Inspection of Select Vet Centers in Midwest District 3 Zone 1

Report Information

Issue Date
Report Number
24-00393-180
VISN
State
District
Midwest
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Vet Center Inspection Program
Report Topic
Care Coordination
Mental Health
Suicide Prevention
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
10
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered at vet centers. This inspection report evaluated four randomly selected vet centers throughout Midwest district 3 zone 1: Fort Wayne, Indiana; Detroit and Escanaba, Michigan; and Cincinnati, Ohio.

This OIG inspection focused on four review areas: suicide prevention; consultation, supervision, and training; outreach; and environment of care. The suicide prevention review evaluated vet center staff participation in VA medical facility mental health executive council meetings, resulting in one recommendation across three of the four inspected vet centers. The consultation, supervision, and training review evaluated external clinical consultation, monthly client record reviews, and completion of select trainings resulting in two recommendations related to external clinical consultation and training across all four inspected vet centers. The outreach review evaluated outreach plan completion, inclusion of strategic components, and tailoring of outreach activities to eligible individuals, which resulted in one recommendation across all four inspected vet centers. The environment of care review evaluated vet centers’ physical environment and general safety resulting in four recommendations across all four inspected vet centers and two recommendations to the Readjustment Counseling Service Chief Officer.

The OIG issued a total of 10 recommendations for improvement.
 

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)

District leaders and the Detroit, Escanaba, and Cincinnati Vet Center Directors collaborate with the supporting VA medical facility to determine reasons for noncompliance with staff participation on the mental health executive council, take action as indicated, and monitor compliance.

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

District leaders and the Fort Wayne, Escanaba, and Cincinnati Vet Center Directors determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented, and monitor compliance.

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

District leaders and the Detroit and Escanaba Vet Center Directors determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

District leaders and the Fort Wayne, Detroit, Escanaba, and Cincinnati Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

District leaders and the Escanaba Vet Center Director determine reasons for noncompliance with annual fire or safety inspections, ensure completion, and monitor compliance.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

District leaders and the Fort Wayne, Detroit, and Escanaba Vet Center Directors determine reasons for noncompliance with having an annual risk and vulnerability assessment completed by VA police or local law enforcement, ensure completion, and monitor compliance.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

District leaders and the Cincinnati Vet Center Director determine reasons for noncompliance with annual automated external defibrillator servicing by VA medical center biomedical engineering, ensure completion, and monitor compliance.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

District leaders and the Detroit and Escanaba Vet Center Directors determine reasons for noncompliance with having a current emergency and crisis plan that includes required components, ensure completion, and monitor compliance.

No. 9
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Readjustment Counseling Service Chief Officer reviews the administrative site visit protocol and Veterans Health Administration requirements related to inconsistencies in frequency for risk and vulnerability assessments and updates the administrative site visit protocol as indicated.

No. 10
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Readjustment Counseling Service Chief Officer reviews the administrative site visit protocol and Veterans Health Administration requirements related to automated external defibrillator annual servicing and updates the administrative site visit protocol as indicated.