Breadcrumb

Inspection of Select Vet Centers in North Atlantic District 1 Zone 3

Report Information

Issue Date
Closure Date
Report Number
25-00372-96
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
3
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 the quality of care delivered at vet centers. This inspection report evaluated three randomly selected vet centers throughout North Atlantic district 1 zone 3: Dubois, Lancaster, and White Oak, Pennsylvania.

This OIG inspection focused on four review areas: suicide prevention; consultation, supervision, and training; outreach; and environment of care. The suicide prevention review evaluated vet center staff participation on supporting VA medical facility mental health executive councils and documentation of contacts and outcomes in the high risk suicide flag SharePoint site, which resulted in no recommendations for the three vet centers inspected. The consultation, supervision, and training review evaluated external clinical consultation, monthly client record reviews, and completion of select trainings. This resulted in two recommendations related to external clinical consultation and training for the Lancaster and White Oak Vet Centers. The outreach review evaluated outreach plan completion, inclusion of strategic components, and tailoring of outreach activities to eligible individuals, which resulted in one recommendation across all three vet centers inspected. The environment of care review evaluated vet centers’ physical environment and general safety, resulting in no recommendations for the three vet centers inspected.

The Chief Readjustment Counseling Officer and District Director concurred with the OIG’s three recommendations. District leaders reviewed requirements and developed processes to ensure compliance with external clinical consultation and outreach plans with vet center directors. Further, district leaders ensured staff are compliant with required trainings.
 

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)
Closure Date: 3/31/2026

District leaders and the Lancaster Vet Center Director determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented to complete consultation requirements, and monitor compliance.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2026

District leaders and the White Oak Vet Center Director determine reasons for noncompliance with employees completing select training in the required time frame, ensure completion, and monitor compliance.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2026

District leaders and the Dubois, Lancaster, and White Oak Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.