Inspection of Continental District 4 Vet Center Operations

The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered throughout Readjustment Counseling Service (RCS). This inspection evaluates four review areas within Continental District 4 including leadership stability, morbidity and mortality reviews, the high risk suicide flag (HRSF) SharePoint site, and safety plans. There were no findings in stability of leadership. Based on active policy at the time of the inspection, the OIG identified that district leaders did not complete timely morbidity and mortality reviews for clients who died by suicide. Inconsistent with requirements at the time, leaders also implemented a peer review process for all suicide attempts instead of the morbidity and mortality reviews. The OIG did not conduct the HRSF SharePoint site review due to concerns with data accuracy. In April 2024, the OIG made a recommendation to the RCS Chief Officer related to HRSF SharePoint site functionality. The recommendation remained open at the time of the inspection; therefore, the OIG will continue to monitor progress to closure and did not make a new recommendation. Vet center staff were noncompliant with completing and providing safety plans to clients. The OIG issued three recommendations for improvement to the District Director.