The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of care delivered at vet centers. This report focuses on North Atlantic district 1 zone 3 and four selected vet centers: Center City Philadelphia, Northeast Philadelphia, and Scranton in Pennsylvania; and Huntington in West Virginia. The OIG inspection focused on five review areas: leadership and organizational risks; quality reviews; suicide prevention; consultation, supervision, and training; and environment of care.Generally, district leaders had a good understanding of quality improvement principles and implemented quality improvement programs in response to VA All Employee Survey results. District 1 zone 3 Vet Center Service Customer Feedback survey results were above the national average in all areas except convenience of appointment scheduling and vet center location.The OIG conducted an analysis of vet center quality reviews required to ensure compliance with policies and procedures. The OIG made six recommendations for clinical and administrative quality reviews and one recommendation for morbidity and mortality reviews.The suicide prevention review included a zone-wide evaluation of electronic client records, and a focused review of the four selected vet centers. The OIG issued nine recommendations—two specific to electronic client records and seven for selected vet centers’ suicide prevention and intervention processes.The consultation, supervision, and training review evaluated the four selected vet centers. The OIG identified concerns with external clinical consultation, supervision, and training, and issued five recommendations.The environment of care review evaluated the four selected vet centers. The OIG made three recommendations.The OIG issued a total of 24 recommendations for improvement to the District Director.
Open Recommendations
| Recommendation Number | Significant Recommendation | Recommended Questioned Costs | Recommended Funds for Better Use | Additional Details | |
|---|---|---|---|---|---|
| 02 | No | $0 | $0 | ||
| The District Director determines reasons for lack of evidence that clinical quality review deficiencies were resolved at the Center City, Huntington, Northeast, and Scranton Vet Centers; takes indicated actions to ensure completion; and monitors compliance. | |||||
| 05 | No | $0 | $0 | ||
| The District Director determines reasons administrative quality review remediation plans did not include documentation of deficiency resolution and the time frame for resolution for the Center City, Huntington, Northeast, and Scranton Vet Centers; takes indicated actions to ensure completion; and monitors compliance. | |||||
| 06 | No | $0 | $0 | ||
| The District Director determines reasons for lack of evidence for administrative quality review deficiency resolution for the Center City, Huntington, Northeast, and Scranton Vet Centers; takes indicated actions to ensure completion; and monitors compliance. | |||||
| 11 | No | $0 | $0 | ||
| The District Director verifies clinical staff follow confidentiality requirements when consulting and coordinating care with the support VA medical facility for shared clients at high risk for suicide, and monitors compliance across all zone vet centers. | |||||
