Inspection of Continental District 4 Vet Center Operations

Report Information

Issue Date
Closure Date
Report Number
22-04109-238
VISN
State
Colorado
District
Continental
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 evaluates four review areas within Continental District 4 including leadership stability, morbidity and mortality reviews, the high risk suicide flag (HRSF) SharePoint site, and safety plans.

There were no findings in stability of leadership. Based on active policy at the time of the inspection, the OIG identified that district leaders did not complete timely morbidity and mortality reviews for clients who died by suicide. Inconsistent with requirements at the time, leaders also implemented a peer review process for all suicide attempts instead of the morbidity and mortality reviews. The OIG did not conduct the HRSF SharePoint site review due to concerns with data accuracy. In April 2024, the OIG made a recommendation to the RCS Chief Officer related to HRSF SharePoint site functionality. The recommendation remained open at the time of the inspection; therefore, the OIG will continue to monitor progress to closure and did not make a new recommendation. Vet center staff were noncompliant with completing and providing safety plans to clients.

The OIG issued three recommendations for improvement to the District Director.

 

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/11/2024

The District Director monitors compliance with leaders’ completion of morbidity and mortality reviews for client deaths by suicide, including timeliness, as required.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2025

The District Director determines reasons vet center counselors did not complete safety plan components for clients assessed at intermediate or high suicide risk level in either acute, chronic, or both categories; ensures completion of safety plans for all active clients assesses at intermediate or high suicide risk levels; and monitors compliance across all zone vet centers.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2025

The District Director determines reasons staff did not document providing safety plans to clients, ensures that a safety plan was provided to all active clients assessed at intermediate or high suicide risk levels, and monitors compliance across all zone vet centers