The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered throughout the Readjustment Counseling Service (RCS).
This inspection evaluated four review areas within Pacific District 5 including leadership stability, morbidity and mortality reviews, high risk suicide flag (HRSF) SharePoint site, and safety plans.
In the leadership stability review, the OIG found Associate District Directors for Counseling provided extended coverage for vet center director vacant positions, which limited their ability to provide effective oversight. In the morbidity and mortality review, the OIG identified that, based on active policy at the time of the inspection, district leaders did not complete timely, required reviews following notification of suicides and homicides. 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. In the safety plan review, the OIG found vet center staff noncompliant with completing and providing safety plans to clients.
The OIG issued five recommendations for improvement.
