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. The OIG inspected four randomly selected vet centers throughout Pacific district 5 zone 3: Phoenix and West Valley, Arizona; Antelope Valley, California; and Santa Fe, New Mexico.The OIG inspection focused on four review areas: suicide prevention; consultation, supervision, and training; outreach; and environment of care. In the suicide prevention review, the OIG team evaluated vet center staff participation in the VA medical facility mental health executive council meeting resulting in one recommendation across two of the four vet centers inspected. The consultation, supervision, and training review identified concerns with external clinical consultation, vet center director monthly chart reviews, and completion of select trainings resulting in three recommendations across three of the four vet centers inspected. The outreach review evaluated outreach plan completion, inclusion of strategic components, and tailoring of outreach activities to cultural background information identified in the plan which resulted in one recommendation across all four vet centers inspected. The environment of care review evaluated vet centers’ physical environment and general safety resulting in five recommendations across all four vet centers inspected.The OIG issued a total of 10 recommendations for improvement.
Open Recommendations
Recommendation Number | Significant Recommendation | Recommended Questioned Costs | Recommended Funds for Better Use | Additional Details | |
---|---|---|---|---|---|
02 | No | $0 | $0 | ||
District leaders and the Antelope Valley, Phoenix, and West Valley 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, and monitor compliance. | |||||
05 | No | $0 | $0 | ||
District leaders and the Antelope Valley, Phoenix, Santa Fe, and West Valley Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance. | |||||
06 | No | $0 | $0 | ||
District leaders and the Santa Fe Vet Center Director determine reasons for noncompliance with having an annual risk and vulnerability assessment completed by VA police or local law enforcement, ensure completion, and monitor compliance. | |||||
08 | No | $0 | $0 | ||
District leaders and the Antelope Valley and Santa Fe Vet Center Directors determine reasons for noncompliance with having an automated external defibrillator located on-site and ensure compliance with the requirement. | |||||
01 | No | $0 | $0 | ||
District leaders and the Phoenix and West Valley Vet Center Director collaborate with the support VA medical facility to determine reasons for noncompliance with staff participation on the mental health executive council, take action as indicated, and monitor compliance. | |||||
02 | No | $0 | $0 | ||
District leaders and the Antelope Valley, Phoenix, and West Valley 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, and monitor compliance. | |||||
04 | No | $0 | $0 | ||
District leaders and the Antelope Valley Vet Center Director determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance. | |||||
05 | No | $0 | $0 | ||
District leaders and the Antelope Valley, Phoenix, Santa Fe, and West Valley Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance. | |||||
06 | No | $0 | $0 | ||
District leaders and the Santa Fe Vet Center Director determine reasons for noncompliance with having an annual risk and vulnerability assessment completed by VA police or local law enforcement, ensure completion, and monitor compliance. | |||||
07 | No | $0 | $0 | ||
District leaders and the Antelope Valley Vet Center Director determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance. | |||||
08 | No | $0 | $0 | ||
District leaders and the Antelope Valley and Santa Fe Vet Center Directors determine reasons for noncompliance with having an automated external defibrillator located on-site and ensure compliance with the requirement. | |||||
09 | No | $0 | $0 | ||
District leaders and the Phoenix and Santa Fe Vet Center Directors determine reasons for noncompliance with having an emergency and crisis plan that includes required components, ensure completion, and monitor compliance. |