Inspection of Southeast District 2 Vet Center Operations

Report Information

Issue Date
Report Number
22-03941-144
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
7
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 throughout Readjustment Counseling Service (RCS).

This inspection evaluated four review areas within Southeast District 2 including leadership stability, morbidity and mortality reviews, high risk suicide flag (HRSF) SharePoint site, and consultation and safety plans.

There were no findings in leadership stability.  For the morbidity and mortality review, the OIG identified that district leaders did not complete reviews timely for clients who died by suicide based on the active policy at the time of the inspection. Leaders also did not follow established tracking methods and had different processes, as well as unclear criteria, when evaluating the need for morbidity and mortality reviews for clients who had serious suicide attempts. In the HRSF SharePoint Site review, the OIG identified noncompliance with timely documentation by vet center staff in RCSNet and highlighted concerns with the accuracy of information in, and utilization of, the HRSF SharePoint site. Additionally, the OIG found care coordination practices in violation of RCS client confidentiality requirements. In the consultation and safety plan review, the OIG found vet center staff noncompliant with seeking consultation and completing and providing safety plans to clients.

The OIG issued six recommendations to the District Director and one to the RCS Chief Officer 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)

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

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The District Director identifies reasons for noncompliance with timely documentation requirements of high-risk client contacts and outcomes in the electronic record and High Risk Suicide Flag SharePoint site, ensures requirements are met, and monitors compliance.

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

The Readjustment Counseling Service Chief Officer ensures the High Risk Suicide Flag SharePoint site functions as intended and includes accurate data.

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

The District Director and zone leaders identify reasons for noncompliance, ensure Readjustment Counseling Service policy confidentiality requirements are followed when collaborating care with the support VA medical facility for shared clients at high risk for suicide, and monitor compliance across all zone vet centers.

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

The District Director identifies reasons for noncompliance with consultation requirements for clients who are assessed at intermediate or high suicide risk level in either acute, chronic, or both categories; ensures consultation requirements are met; and monitors compliance.

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

The District Director identifies reasons for noncompliance; ensures clinical staff complete safety plans for clients who are assessed at intermediate or high suicide risk level in either acute, chronic, or both categories as required; and monitors compliance across all zone vet centers.

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

The District Director identifies reasons for noncompliance, ensures clients are provided a copy of their completed safety plan as required, and monitors compliance across all zone vet centers.