Healthcare Inspection – Suicide of a Veteran Enrolled in VA Supported Housing, Bay Pines VA Healthcare System, Bay Pines, FL

OIG reviewed allegations that a veteran living in Housing and Urban Development (HUD) VA Supported Housing (VASH) committed suicide; that he was considered high risk for suicide; that he did not have contact with a VA case manager (CM) for months prior to his death; that the CM supervisor only visited the Port Charlotte clinic once since being assigned to the position; and that the supervisor told a CM to “audit himself and get his charts straight” after learning of the suicide. We substantiated that the veteran committed suicide, but not that he had been identified as high risk for suicide, and that the veteran did not see or speak to a CM during 9 of 18 months in the program. We substantiated that a supervisor visited the Port Charlotte clinic only once, but not that this was inappropriate. We could neither substantiate nor refute that a CM was told by the supervisor to “audit himself and get his charts straight” after learning of the suicide. We found that network and system level oversight of the HUD–VASH program needed improvement and that 23 of 25 other veterans in the program did not receive required case management services. We recommended that the System Director ensure HUD–VASH program case management services are provided as required and that Network and System Directors implement measures to strengthen management controls and oversight.