Federal Reports

The VA Office of Inspector General (OIG) reviewed the Veterans Crisis Line’s (VCL’s) preparation for implementation of the National Suicide Prevention Hotline three-digit dialing code “9-8-8 press 1” (988 press 1). The review focused on responder and supervisor staffing and training, including postvention support awareness; information technology equipment and support; and quality metrics data and oversight.VCL leaders collaborated with the Substance Abuse and Mental Health Services Administration to add the 988 press 1 option. VCL leaders expected an increase in call volume from the addition of 988 press 1 access. The OIG determined VCL leaders hired additional frontline staff in anticipation of the call volume increase. However, VCL had not increased the number of supervisors to meet the identified supervisor-to-staff ratio. Supervisors’ oversight ensures frontline staff provide adequate assessments of callers.The OIG identified a concern related to frontline staff’s awareness of and feelings of support from supervisors to use postvention resources. VCL staff would benefit from awareness and training regarding postvention resources.VCL leaders, in conjunction with the Office of Information and Technology leaders, assessed, planned for, and implemented technology changes related to 988 press 1. The VCL did not encounter technology concerns. The OIG also found quality metrics data were reported monthly to VCL leaders at Executive Leadership Committee meetings and reflected quality oversight.The OIG obtained and compared pre- and post-988 press 1 call volumes from July through December of each calendar year. From 2021 to 2022, call volume increased by 12.5 percent; from 2022 to 2023, call volume increased by 15.1 percent.The OIG made two recommendations to the VCL Director related to determining the optimal supervisor-to-staff ratio and ensuring staff are aware and trained on postvention resources available to them.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess whether leaders implemented corrective actions to address pharmacy-related concerns at the VA Central Western Massachusetts Healthcare System (system) in Leeds.In early 2023, the OIG received five allegations related to prescription processing delays and inadequate pharmacy staff training, and requested the Veterans Integrated Service Network (VISN) Director to respond to the allegations. According to the response, an external review, performed by individuals associated with another VISN, partially substantiated or substantiated four of the five allegations and made 12 recommendations. The System Associate Director (Associate Director) adopted the recommendations as corrective actions and, in July, tasked the chief of pharmacy with implementation. The OIG opened a hotline in September to determine whether system leaders had implemented the 12 corrective actions.The OIG determined that 11 of the 12 corrective actions were incomplete. The OIG found the chief of pharmacy perceived the corrective actions as a disciplinary tool rather than an opportunity to improve pharmacy services and that this impacted implementation of the corrective actions.Further, the Associate Director and the acting Associate Director, as the chief of pharmacy’s supervisors, did not provide effective and timely oversight to ensure completion of the corrective actions. Although not required, they also missed opportunities to involve the VISN Pharmacist Executive earlier, rather than waiting until corrective action deadlines had passed, diminishing the effectiveness of the VISN Pharmacist Executive to assist the system with timely intervention.The OIG made three recommendations to the VISN Director related to the completion of the corrective actions; training of pharmacy staff and supervisors; and ensuring that leaders receive administrative action, as appropriate.