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

Report Information

Issue Date
Report Number
25-00369-98
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
8
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 1: New Haven, Connecticut; Sanford, Maine; and Providence, Rhode Island.

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 one recommendation for the New Haven Vet Center. The consultation, supervision, and training review evaluated external clinical consultation, monthly client record reviews, and completion of select trainings. This resulted in three recommendations related to external clinical consultation and training across all three vet centers inspected. 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 three recommendations across all three vet centers inspected. 

The Chief Readjustment Counseling Officer and District Director concurred with the OIG’s eight recommendations. District leaders reviewed requirements and developed plans for participation in VA mental health executive council, external clinical consultation, outreach plans, and emergency and crisis plans with vet center directors. Further, district leaders developed processes to ensure monthly review of active client records, staff complete trainings, and fire extinguisher and automated external defibrillators are inspected as required.
 

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)

District leaders and the New Haven Vet Center Directors collaborate with the supporting VA medical facility to determine reasons for noncompliance with staff participation on the mental health executive council, take action as indicated, and monitor compliance.

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

District leaders and the New Haven, Sanford, and Providence Vet Center Directors 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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2026

District leaders and the Sanford Vet Center Director determine reasons for noncompliance with completing monthly reviews of 10 percent of active client records for each counselor’s caseload, ensure completion and monitor compliance.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2026

District leaders and the New Haven, Sanford, and Providence Vet Center Directors determine reasons for noncompliance with employees completing select training in the required time frame, ensure completion, and monitor compliance.

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

District leaders and the New Haven, Sanford, and Providence Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2026

District leaders and the New Haven and Providence Vet Center Directors determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2026

District leaders and the New Haven Vet Center Director determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

District leaders and the Sanford Vet Center Director determine reasons for noncompliance with having an emergency and crisis plan that includes required components, ensure completion, and monitor compliance.