Vet Center Inspection of North Atlantic District 1 Zone 4 and Selected Vet Centers

Report Information

Issue Date
Report Number
21-03269-123
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
22
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 North Atlantic district 1 zone 4 and four selected vet centers: Baltimore and Dundalk in Maryland, Raleigh in North Carolina, and Richmond in 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 district-wide quality improvement programs in response to VA All Employee Survey results. District 1 zone 4 Vet Center Service Customer Feedback survey results were below the national average in all areas except one regarding vet center location. High turnover and use of technology instead of face-to-face visits were noted as reasons. The OIG conducted an analysis of vet center quality reviews required to ensure compliance with policies and procedures. The OIG made five recommendations for clinical and administrative quality reviews and issued one finding 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 ten recommendations—six related to the review of electronic client records and four specific to the 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, chart audits and training, and issued four recommendations. The environment of care review evaluated the four selected vet centers. The OIG made three recommendations. The OIG issued a total of 22 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
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 Baltimore, Dundalk, Raleigh, and Richmond 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 for clinical quality review deficiency resolution for the Baltimore, Dundalk, Raleigh, and Richmond 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 the administrative quality review remediation plan was not completed for one vet center within the zone, ensures completion, and monitors compliance.
No. 4
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 of resolution for the Dundalk, Raleigh, and Richmond Vet Centers; takes indicated actions to ensure completion; and monitors compliance.
No. 5
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 Dundalk, Raleigh, and Richmond Vet Centers; takes indicated actions to ensure completion; and monitors compliance.
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
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. 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
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. 10
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. 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 following a client’s suicide risk assessment as required; and monitors compliance across all zone vet centers.
No. 12
Open Recommendation Image, Square
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 Baltimore, Dundalk, Raleigh, and Richmond Vet Centers; and takes action as indicated to ensure compliance with Readjustment Counseling Services requirements.
No. 13
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 at risk at the Raleigh Vet Center and takes action to ensure requirements are met, and monitors compliance.

No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director determines reasons the Raleigh and Richmond Vet Center Directors did not have accurate knowledge of type of clients on the High Risk Suicide Flag SharePoint site, takes actions to ensure vet center directors incorporate relevant information from the SharePoint site to safely disposition clients, and monitors compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The District Director determines the reasons for noncompliance with staff access to critical event plans that included a desktop reference at the Baltimore and Dundalk 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 reasons for noncompliance with a process for completing and tracking four hours of external clinical consultation per month at the Baltimore, Dundalk, and Raleigh Vet Centers; ensures vet center directors implement processes; and monitors compliance.

No. 17
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 Baltimore and Dundalk Vet Centers, ensures staff supervision occurs as required, and monitors compliance.
No. 18
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 Baltimore, Dundalk, Raleigh, and Richmond Vet Centers; ensures chart audits are completed as required; and monitors compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The District Director determines reasons employees at the Baltimore, Dundalk, Raleigh, and Richmond Vet Centers did not complete required trainings; ensures all staff complete mandatory trainings; and monitors compliance.

No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The District Director evaluates and determines reasons for noncompliance with a presentable exterior at the Richmond Vet Center and ensures all exterior grounds are in good repair.
No. 21
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 Baltimore, Dundalk, and Raleigh Vet Centers and ensures all exit doors are compliant with Architectural Barriers Act Accessibility Standards.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The District Director reviews reasons for noncompliance with maintaining a current and comprehensive emergency and crisis plan at the Raleigh and Richmond Vet Centers and ensures all emergency and crisis plans are updated and comprehensive as required.