Inspection of Select Vet Centers in Midwest District 3 Zone 2

Report Information

Issue Date
Report Number
24-00394-122
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
8
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 2: Evanston, Illinois; Gary Area, Indiana; and La Crosse and Milwaukee, Wisconsin.

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 on VA medical facility mental health executive councils, resulting in one recommendation across three of the four 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 four vet centers inspected. 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 three of the four vet centers inspected. The environment of care review evaluated vet centers’ physical environment and general safety, resulting in one recommendation at one of the three vet centers inspected. One vet center was closed and had a temporary location; therefore, an environment of care review was not completed at this site. However, the inspection did result in additional findings related to the vet center’s closure and relocation, resulting in two recommendations.

The OIG issued a total of eight 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 Evanston, La Crosse, and Milwaukee 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 Evanston, Gary Area, La Crosse, and Milwaukee 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 Gary Area Vet Center Director determine reasons for noncompliance with Vet Center Director review of 10 percent of active client records monthly for each counselor’s caseload, ensure completion, and monitor compliance.

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

District leaders and the Gary Area, La Crosse, and Milwaukee Vet Center Directors determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.

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

District leaders and the Evanston, Gary Area, and Milwaukee Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.

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

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

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

District leaders determine reasons why the closing of the Milwaukee Vet Center resulted in multiple communication failures, and ensure all clients are notified of the new location, the Vet Center Call Center has accurate information, and websites include correct location and phone number information.

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

The Readjustment Counseling Service Chief Officer considers developing written guidance for vet center closure and temporary relocation processes including oversight responsibilities.