Inspection of Midwest District 3 Vet Center Operations

Report Information

Issue Date
Report Number
24-00392-240
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Vet Center Inspection Program
Report Topic
Mental Health
Suicide Prevention
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
3
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 throughout Readjustment Counseling Service (RCS).

This inspection evaluated leadership stability, morbidity and mortality reviews, and the high risk suicide flag (HRSF) SharePoint site within Midwest District 3. 

There were no findings in leadership stability. The morbidity and mortality review identified that district leaders did not ensure reviews had the required RCS panel members and contained all required components. The HRSF review identified noncompliance with documentation requirements for high-risk client contacts and outcomes in both RCSNet and the HRSF SharePoint site. This noncompliance was attributed to unclear or insufficient guidance provided to staff. The OIG issued two recommendations for improvement to the District Director and one recommendation to the Chief Officer. 
 

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)

The District Director ensures district leaders follow the Readjustment Counseling Service policy requirements to provide oversight of morbidity and mortality review panel member assignments and report completion.

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

The District Director identifies reasons for noncompliance with documentation requirements of high-risk client contacts and outcomes in RCSNet and the High Risk Suicide Flag SharePoint site, ensures requirements are met, and monitors compliance.

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

The Readjustment Counseling Service Chief Officer considers developing an additional written policy for High Risk Suicide Flag SharePoint disposition and related RCSNet documentation.