of discharge.

The Chief of Staff ensures discharge instructions for veterans include appointment locations written in easy-to-understand language.

The Chief of Staff ensures discharge instructions for veterans include an explanation when both trade and generic names are used for the same medication.

The Facility Director directs nonclinical staff to complete VA S.A.V.E. training requirements.

The Facility Director ensures compliance with Veterans Health Administration requirements for the Interdisciplinary Safety Inspection Team, including an assigned lead and recording of meeting minutes and membership.

The Facility Director implements processes to ensure the Interdisciplinary Safety Inspection Team applies Mental Health Environment of Care Checklist standards on the inpatient mental health unit.

The Facility Director directs inpatient unit staff and Interdisciplinary Safety Inspection Team members to complete Mental Health Environment of Care Checklist training requirements.

Develop and implement a comprehensive plan to improve arrow key controls that provides annual Daily Arrow Key Accountability training for all employees with oversight responsibility, including clerks; an accurate 24-Hour arrow key management system dashboard; and review of dashboard metrics to achieve corrective actions for noncompliant conditions.