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Report File
Date Issued
Submitting OIG
Department of Veterans Affairs OIG
Agencies Reviewed/Investigated
Department of Veterans Affairs
Components
Veterans Health Administration
Report Number
25-00371-97
Report Description

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 2: Buffalo, Nassau, and Syracuse, New York.

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 Buffalo Vet Center. 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 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 for the Buffalo and Nassau Vet Centers. The environment of care review evaluated vet centers’ physical environment and general safety, resulting in five recommendations for the Syracuse Vet Center and one recommendation for the Nassau Vet Center. In addition, the OIG made one recommendation to the Buffalo Vet Center specific to discrepancies in the vet center address on VA and public-facing websites.

The Chief Readjustment Counseling Officer and District Director concurred with the OIG’s 10 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 staff complete training, fire extinguishers and automated external defibrillators are serviced as required, and to update public-facing websites.

Report Type
Inspection / Evaluation
Agency Wide
Yes
Number of Recommendations
10
Questioned Costs
$0
Funds for Better Use
$0
Report updated under NDAA 5274
No

Open Recommendations

This report has 5 open recommendations.
Recommendation Number Significant Recommendation Recommended Questioned Costs Recommended Funds for Better Use Additional Details
02 No $0 $0

District leaders and the Buffalo, Nassau, and Syracuse 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.

03 No $0 $0

District leaders and the Buffalo, Nassau, and Syracuse Vet Center Directors determine reasons for noncompliance with employees completing select training in the required time frame, ensure completion, and monitor compliance.

08 No $0 $0

District leaders and the Syracuse Vet Center Director determine reasons for noncompliance with annual automated external defibrillator servicing by VA medical center biomedical engineering, ensure completion, and monitor compliance.

09 No $0 $0

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

10 No $0 $0

District leaders determine reasons why there are discrepancies in the vet center address on VA and public-facing websites and ensure all websites include correct location information.

Department of Veterans Affairs OIG

United States