Vet Center Inspection of Midwest District 3 Zone 1 and Selected Vet Centers

Report Information

Issue Date
Closure Date
Report Number
21-03231-38
VISN
State
Ohio
District
Midwest
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Vet Center Inspection Program
Report Topic
Suicide Prevention
Major Management Challenges
Leadership and Governance
Recommendations
23
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The 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 report focuses on Midwest district 3 zone 1 and four selected vet centers: Cleveland, Columbus, and Toledo in Ohio; and South Bend in Indiana. The OIG inspection focused on five review areas: leadership and organizational risks; quality reviews; suicide prevention; consultation, supervision, and training; and environment of care. Generally, district leaders had a good understanding of quality improvement principles and implemented district-wide quality improvement programs in response to VA All Employee Survey results. District 3 zone 1 Vet Center Service Customer Feedback survey results were below the national average in all areas except satisfaction with overall quality of services at the vet center. The OIG issued one recommendation to the district director specific to annual in-service training; this recommendation was closed at the time of publication. The OIG conducted an analysis of vet center quality reviews required to ensure compliance with policy and procedures. The OIG made five recommendations for clinical and administrative quality reviews and two recommendations for morbidity and mortality reviews. The suicide prevention review included a zone-wide evaluation of electronic client records, and a focused review of the four selected vet centers. The OIG issued nine recommendations—seven specific to electronic client records and two for selected vet centers’ suicide prevention and intervention processes. The consultation, supervision, and training review evaluated the four selected vet centers. The OIG identified concerns with external clinical consultation, supervision, audits, and training, and issued four recommendations. The environment of care review evaluated the four selected vet centers. The OIG made two recommendations.

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: 1/19/2023
The District Director determines reasons annual in-service training was not provided for vet center directors, veteran outreach program specialists, and office managers and ensures training is offered for all positions as required.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/26/2023
The District Director determines reasons clinical quality review remediation plans were not completed for the Grand Rapids and South Bend Vet Centers, ensures completion, and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/11/2024

The District Director determines reasons clinical quality review remediation plans at the four selected vet centers did not include documentation of deficiency resolution and the time frame of resolution, takes indicated actions to ensure completion, and monitors compliance.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2025

The District Director determines reasons for lack of evidence that clinical quality review deficiencies were resolved at the Cleveland, Columbus, and Toledo Vet Centers, takes indicated actions to ensure completion, and monitors compliance.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2025

The District Director determines reasons for lack of evidence for administrative quality review deficiency resolution for the Cleveland, Columbus, and South Bend Vet Centers, takes indicated actions to ensure completion, and monitors compliance

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/11/2024

The District Director determines reasons administrative quality review remediation plans did not include documentation of deficiency resolution and the time frame of resolution for the Columbus and South Bend Vet Centers, takes indicated actions to ensure completion, and monitors compliance.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2023
The District Director determines reasons why morbidity and mortality reviews for serious suicide attempts were not completed, ensures completion, and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2023

The Readjustment Counseling Service Chief Officer defines “serious suicide attempt” and establishes criteria for when a morbidity and mortality review is required as well as a standardized process for completing the review.

No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2024

The District Director ensures the intake portion of the psychosocial assessment is completed and monitors compliance across all zone vet centers.

No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2024

The District Director ensures suicide risk assessments are completed on the first clinical visit and monitors compliance across all zone vet centers.

No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2025

The District Director ensures clinical staff consult and coordinate care with the support VA medical facility for shared clients flagged as high risk for suicide and monitors compliance across all zone vet centers.

No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2023
The District Director ensures clinical staff follow confidentiality requirements when consulting and coordinating care with the support VA medical facility for shared clients at high risk for suicide and monitors compliance across all zone vet centers.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/26/2023
The District Director ensures clinical staff make timely notification to the suicide prevention coordinator at the support VA medical facility for clients with significant safety risks and monitors compliance across all zone vet centers.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2024

The District Director 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. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2025

The District Director ensures clinical staff consult with the vet center director, external clinical consultant, associate district director for counseling, or support VA medical facility mental health provider to include the suicide prevention coordinator following a client’s suicide risk assessment as required, and monitors compliance across all zone vet centers.

No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/26/2023
The District Director, in collaboration with the support VA medical facility clinical or administrative liaisons, determines the reasons for noncompliance with staff participation on the mental health council for the Columbus, South Bend, and Toledo Vet Centers and takes actions as indicated to ensure compliance with Readjustment Counseling Service requirements.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2024

The District Director determines reasons for noncompliance with High Risk Suicide Flag SharePoint site requirements and the tracking of continuity of care for clients with a high risk-suicide flag or clients with an increased predictive risk for suicide at the Columbus, South Bend, and Toledo Vet Centers, takes action to ensure requirements are met, and monitors compliance.

No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2023

The District Director determines reasons a process for completing and tracking four hours of external clinical consultation per month did not occur at Cleveland, Columbus, South Bend, and Toledo Vet Centers, ensures vet center directors implement processes, and monitors compliance.

No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/26/2023
The District Director determines reasons for noncompliance with staff supervision provided by vet center directors at the Cleveland, Columbus, South Bend, and Toledo Vet Centers, ensures staff supervision occurs as required, and monitors compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/26/2023
The District Director verifies and determines reasons for noncompliance with monthly RCSNet chart audits at the Cleveland, Columbus, South Bend, and Toledo Vet Centers; ensures chart audits are completed as required; and monitors compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2023

The District Director determines reasons staff at the Cleveland, Columbus, South Bend, and Toledo Vet Centers did not complete required trainings, ensures all staff complete mandatory trainings, and monitors compliance.

No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/26/2023
The District Director evaluates and determines reasons for noncompliance with tactile (braille) signage at the Toledo Vet Center and ensures all exit doors are compliant with Architectural Barriers Act Accessibility Standards.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2023
The District Director reviews reasons for noncompliance with maintaining a current and comprehensive emergency and crisis plan at the Cleveland, South Bend, and Toledo Vet Centers and ensures all emergency and crisis plans are comprehensive and updated as required.