Report Summary

Title: Vet Center Inspection of Southeast District 2 Zone 2 and Selected Vet Centers
Report Number: 20-02014-270 Download
Issue Date: 9/30/2021
City/State: Clearwater, FL
Ocala, FL
Ponce, PR
Sarasota, FL
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Vet Center Inspection Program
Release Type: Unrestricted

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 Southeast district 2 zone 2 and four selected vet centers: Clearwater, Ocala, and Sarasota in Florida; and Ponce in Puerto Rico. The OIG inspection focused on six review areas: leadership and organizational risks; quality reviews; COVID-19 response; 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 2 zone 2 Vet Center Service Customer Feedback survey results exceeded national scores. The OIG conducted an analysis of vet center quality reviews required to ensure compliance with policy and procedures. The OIG made four recommendations for clinical and administrative quality reviews and two recommendations for critical incident quality reviews. The COVID-19 response review showed that although initially feeling ill-equipped, district leaders enacted emergency plan procedures and vet centers remained operational. Employees’ response to an OIG questionnaire indicated the pandemic response was well managed by district leaders and vet center directors. 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 10 recommendations—four specific to client records and six for selected vet centers’ suicide prevention and intervention processes. The consultation, supervision, and training review evaluated the four vet centers. The OIG identified concerns with external clinical consultation, supervision, and training, and issued four recommendations. The environment of care review evaluated the four vet centers. The OIG made two recommendations.

The OIG issued a total of 22 recommendations for improvement, including three to the Under Secretary for Health and 19 to the District Director.