Inspection of Southeast District 2 Vet Center Operations

The VA Office of Inspector General (OIG) Vet Center Inspection Program evaluated aspects of the quality of care delivered throughout Readjustment Counseling Service (RCS). This inspection evaluated four review areas within Southeast District 2 including leadership stability, morbidity and mortality reviews, high risk suicide flag (HRSF) SharePoint site, and consultation and safety plans. There were no findings in leadership stability. For the morbidity and mortality review, the OIG identified that district leaders did not complete reviews timely for clients who died by suicide based on the active policy at the time of the inspection. Leaders also did not follow established tracking methods and had different processes, as well as unclear criteria, when evaluating the need for morbidity and mortality reviews for clients who had serious suicide attempts. In the HRSF SharePoint Site review, the OIG identified noncompliance with timely documentation by vet center staff in RCSNet and highlighted concerns with the accuracy of information in, and utilization of, the HRSF SharePoint site. Additionally, the OIG found care coordination practices in violation of RCS client confidentiality requirements. In the consultation and safety plan review, the OIG found vet center staff noncompliant with seeking consultation and completing and providing safety plans to clients. The OIG issued six recommendations to the District Director and one to the RCS Chief Officer for improvement.