Inspection of Select Vet Centers in Midwest District 3 Zone 3

Report Information

Issue Date
Report Number
24-00395-179
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
5
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 3: Des Moines and Sioux City, Iowa; Kansas City, Missouri; and Rapid City, South Dakota.

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 and all four inspected vet centers were compliant. The consultation, supervision, and training review evaluated external clinical consultation, monthly client record reviews, and completion of select trainings resulting in one recommendation related to training at one of the 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 at three of the inspected four vet centers. The environment of care review evaluated vet centers’ physical environment and general safety resulting in three recommendations across all four inspected vet centers.

The OIG issued a total of five 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 Kansas City Vet Center Director determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2025

District leaders and the Des Moines, Sioux City, and Kansas City Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.

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

District leaders and the Des Moines, Sioux City, Kansas City, and Rapid City 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. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

District leaders and the Kansas City Vet Center Director determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2025

District leaders and the Kansas City and Rapid City Vet Center Directors determine reasons for noncompliance with having an emergency and crisis plan that includes required components, ensure completion, and monitor compliance.