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

Submitting OIG:

Report Description:

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.

Date Issued:

Thursday, May 25, 2023

Agency Reviewed / Investigated:

Department of Veterans Affairs

Submitting OIG-Specific Report Number:

21-03269-123

Location(s):

Agency-Wide

Type of Report:

Inspection / Evaluation

Questioned Costs:

Funds for Better Use:

Number of Recommendations:

Report updated under NDAA 5274:

View Document:

Attachment	Size
VAOIG-21-03269-123.pdf	23.49 MB

Additional Details Link:

https://www.va.gov/oig/pubs/VAOIG-21-03269-123.pdf

Recommendation Number	Recommendation Status	Significant Recommendation
01	Open	No
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.
02	Open	No
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.
03	Open	No
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.
04	Open	No
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.
05	Open	No
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.
06	Open	No
The District Director ensures the intake portion of the psychosocial assessment is completed and monitors compliance across all zone vet centers.
07	Open	No
The District Director ensures suicide risk assessments are completed on the first clinical visit and monitors compliance across all zone vet centers.
08	Open	No
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.
09	Open	No
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.
10	Open	No
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.

Recommendation Number

Recommendation Status

Significant Recommendation

Additional Details

Open

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.

Open

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.

Open

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.

Open

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.