Inspection of Select Vet Centers in Southeast District 2 Zone 1

Report Information

Issue Date
Report Number
22-03939-142
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
13
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The VA Office of Inspector General (OIG) Vet Center Inspection Program evaluated aspects of the quality of care delivered at six randomly selected vet centers throughout Southeast district 2 zone 1: Augusta, Marietta, and Savannah in Georgia; Johnson City, Tennessee; Charleston, South Carolina; and Bay County, Florida.

This inspection focused on four review areas: suicide prevention; consultation, supervision, and training; outreach; and environment of care. For the suicide prevention review, the OIG evaluated vet center staff participation on VA medical facility mental health executive councils and High Risk Suicide Flag SharePoint Site client dispositions, which resulted in one recommendation across three of the six vet centers inspected. In the consultation, supervision, and training review, the OIG identified concerns with external clinical consultation and completion of select trainings, which resulted in two recommendations across all six vet centers inspected. The OIG’s outreach review evaluated outreach plan completion, inclusion of strategic components, and tailoring of outreach activities to cultural background information, which resulted in three recommendations across all six vet centers inspected. During the environment of care review, the OIG evaluated vet centers’ physical environment and general safety, which resulted in seven recommendations across four of the six vet centers inspected.

The OIG issued 13 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)

District leaders and the Marietta, Bay County, and Savannah Vet Center Directors collaborate with the support VA medical facility clinical liaisons to determine the reasons for noncompliance, take action as indicated, and monitor to ensure compliance with staff participation on the mental health executive council.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Marietta and Charleston Vet Center Directors determine reasons for noncompliance, ensure a process is implemented for completing and tracking four hours of external clinical consultation per month, and monitor compliance.

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

District leaders and the Augusta, Johnson City, Marietta, Charleston, Bay County, and Savannah Vet Center Directors determine reasons for noncompliance, develop processes to ensure all staff complete mandatory trainings, and monitor compliance.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Charleston Vet Center Director determine reasons for noncompliance and ensure outreach plans are completed.

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

District leaders and the Augusta, Johnson City, Marietta, Bay County, and Savannah Vet Center Directors determine reasons for noncompliance and ensure outreach plans include all required strategic components.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Augusta, Johnson City, and Savanah Vet Center Directors determine reasons for noncompliance, ensure outreach activities are tailored to the cultural demographics of the vet center’s veteran service area, and monitor compliance.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Augusta Vet Center Director determine reasons for noncompliance, ensure the risk and vulnerability assessment is completed by VA police or local law enforcement, and monitor compliance.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Augusta Vet Center Director determine reasons for noncompliance, ensure fire extinguishers are serviced annually and monitor compliance.

No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Augusta, Johnson City, Charleston, and Bay County Vet Center Directors determine reasons for noncompliance, ensure fire extinguishers are inspected monthly, and monitor compliance.

No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The District Director and zone leaders, in conjunction with the Augusta Vet Center Director, determine reasons for noncompliance and ensure vet center obtains an automated external defibrillator.

No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Charleston Vet Center Director determine reasons for noncompliance, ensure automated external defibrillators are inspected monthly, and monitors compliance.

No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Charleston and Bay County Vet Center Directors determine reasons for noncompliance, ensure completion of a current and comprehensive emergency and crisis plan, and monitor compliance.

No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Charleston Vet Center Director determine reasons for noncompliance, and ensures ancillary staff have a desktop reference sheet to address mental health crisis situations.