Vet Center Inspection of North Atlantic District 1 Zone 3 and Selected Vet Centers

Report Information

Issue Date
Report Number
21-03233-122
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
24
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 focuses on North Atlantic district 1 zone 3 and four selected vet centers: Center City Philadelphia, Northeast Philadelphia, and Scranton in Pennsylvania; and Huntington in West Virginia. 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 principles and implemented quality improvement programs in response to VA All Employee Survey results. District 1 zone 3 Vet Center Service Customer Feedback survey results were above the national average in all areas except convenience of appointment scheduling and vet center location. The OIG conducted an analysis of vet center quality reviews required to ensure compliance with policies and procedures. The OIG made six recommendations for clinical and administrative quality reviews and one recommendation for morbidity and mortality reviews. 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 nine recommendations—two specific to electronic client records and seven 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, and training, and issued five recommendations. The environment of care review evaluated the four selected vet centers. The OIG made three recommendations. The OIG issued a total of 24 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 reasons clinical quality review remediation plans did not include documentation of deficiency resolution and the time frame for resolution for the Center City, Huntington, Northeast, and Scranton Vet Centers; takes indicated actions to ensure completion; and monitors compliance.
No. 2
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 Center City, Huntington, Northeast, and Scranton Vet Centers; takes indicated actions to ensure completion; and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director determines reasons administrative quality review remediation plans were not completed at the Beckley and Bucks County Vet Centers, ensures completion, and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director determines the reasons administrative quality review remediation plans do not include the Deputy District Director’s approval and date of approval as required, and ensures compliance.
No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The District Director determines reasons administrative quality review remediation plans did not include documentation of deficiency resolution and the time frame for resolution for the Center City, Huntington, Northeast, and Scranton Vet Centers; takes indicated actions to ensure completion; and monitors compliance.
No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The District Director determines reasons for lack of evidence for administrative quality review deficiency resolution for the Center City, Huntington, Northeast, and Scranton Vet Centers; takes indicated actions to ensure completion; and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director ensures completion of a morbidity and mortality review for the death by homicide, and ensures all future morbidity and mortality reviews are completed as required.
No. 8
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. 9
Closed and Implemented Recommendation Image, Checkmark
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. 10
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. 11
Open Recommendation Image, Square
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. 12
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The District Director confirms clinical staff make timely notification to the suicide prevention coordinator at the support VA medical facility for clients with significant safety risks, and monitors compliance across all zone vet centers.
No. 13
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The District Director ensures clinical staff complete safety plans for clients that are assessed at intermediate or high suicide risk level in either acute, chronic, or both categories as required, and monitors compliance across all zone vet centers.
No. 14
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 following a client’s suicide risk assessment as required, and monitors compliance across all zone vet centers.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The District Director, in collaboration with the support VA medical facility clinical or administrative liaisons, determines the reasons for noncompliance with staff participation on the mental health council for the Center City, Huntington, Northeast, and Scranton Vet Centers, and takes actions as indicated to ensure compliance with Readjustment Counseling Service requirements.

No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director determines the reasons for noncompliance with critical event plans with desktop reference at the Center City and Northeast Philadelphia Vet Centers, and takes actions as indicated to ensure compliance with Readjustment Counseling Service requirements.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director determines reasons for noncompliance with the appointment of a clinical liaison at the Scranton Vet Center, ensures assignment of a mental health professional as liaison, and monitors compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director determines reasons for noncompliance with a process for completing and tracking four hours of external clinical consultation per month at the Center City, Scranton, and Northeast Vet Centers; ensures Vet Center Directors implement processes; and monitors compliance.
No. 19
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 Center City, Huntington, Northeast, and Scranton Vet Centers; ensures staff supervision occurs as required; and monitors compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director verifies and determines reasons for noncompliance with monthly chart audits at the Center City, Huntington, Northeast, and Scranton Vet Centers; ensures chart audits are completed as required; and monitors compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The District Director determines reasons employees at the Center City, Huntington, Northeast, and Scranton Vet Centers did not complete required trainings; ensures all staff complete mandatory trainings; and monitors compliance.

No. 22
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 Center City, Huntington, and Northeast Vet Centers, and ensures all exit doors are compliant with Architectural Barriers Act Standards.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director reviews reasons for noncompliance with securing confidential and sensitive information at the Center City Vet Center, and ensures all vet center employees safely and securely store protected health information.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The District Director reviews reasons for noncompliance with having a current and comprehensive emergency and crisis plan at the Center City and Northeast Vet Centers, ensures completion of a current and comprehensive emergency and crisis plan, and monitor’s compliance.