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Vet Center Inspection of Continental District 4 Zone 1 and Selected Vet Centers

Report Information

Issue Date
Report Number
20-04050-37
VISN
State
District
Continental
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
20
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The VA 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 Continental district 4 zone 1 and four selected vet centers: Casper, Wyoming; Denver, Colorado; and El Paso and Midland in Texas. The 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 were knowledgeable about quality improvement principles and engaged in continuous improvement activities in response to VA All Employee Survey results. District 4 zone 1 Vet Center Service Customer Feedback survey results exceeded national scores in four of the six categories. The OIG conducted an analysis of vet center quality reviews required to ensure compliance with policy and procedures. The OIG made three recommendations for clinical and administrative quality reviews and one recommendation for critical incident quality reviews. The COVID-19 response review showed that while initially there were personal protective equipment shortages for staff, adequate supplies were reported at the time of inspection. Employees’ responses indicated that district leaders and vet center directors provided communication and guidance that helped with employee and client safety. The suicide prevention review included a zone-wide evaluation of electronic client records, and a focused review of four selected vet centers. The OIG issued eight recommendations—seven specific to electronic client records and one 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 five recommendations. The environment of care review evaluated the four vet centers. The OIG made three recommendations. The OIG issued a total of 20 recommendations for improvement to the District Director.

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)
The District Director determines the reasons clinical and administrative quality review remediation plans do not include the Deputy District Director’s approval and date of approval as required and ensures compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director evaluates the clinical and administrative quality review process for resolution of quality review deficiencies and initiates action steps as necessary.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director evaluates the clinical and administrative quality review report process for determining timeliness in resolving quality review site visit deficiencies and initiates action steps as necessary.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director determines the reasons critical incident quality reviews (currently known as mortality and morbidity review) for serious suicide attempts including analysis for corrective action were not completed, ensures completion, and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director ensures the intake assessment portion of the psychosocial assessment is completed and monitors compliance across all zone vet centers.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director ensures lethality risk assessments are completed and monitors compliance across all zone vet centers.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director in collaboration with Readjustment Counseling Service Central Office evaluates the limitations of current tools and tracking methods including reasons completion dates are not visible in RCSnet and ensures compliance with standards for timely completion of intake assessments, military histories, and lethality risk assessments.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director ensures clinical staff consult and coordinate care with the support Veterans Affairs medical facility for shared clients flagged as high risk for suicide and monitors compliance across all zone vet centers.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director ensures clinical staff follow confidentiality requirements when consulting and coordinating care with shared support Veterans Affairs medical facility for shared clients who are flagged as high risk for suicide and monitors compliance across all zone vet centers.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director ensures clinical staff consult with the vet center director, external clinical consultant or suicide prevention coordinator following a lethality status change as required and monitors compliance across all zone vet centers.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director ensures clinical staff complete crisis reports as required and monitors compliance across all zone vet centers.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director in collaboration with the support Veterans Affairs medical facility clinical or administrative liaison determines the reasons for noncompliance with staff participation on mental health councils at the Casper, Denver, and Midland Vet Centers, and takes actions to ensure compliance with Readjustment Counseling Service requirements.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director determines reasons an external clinical consultant was not assigned as required at the Midland Vet Center and ensures compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director determines reasons for noncompliance with processes for completing and tracking four hours per month of external clinical consultation at the Casper, Denver, El Paso, and Midland Vet Centers, and ensures that Vet Center Directors implement processes and monitors compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director determines reasons for noncompliance with staff supervision provided by the vet center directors at the Casper, Denver, El Paso, and Midland Vet Centers, ensures that staff supervision occurs as required, and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director determines reasons for noncompliance with monthly RCSnet chart audits at the Casper, Denver, El Paso, and Midland Vet Centers, ensures that chart audits are completed as required, and monitors compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director determines reasons for errors in training assignments for staff at the Casper, Denver, El Paso, and Midland Vet Centers, ensures all staff complete mandatory trainings, and monitors compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director evaluates and determines reasons tactile (braille) signage was not posted at all exit doors at the Casper, Denver, El Paso, and Midland Vet Centers and ensures all exit doors are compliant with the Architectural Barriers Act.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director reviews the reasons an updated emergency and crisis plan was not available at the Denver and Midland Vet Centers and ensures an updated plan is accessible to all staff.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director reviews reasons for noncompliance with client record storage at the Denver, El Paso, and Midland Vet Centers and ensures all client records are stored as required.