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

Report Information

Issue Date
Report Number
21-03232-37
VISN
State
Missouri
Nebraska
North Dakota
South Dakota
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
18
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 care delivered at vet centers. This report focused on Midwest district 3 zone 3 and four selected vet centers: Columbia, Missouri; Fargo, North Dakota; Omaha, Nebraska; and Sioux Falls, South Dakota. 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 and implemented quality improvement programs in response to VA All Employee Survey results. District 3 zone 3 Vet Center Service Customer Feedback survey results exceeded national scores. The OIG issued one recommendation to the District Director related to annual training. The OIG closed the recommendation because overdue trainings were completed and future trainings were scheduled. The OIG conducted an analysis of vet center quality reviews required to ensure compliance with policy and procedures. The OIG made two recommendations to the District Director for clinical and administrative quality reviews. The OIG made two recommendations specific to morbidity and mortality reviews: one recommendation to the District Director and one to the Readjustment Counseling Service Chief Officer (RCS). The suicide prevention review included zone-wide evaluation of electronic client records, and a focused review of the four selected vet centers. The OIG issued seven recommendations—six 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 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)
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
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The District Director determines reasons clinical quality review remediation plans did not include documentation of deficiency resolution and the time frame for resolution for the Fargo, Omaha, and Sioux Falls Vet Centers, takes indicated actions to ensure completion, and monitors compliance.
No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The District Director determines reasons for lack of evidence that clinical quality review deficiencies were resolved at the Columbia, Fargo, Omaha, and Sioux Falls Vet Centers, takes indicated actions to ensure completion, and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director determines reasons why morbidity and mortality reviews for serious suicide attempts were not completed, ensures completion, and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

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. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

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

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The District Director ensures suicide risk assessments are completed on the first clinical visit and monitors compliance across all zone vet centers.
No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
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. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The District Director verifies 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. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The District Director ensures clinical staff complete safety plans for clients that are assessed at intermediate or high, acute or chronic, risk level as required and monitors compliance across all zone vet centers.

No. 11
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
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. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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 at the Columbia and Fargo Vet Centers, takes action to ensure requirements are met, and monitors compliance.
No. 13
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 of external clinical consultation per month at the Columbia, Fargo and Omaha Vet Centers, ensures vet center directors implement processes, and monitors compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director determines reasons for noncompliance with staff supervision provided by vet center directors at the Columbia, Fargo, Omaha, and Sioux Falls Vet Centers, ensures staff supervision occurs as required, and monitors compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director verifies and determines reasons for noncompliance with monthly RCSNet chart audits at the Columbia, Fargo, Omaha, and Sioux Falls Vet Centers, ensures chart audits are completed as required, and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director determines reasons staff at the Columbia, Fargo, Omaha, and Sioux Falls Vet Centers did not complete required trainings, ensures all mandatory trainings are complete, and monitors compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director evaluates and determines reasons for noncompliance with tactile (braille) signage at the Columbia, Fargo, and Omaha Vet Centers and ensures all exit doors are compliant with Architectural Barriers Act requirements.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director reviews reasons for noncompliance of a missing date on the emergency and crisis plan at the Fargo Vet Center and ensures compliance.