Inspection of North Atlantic District 1 Vet Center Operations

Report Information

Issue Date
Report Number
24-02172-253
VISN
State
District
North Atlantic
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Vet Center Inspection Program
Report Topic
Care Coordination
Mental Health
Suicide Prevention
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
5
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 organizational risk and the quality of care delivered at vet centers.

This inspection evaluated leadership stability and staff perceptions of Readjustment Counseling Service (RCS) operations, morbidity and mortality reviews, and the high risk suicide flag (HRSF) SharePoint site within North Atlantic District 1.

There were no findings in leadership stability and staff perceptions of RCS operations review. The morbidity and mortality review identified that district leaders did not ensure that all reviews were completed within 120 days and did not notify the RCS Deputy Chief Officer of the delays. Additionally, some reviews did not contain all VHA Directive 1500(4) required information and staff did not distribute morbidity and mortality review report lessons learned nationally across RCS. The HRSF review identified noncompliance with documentation requirements for high-risk client contacts and outcomes in both RCSNet and the HRSF SharePoint site, as well as concerns with the accuracy and functionality of the SharePoint site.

The OIG issued two recommendations to the RCS Chief Officer who provided plans to distribute morbidity and mortality review lessons learned nationally across RCS and implement a solution to address individuals identified on the High Risk for Suicide list.

The OIG issued three recommendations to the District Director who provided plans to monitor compliance with the implemented morbidity and mortality tracker; ensure that all morbidity and mortality review components are addressed and all warranted recommendations are included; and improve compliance with HRSF SharePoint-related RCSNet documentation requirements.

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 monitors district leaders’ compliance with completion of morbidity and mortality reviews for client deaths by suicide, including timeliness, as required.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The District Director ensures district leaders are aware of the Readjustment Counseling Service policy requirements to provide oversight of morbidity and mortality review completion, including all review components, the appropriateness of recommendations, and reporting delays to the Deputy Chief Officer.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Readjustment Counseling Service Chief Officer ensures morbidity and mortality review lessons learned are distributed nationally across Readjustment Counseling Service to support suicide prevention efforts.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The District Director identifies reasons for noncompliance with HRSF SharePoint-related RCSNet documentation requirements, ensures requirements are met, and monitors compliance.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Readjustment Counseling Service Chief Officer ensures implementation of a planned solution to address the high risk suicide flag SharePoint site malfunction and ensures data accuracy and functionality as intended.