Inspection of Select Vet Centers in Continental District 4 Zone 2

Report Information

Issue Date
Report Number
22-04108-235
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
11
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. The OIG inspected six randomly selected vet centers throughout Continental district 4 zone 2: Fayetteville, Arkansas; New Orleans, Louisiana; Jackson, Mississippi; and Corpus Christi, Fort Worth, and San Antonio Northeast, Texas.

The OIG inspection focused on four review areas: suicide prevention; consultation, supervision, and training; outreach; and environment of care. In the suicide prevention review, the OIG team evaluated vet center staff participation in the VA medical facility mental health executive council meetings resulting in one recommendation across two of the six vet centers inspected. The OIG identified one incidental finding related to documentation standards and made one recommendation at one of six vet centers inspected. The consultation, supervision, and training review identified concerns with external clinical consultation, monthly client record reviews, and completion of select trainings resulting in three recommendations across all six vet centers inspected. The outreach review evaluated outreach plan completion, inclusion of strategic components, and tailoring of outreach activities to cultural background information identified in the plan which resulted in one recommendation across all six vet centers inspected. The environment of care review evaluated vet centers’ physical environment and general safety resulting in five recommendations across five of the six vet centers inspected. 

The OIG issued a total of 11 recommendations for improvement.
 

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: 1/23/2025

District leaders and the Jackson and Corpus Christi Vet Center Directors collaborate with the support 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 Worth Vet Center Director determine reasons for noncompliance with Readjustment Counseling Service documentation standards, ensure completion, and monitor compliance.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2025

District leaders and the Fayetteville, New Orleans, Jackson, Corpus Christi, Fort Worth, and San Antonio Northeast 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. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2024

District leaders and the Jackson and San Antonio Northeast Vet Center Directors determine reasons for noncompliance with Vet Center Directors review of 10 percent of active client records monthly for each counselor’s caseload, ensure completion, and monitor compliance.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2024

District leaders and the Fayetteville, New Orleans, Jackson, Corpus Christi, Fort Worth, and San Antonio Northeast Vet Center Directors determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2024

District leaders and the Fayetteville, New Orleans, Jackson, Corpus Christi, Fort Worth, and San Antonio Northeast Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2024

District leaders and the Fayetteville Vet Center Director 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. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2024

District leaders and the New Orleans Vet Center Director determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.

No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2024

District leaders and the New Orleans, Jackson, and Corpus Christi Vet Center Directors determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.

No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2024

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

No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2024

District leaders and the Fayetteville, Corpus Christi, Fort Worth, and San Antonio Northeast Vet Center Directors determine reasons for noncompliance with a desktop reference sheet outlining steps for ancillary office staff to follow in case of a suicidal or homicidal client, ensure completion, and monitor compliance.