Inspection of Select Vet Centers in Southeast District 2 Zone 2

Report Information

Issue Date
Report Number
22-03940-143
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
17
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

VA Office of Inspector General (OIG) Vet Center Inspection Program staff evaluated aspects of the quality of care at six randomly selected vet centers throughout Southeast District 2 zone 2: Ft. Lauderdale, Ft. Myers, Gainesville, Lakeland, and Naples in Florida; and San Juan in Puerto Rico.  

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 two recommendations across all six vet centers inspected. In the consultation, supervision, and training review, the OIG identified concerns with external clinical consultation, vet center director monthly chart audits, and completion of select trainings, which resulted in five recommendations across five of the 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 five of the six vet centers inspected.

The OIG issued 17 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 Ft. Lauderdale, Ft. Myers, Gainesville, Lakeland, Naples, and San Juan Vet Center Directors, collaborate with the support VA medical facility clinical liaison 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
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

District leaders and the Lakeland Vet Center Director, determine reasons for noncompliance with High Risk Suicide Flag SharePoint site requirements and the tracking of continuity of care for at-risk clients, take action to ensure requirements are met, and monitor compliance.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Lakeland Vet Center Director determine reasons for noncompliance and ensure assignment of a liaison.

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

District leaders and the Lakeland Vet Center Director determine reasons for noncompliance and ensure assignment of an external clinical consultant.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Ft. Lauderdale, Ft. Myers, Gainesville, Naples, and San Juan 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. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

District leaders and the Ft. Lauderdale, Gainesville, and Lakeland Vet Center Directors determine reasons for noncompliance with monthly active counseling records, ensure chart audits are completed as required, and monitor compliance.

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

District leaders and the Ft. Lauderdale, Ft. Myers, Gainesville, Lakeland, and San Juan Vet Center Directors determine reasons for noncompliance, develop processes to ensure all staff complete mandatory trainings, and monitor compliance.

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

District leaders and the Gainesville and Lakeland Vet Center Directors determine reasons for noncompliance and ensure outreach plans are completed.

No. 9
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

District leaders and the Ft Lauderdale, Ft. Myers, Naples, and San Juan Vet Center Directors determine reasons for noncompliance and ensure outreach plans include all required strategic components.

No. 10
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

District leaders and the Ft. Myers, Naples, and San Juan 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. 11
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

District leaders and the Gainesville Vet Center Director determine reasons for noncompliance, ensure completion of fire and/or safety inspections, and monitor compliance.

No. 12
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

District leaders and the Gainesville 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. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Gainesville and Naples Vet Center Director determine reasons for noncompliance, ensure automated external defibrillators are serviced annually, and monitor compliance.

No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Ft. Lauderdale and Naples Vet Center Directors determine reasons for noncompliance, ensure fire extinguishers are inspected monthly, and monitor compliance.

No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

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

No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders, and the Naples Vet Center Director, determine reasons for noncompliance and ensure evacuation plans are posted in a communal area.

No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Ft. Lauderdale, Ft. Myers, Lakeland, and Naples Vet Center Directors determine reasons for noncompliance, ensure completion of a current and comprehensive emergency and crisis plan, and monitor compliance.