Report Summary

Title: Deficiencies in Suicide Risk Assessments, Continuity of Care, and Leadership at the South Bend Vet Center in Indiana
Report Number: 21-02511-28 Download
Issue Date: 1/19/2023
City/State: South Bend, IN
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Hotline Healthcare Inspection
Release Type: Unrestricted

The VA Office of Inspector General (OIG) conducted an inspection to assess allegations and concerns related to quality client care and leadership at the South Bend Vet Center (facility) in Indiana. The facility is aligned under Readjustment Counseling Service’s (RCS) Midwest district 3.

The OIG substantiated facility staff inaccurately assessed the suicide risk level for three clients. Facility staff documented clients’ risk factors for suicide but failed to account for the risks when assigning risk levels. The OIG found the assigned levels lower than clinically indicated.

The OIG substantiated the vet center director (VCD) guided staff to rate suicide risk levels low to avoid RCS leader involvement. This guidance, the VCD’s clinical and leadership competency deficits, and staff’s lack of understanding suicide risk evaluation and management contributed to the inaccurate levels.

The VCD failed to provide adequate oversight and instruction to a counseling intern, including on actions needed to mitigate suicide risk. The OIG substantiated the VCD failed to facilitate a time-sensitive transition of care and ensure measures, consistent with a client’s high-risk behaviors, hospitalization, and post-hospitalization needs, were in place. The client subsequently died by suicide. The OIG considered the failure to mitigate suicide risk an adverse event.

The OIG determined a district leader, who removed the VCD from clinical care, failed to report clinical deficiencies to the state licensing board. Further, RCS lacked a clear process for state licensing board reporting. The OIG found district leaders failed to ensure remediation of repeat deficiencies identified during the facility’s quality reviews.

The OIG made three recommendations to the Chief Readjustment Counseling Officer related to adverse events, intern oversight, and state licensing boards. The OIG made five recommendations to the Midwest District 3 Director related to assessing and mitigating suicide risk, continuity of care, adverse events, and state licensing board reporting.

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