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VA OIG healthcare inspectors share the history of vet centers, OIG’s oversight of vet center operations, and the findings from the first five VCIP reports published.
Inside Oversight is an official podcast of the Department of Veteran Affairs, Office of Inspector General. Each episode examines in detail some of our more nuanced oversight reporting. To understand the complexities of the topics, we talk with the report authors to gain insight into how the team conducted its work, what it found, and the impact on veterans and the public. Visit the VA OIG website for recently published reports.
Adam Roy:
Hello and welcome back to another episode of Inside Oversight, a podcast of the Veterans Affairs Office of the Inspector General.
This is your host, Adam Roy.
Today’s episode will focus on the Vet Center Inspection Program and its related reports. For brevity purposes, we will often use the acronym VCIP—that’s V-C-I-P. This program’s purpose is to provide oversight of vet centers, which deliver a multitude of social and psychological services to veterans, including mental health counseling. We’re going to talk about the history of vet centers, OIG’s oversight of vet center operations, and the findings from the first five VCIP reports published by the OIG.
To help me do that, I have Mahshid Lee and Dr. Bina Patel with me today. Mahshid is a healthcare inspector, and Dr. Patel is an associate director here at the VA OIG. Thank you both for being here. How are you guys doing?
Mahshid Lee:
I am doing great. Thank you for having us today, Adam. And feel free to call me Mash?
Adam Roy:
Absolutely.
Dr. Bina Patel:
Yeah, this is great, and we’re really excited to share what we’ve learned. Thanks for having us, like Mash said.
Adam Roy:
Awesome. And I also have Lindsay Gold with us who I’m going to talk to later about the VA OIG’s published VCIP reports. Lindsay, good to have you, too. How are you?
Lindsay Gold:
Thank you for having us, Adam. I am great and excited to share some VCIP info with everyone.
Adam Roy:
Okay, awesome. Let’s get started. Bina, let’s start by helping the listener get an understanding of vet centers. Can you explain what vet centers are and why they were established?
Dr. Bina Patel:
Yes. Vet centers, the services they offer, and where they sit operationally within VHA is less widely understood compared to services that are offered within the more traditional hospital based or outpatient healthcare settings. Back in 1979, Public Law 96-22 was signed establishing the Readjustment Counseling Service, also known as RCS. It’s the branch of VHA responsible for operation and oversight of vet centers.
Adam Roy:
Mash, why was there a need for vet centers, specifically during this time period?
Mahshid Lee:
The Readjustment Counseling Service was established to assist returning Vietnam era veterans transitioning back into civilian life. Many vet center counselors, being veterans themselves, understand that transition. It was authorized as a separate program from VA medical facilities partially based on the premise that many Vietnam era veterans were distrustful of the government and would not seek VA care.
Adam Roy:
That’s very interesting. Why was having vet centers separate from VA medical facilities so important?
Mahshid Lee:
It was believed that providing services in an outpatient mental health setting would reduce stigma associated with mental illness. Post-traumatic stress disorder wasn’t a recognized mental health diagnosis in 1979, so vet centers were really ahead of their time in addressing war-time trauma. One of the sayings you often hear when people talk about vet centers is “help without the hassle.”
Adam Roy:
Thank you. Bina, tell me about the Readjustment Counseling Service organizational structure? How many vet centers are there?
Dr. Bina Patel:
Sure, Adam. When we’re picturing RCS, I want you to imagine that there are three levels. The first level is where the chief officer, Michael Fischer, sits and he oversees the whole organization. From there we move into that second level, which is comprised of five separate districts, and then there’s a third level with the individual vet centers, of which there are 300.
Adam Roy:
Share with me a little more about the district level?
Dr. Bina Patel:
They’re five districts, and they’re spread across the 50 states as well as Puerto Rico, Guam, American Samoa, and the Virgin Islands. The district office has one district director who oversees that entire district. Each district is then further split into anywhere from two to four geographically organized zones. The zone then has its own leadership team that includes a deputy district director and associate district directors for counseling and administration, all of which oversee the administrative and clinical operations of vet centers that are located in the zones.
Adam Roy:
Where do the individual vet centers in the community fit into this structure?
Mahshid Lee:
This is a great question. Each zone leadership team is responsible for about 18 to 25 vet centers. Each vet center consists of a small interdisciplinary team of a vet center director, readjustment counselors, a veteran’s outreach specialist, and a program support assistant. Some vet centers also have outstations and mobile vet centers as part of their services. The outstations and mobile vet centers are managed by the vet center director. The outstations are typically located in more rural areas allowing easier access for clients, and the mobile vet centers are just that--they move around, assist with special events and community crisis situations, and provide services at certain locations based on need.
Adam Roy:
Just to clarify, are vet centers located near a VA medical center and medical facility or within a VA medical facility?
Dr. Bina Patel:
Vet centers are established in the community so that they can promote ease of access for clients, and they typically have convenient locations for all modes of local transportation. Because of these established community partnerships, vet center counselors can and do conduct outreach and provide services within those communities, at locations such as local libraries, in those areas located at some distance from the vet center.
Adam Roy:
There seems to be an emphasis on the veteran’s military experience and the importance of pride in their service. Mash, can you tell us a little bit more about that in regard to the Readjustment Counseling Service?
Mahshid Lee:
Certainly. RCS care is enhanced by the presence of veteran staff on vet center teams. By design, the vet centers interior decor resonates with a veteran’s military experience through a display of military artwork and memorabilia. The vet center’s relaxed, non-institutional culture is also planned to represent the local community and really enables veterans to feel at home.
Adam Roy:
We keep saying “readjustment counseling.”. For any listeners out there who are not a veteran themselves or they’re not familiar with these programs, can you explain readjustment counseling and elaborate more on the services vet centers provide?
Dr. Bina Patel:
Absolutely. Vet centers serve both active-duty service members and veterans, and this includes the national guard and reserves, but they also serve their family members, too. The centers provide both psychological and psychosocial services, but vet center staff don’t diagnosis nor do they require the client to have a mental health condition in order to get their services there. And when you’re talking about readjustment counseling, it can help individuals and their families transition successfully from their military life to their civilian life and address some of those traumatic events individuals may experience in the military.
But vet center services aren’t just limited to counseling either, Adam. They also have a veteran outreach program specialist, who’s also known as a VOPs, and they’re veterans themselves and spend time in the community to improve awareness and access to care through some face-to-face connections they make with veterans in those communities.
Adam Roy:
Mash, did you want to add anything to that?
Mahshid Lee:
Yes, just to add on to what Bina was saying, I think it’s important to know that although vet centers are not open 24 hours a day, they do have evening and weekend hours that vary by vet center. They also have a 24-hour-a-day, 7-days-a-week call center that’s available for veterans, service members, and their families to talk about their military experience or any other issues they’re facing with readjustment to civilian life. In an event of a suicidal caller, the call center can seamlessly transfer calls to the VHA Crisis Line. The staff at the call center is composed of combat veterans from different eras and family members of combat veterans.
Adam Roy:
The call center sounds like a very valuable resource to veterans. Mahshid, who can go to a vet center?
Mahshid Lee:
Vet center eligibility has expanded several times over the years. Individuals who are eligible to receive services at vet center include:
• Individuals who have served on active military duty in any combat theater or area of hostility including members of the National Guard and Reserves,
• Individuals who have experienced a military sexual trauma regardless of gender or service era,
• Individuals who provided direct emergency medical, mental health care, or mortuary services to the casualties of combat operations or hostilities, and
• Individual crew members conducting combat drone operations regardless of their physical location.
These are just a few examples. For full eligibility information, individuals should contact their nearest vet center.
Adam Roy:
And how would eligible veterans establish care at a vet center?
Mahshid Lee:
Eligibility can be established in a variety of ways. Discharge paperwork is probably the most common way, but a veteran can bring in awards or deployment orders. Anything to show deployment to a combat zone would be accepted as evidence.
Adam Roy:
Bina, you mentioned earlier that vet centers also provide services to family members as well.
Dr. Bina Patel:
Yes, vet centers see family members, as long as it is tied to the Veteran’s readjustment to civilian life or for services such as bereavement counseling.
Adam Roy:
What other types of counseling are offered, and is there an associated cost with that?
Dr. Bina Patel:
Vet centers provide therapy in different treatment modalities, such as individual, group, and family therapy. There is no time limit to the services, as long as it’s related to that individual actively working on treatment goals. And there is no cost to either the veteran or family member.
Adam Roy:
Do vet center counselors have access to the same electronic record keeping system as VA medical facilities have?
Mahshid Lee:
That’s a really good question. Vet center documentation is separate from VHA and DoD records, and is not shared unless the individual signs a release of information. But most vet centers can view VHA electronic health records.
Adam Roy:
If they’re separate, are veterans able to receive services from both at the same time?
Mahshid Lee:
Yes, definitely. A client can receive services at both the vet center and VA. For example, an individual can see a counselor at the vet center and still see a psychiatrist at the VA for medication management.
Adam Roy:
That’s a really good point to make there. I can see how collaboration between these vet centers and VHA is really important to providing vets with the care and services that they need. We’re going to talk a little bit more about vet centers and VHA collaboration later in this podcast.
Before you began the Vet Center Inspection Program, had the OIG previously done any investigations or reports in this area?
Mahshid Lee:
Yes. Prior to launching VCIP in September 2020, the OIG published five reports on vet centers between 2000 and 2017. The reports ranged from concerns related to supervision, consultation, and quality of care, to care collaboration and documentation. Four of the five reports resulted in recommendations to RCS.
Adam Roy:
Let’s dig into that a little bit. Can we talk about the 2000 report?
Mahshid Lee:
Sure. This report did not result in a recommendation for the vet center; however, it did result in a recommendation to the Omaha VA medical facility. We recommended that they have a formalized relationship, through a local memorandum, and alert the vet center when veterans are referred for medication therapy and talk therapy at the VA. A second report in 2009 found documentation deficiencies in the vet center client records and recommended the RCS comply with their requirements or revise them to be consistent with practice.
Adam Roy:
Did the 2009 report have any other recommendations of importance?
Mahshid Lee:
Yes. One recommendation was for vet centers to have to an external clinical consultant from the VA medical facility, and the other was for vet centers to have a seat on the VA medical facility mental health council. Again, as you can see, the focus is on that shared collaboration between vet centers and VA medical facilities.
Adam Roy:
You mentioned external consultants and the mental health council. What are those and what is their importance?
Mahshid Lee:
Vet centers are required to have an external clinical consultant, and typically this is a licensed mental health professional who provides a peer review of complex and emergent cases. Not only are vet centers required to have that consultant, but they must also have four hours a month of this type of consultation per their policy.
The mental health councils meet monthly or quarterly at VA medical facilities, and it varies from one VA to another. The meetings are a great way for vet centers to learn about VA services but also for the vet centers to share their services as well.
Adam Roy:
The relationship between the vet centers and VA medical facilities is very important. Were there any other reports on vet centers prior to the launch of the VCIP program?
Dr. Bina Patel:
Yes, Adam, there were a few. There was one report each in 2011, 2013, and 2017. That 2011 report focused on oversight, which we also are reviewing in our current inspections. The OIG recommended at that time that team leaders, who we now refer to as vet center directors, perform monthly record reviews, provide supervision and consultation in compliance with RCS policy, and take corrective action in response to district office reviews that were completed during annual clinical quality oversight reviews. That’s a mouthful, but essentially the district office is required to annually provide clinical and administrative oversight of each of its vet centers to ensure compliance with program requirements.
Adam Roy:
What takeaways did you identify in those later 2013 and 2017 reports?
Mahshid Lee:
For the 2013 report, it was about contracted care and there was a recommendation that vet center directors review and approve psychosocial assessments and counseling plans prior to authorizing any contracted counseling services and that there also be annual reviews, and onsite quality reviews for participating contractors. In the 2017 report, this was related to the quality of care at VISN 23 facilities and the St. Paul Vet Center. It recommended that the vet centers identify clients whose non-VA care for post-traumatic stress disorder was terminated and determine which of those clients were offered mental health services and follow up accordingly.
Adam Roy:
That’s a really good summary of all prior reports on vet centers.
We have a good understanding of what vet centers do, how they came to be, and how they help veterans and their families. Now let’s transition to the Vet Center Inspection Program that the VA OIG implemented. How did that come to be?
Dr. Bina Patel:
Adam, as we’ve discussed, vet centers are really an integral part of how veterans receive mental health services. As these vet centers evolved and expanded services, which included evidenced-based treatments for post-traumatic stress disorder and other psychological counseling, the OIG really became interested in the care vet centers were providing and recognized that there had been limited oversight in the past. The OIG wants to ensure that vet centers provide services in accordance with Veterans Health Administration guidance for safe and effective mental health treatment. We also want to ensure that Readjustment Counseling Services and VHA are collaborating, as required—as we’ve mentioned—to provide appropriate care for a veteran population who’s often at higher risk for both mental illness and suicide. For the first time, all vet centers will be inspected in a cyclical, recurring basis, due to this new OIG inspection program, which we fondly call VCIP.
Adam Roy:
Anything you want to add to that?
Mahshid Lee:
Yes, just to piggyback on what Bina was saying, our goal is to provide oversight for RCS vet centers on a cyclical and recurring basis. We want to help vet centers identify areas of vulnerability or conditions that, if properly addressed, could improve the safety and the quality of care delivered at vet centers to veterans, family members, and active service members.
We’ve been researching vet center regulations and building the Vet Center Inspection Program for over two years, so it’s nice to be able to share what we have learned with everyone.
Adam Roy:
Oversight can be a general term. Are there any specific areas that these VCIP inspections focus on?
Dr. Bina Patel:
Yes, one of the key areas we are evaluating is suicide prevention.
As many of us know, suicide prevention is one of VA’s highest priorities. In 2020, the suicide rate for veterans was one and a half times greater than that for non-veteran adults. A primary focus of the cyclical VCIP inspections is coordination of care for veterans at high risk for suicide.
It was back in 2017 that RCS and Office of Mental Health and Suicide Prevention signed a memorandum of understanding outlining the shared responsibilities between the two offices and suicide prevention coordinators at the VA medical centers.
Adam Roy:
What were some of those responsibilities?
Dr. Bina Patel:
There are many components to that memorandum, so I’m just going to touch on a few. One is there must be a standardized communication process between RCS and suicide prevention coordinators. VA medical centers are required to share a list of veterans that are at high risk for suicide with RCS. The Office of Mental Health and Suicide Prevention is required to send RCS a list of veterans identified at increased predictive risk for suicide. RCS staff are required to notify suicide prevention coordinators of clients with significant safety risks in a timely manner; and then RCS staff must receive suicide prevention training.
Adam Roy:
The word that comes to mind right now is collaboration.
Dr. Bina Patel:
Yes, that is the true spirit of the memorandum—to ensure veterans who are at risk are getting the best care.
This is a large part of what the OIG is evaluating through the VCIP. Through recurring inspections, the OIG evaluates that collaboration and coordination of care between vet centers and those VA medical facilities and also evaluates services provided for those shared clients.
Adam Roy:
What other topic areas do the VCIP inspections cover?
Mahshid Lee:
The VCIP inspection cycle typically runs the course of a fiscal year, which is October 1 through September 30. During that time, we review differing requirements related to leadership and organizational risks; quality reviews; suicide prevention; consultation, supervision, and training; and lastly the environment of care.
Adam Roy:
Let’s think about the actual vet centers. Do your inspectors go to these vet centers? And when they’re there, what does the process look like?
Dr. Bina Patel:
Funny you should ask, Adam. Our program actually launched in September of 2020. As many people know, that was right in the middle of the COVID-19 pandemic, which started around March 2020. We had essentially spent over a year creating the program, and our intent was to inspect the vet centers in person. But with the onset of the pandemic, we had to quickly pivot and change plans. We went from an in-person inspection to a virtual inspection pretty quickly. And given the significant impact the pandemic had on individual health and entire health care systems, we added an additional topic to our reviews called the response to the COVID-19 pandemic.
Adam Roy:
Let’s talk about that. What is a virtual inspection?
Dr. Bina Patel:
We used a lot of technology to accomplish this. We used video conferencing, which is similar to Zoom, to conduct interviews with staff. We also used FaceTime to complete our tours of each vet center for the environment of care review. For the clinical care, we reviewed used RCSNet, which is the electronic health record that RCS has, to review client charts.
Adam Roy:
Of course, technology offers many advantages. But, as we all know, it can cause setbacks. And it can cause challenges when you’re communicating virtually versus in person. Did you guys face challenges as you went through this process that had to be changed quite quickly?
Dr. Bina Patel:
Oh yes, there were definitely some technological challenges that we had to handle with a little bit of grace, but for the most part we were able to complete our inspections successfully.
Adam Roy:
And how was the topic of privacy addressed when using technology?
Dr. Bina Patel:
All our conferencing platforms that we use and iPhones are secure, so there were no privacy violations. We also required vet center staff to only use government issued iPhones to ensure that privacy.
Adam Roy:
That’s great. I want to thank you both, Mash and Bina, for your insight into the VCIP program. Now, I’d like to turn our focus to the five reports the OIG published from inspections conducted since the Vet Center Inspection Program launched. These reports were first published in September 2021, followed by several more in December of last year.
Lindsay—who I already introduced, but I’ll say it again—our director of the vet center inspection program, is going to help me. Lindsay, thank you again for being here today.
Before we get into the specifics of these reports, remind us again how many vet centers there are and how that ties into your cyclical inspection process?
Lindsay Gold:
Sure. And thanks again for having us here today, Adam. There are 300 vet centers, 80 mobile vet centers, 18 outstations, and the vet center call center. RCS has 5 districts each with 2 to 4 zones. Within each zone there are 18 to 25 vet centers. Each vet center has a vet center director who’s responsible for all vet center operations. Readjustment Counseling Services (or RCS) is a division within Veterans Health Administration that oversees all vet centers.
Adam Roy:
During the design and building of the inspection program, what factors influenced your decisions and the OIG’s decisions?
Lindsay Gold:
We considered numerous factors when designing VCIP. The large geographical coverage area of RCS, the complexity of the centers’ organizational structure, and the need for a cyclical compliance-based inspection were all things that we considered.
Adam Roy:
It’s an accomplishment—launching a program and getting something off the ground. To date, how many reports have we published and where are we going next?
Lindsay Gold:
So far, we have published 5 reports of inspections conducted in fiscal year 2020 and 2021. We visited 3 districts and 20 individual vet centers in the southeast, continental, and pacific districts. I should point out that the vet centers are randomly selected for each inspection.
Although aligned with VHA, RCS is autonomous in determining the services they provide and how they provide the services. The first step for our team was to really understand the RCS operational requirements, both clinical and administrative. We did this through an extensive review of RCS policies and procedures.
Adam Roy:
After that, where did you guys go next?
Lindsay Gold:
The understanding of RCS policies and procedures is ongoing. RCS continues to evolve and grow, but once we gained that foundational understanding, our next step was determining specific areas of review. We touched briefly on the autonomy of RCS, that its policies are separate from VHA, but RCS also has a clinical documentation system called RCSnet, that’s independent of the electronic health record used by VHA medical facilities.
Adam Roy:
As Mash mentioned earlier; vet center and VHA clinical documentation systems are separate. Did these separate systems create challenges for your inspection teams?
Lindsay Gold:
The reason for the separation is a federal regulation requiring vet centers to maintain confidential records independent of any other VA or DoD medical records. Vet center records can’t be disclosed without voluntary, written approval of the veteran. The separation of the records did create some challenges for the team when we were designing our inspection process. But, more importantly, we found that the separate records created challenges for the vet center efforts to really coordinate that seamless client care with VA medical facilities, especially around suicide prevention.
Adam Roy:
I can see how that may complicate things. Now let’s get into the details of the inspection process. Can you tell us what’s the focus of the VCIP inspections?
Lindsay Gold:
Sure. The VCIP inspections are focused on evaluating the quality and safety of care RCS provides across the nation. In our initial inspections, we focused on five areas. The first area is leadership and organizational risk, which evaluates leadership stability, internal quality oversight processes, and staff perceptions of safety and quality improvement.
The second area is suicide prevention. We evaluated adherence to policies for management of clients at high risk for suicide, which are in place to improve outcomes for clients receiving care at vet centers. That also includes policies related access to care, care coordination with VA medical facilities, high risk client follow-up, and crisis plans.
Thirdly, we reviewed whether staff are trained and have the consultation support and clinical supervision required to provide clients the best care. Next, we looked at the environment of care including the physical environment of the vet centers, general safety, and privacy. Lastly, we evaluated the district staff and vet center directors on how they managed the COVID-19 pandemic, inquiring about policies and procedures, how they managed potential exposure to COVID-19, and cleaning practices.
Adam Roy:
How did you evaluate suicide prevention at the vet centers?
Lindsay Gold:
Suicide prevention is a priority for VA, and a large part of our inspection program. That’s why a portion of our inspection is really focused specifically on that, suicide prevention. We used clinical record reviews, inspection document requests, and interviews with district leaders and vet center directors to evaluate compliance.
For clinical record review, we’re evaluating if clinical assessment documentation, such as intake and military history assessments, and suicide risk assessments, are completed. RCS also requires client case consultation when suicide risk is present or significant safety concerns are identified. We evaluated whether or not consultation is occurring.
Adam Roy:
What did you find during this part of these VCIP inspections?
Lindsay Gold:
We found non-compliance across all districts for the completion of intake, military history, and lethality risk assessments. In some cases, non-compliance is due to documentation not being completed, but in other cases it’s related to issues with the clinical record system that really limits our ability to determine when documentation was completed. We’re reviewing if documentation is not only fully completed but clinically appropriate.
Adam Roy:
Why is this finding significant?
Lindsay Gold:
In healthcare, we know that positive outcomes are maximized when clinicians involved in a client’s care communicate with each other. RCS requires consultation with the vet center director, associate district director for counseling, VA-assigned external clinical consultant, and/or other VHA mental health professionals, including the suicide prevention coordinator at the support VA medical facility whenever a client’s risk level increases. During our inspection we look for documentation of consultation for complex cases that really demonstrate the type of discussion that can influence clinical decision making.
Adam Roy:
During your teams’ visits, what other methods did they use to evaluate suicide prevention?
Lindsay Gold:
One of the strategies and unique elements of RCS is the client-based accessibility to services outside of normal business hours and on weekends. We evaluate whether each vet center offers services during these non-traditional hours. We found that almost all vet centers were compliant with this requirement. Another strategy RCS uses is providing guidance and procedures to vet center staff to manage a client in crisis; we found that 19 of the 20 vet centers had written crisis plans.
Adam Roy:
What types of challenges have you seen?
Lindsay Gold:
Vet centers and VHA have a written agreement from the VA deputy under secretary for health for operations and management to enhance shared responsibility, collaboration, and care coordination for suicide prevention with clients receiving care at both vet centers and VHA medical facilities. As part of our suicide prevention portion of the inspection, we reviewed communication and collaboration between vet center staff and the VA medical facility suicide prevention coordinator. We also reviewed the sharing of updated VHA lists of veterans identified as high risk for suicide.
Adam Roy:
Did you find collaboration and consultation between the vet centers and their local VA suicide prevention coordinator?
Lindsay Gold:
You know, Adam, we found that most vet centers had informal processes in place and reported good relationships with the suicide prevention coordinators, but only 3 of the 20 vet centers had a standardized communication process.
We also evaluated if the vet centers were receiving both the high-risk suicide flag as well as the recovery engagement and coordination for health-veterans enhanced treatment, which is also known as REACH-VET, lists. So, we were really looking to see if they were receiving the high-risk suicide flag veterans as well as those REACH-VET veterans.
Adam Roy:
How are those veterans different?
Lindsay Gold:
The REACH-VET list is a predictive model to identify veterans who may clinically benefit from enhanced care, outreach, or assessment of risk. Those high-risk suicide flag veterans have a flag that was placed by the suicide prevention coordinator at the VA medical facility, and that’s based on provider assessments that deem the veteran to be at a higher risk for suicide. RCS has a SharePoint site, which is updated monthly, that identifies clients seen in the past 12 months at the vet center who are on the high risk suicide flag list. After the FY 2020 inspections and during the FY 2021 inspections, RCS also added clients identified on that REACH-VET list to the SharePoint site.
We found that this information sharing wasn’t occurring really across all the zones. The vet center directors who are responsible for reviewing the RCS SharePoint site each month and identifying clients receiving services at the vet center, they review the client case to determine what interventions or support are needed, and they document the disposition of the review on the SharePoint site. We found that 15 of the 20 vet centers were compliant with completing the RCS SharePoint site review.
Adam Roy:
Earlier you mentioned that these requirements are part of the suicide prevention review. It sounds like suicide prevention components are not limited to the suicide prevention portion of the inspection. Are there components of suicide prevention in other parts of the inspection?
Lindsay Gold:
Very perceptive of you! Suicide prevention is a component of every review area of our inspection. It really is. In leadership and organizational risk, we’re evaluating if district leaders completed critical incident quality reviews for serious suicide attempts and deaths by suicide. We evaluated if staff have completed required suicide prevention training as a part of the consultation, supervision, and training portion of the inspection. This is a really key component in ensuring that vet center staff have the information and knowledge to intervene when clients are in crisis.
As for the environment of care inspection, we evaluate the safety of the physical environment, such the availability of items that can be used as weapons in areas accessible to clients. Although not directly an evaluation of suicide prevention, in the COVID-19 portion of the inspection we evaluated the transition of counseling services from in-person to virtual care through telehealth. An extremely important aspect of preventing suicide is ensuring that clients can access the services they need when in crisis. while mitigating risk of exposure to COVID-19, we wanted to make sure they were still able to access the services they need. We also reviewed each vet center’s crisis plan to ensure that they had those policies set forth for emergency response.
Adam Roy:
What were some key takeaways from your review of these areas?
Lindsay Gold:
The critical incident quality review, which is also known as morbidity and mortality review, allows the district leaders to evaluate clinical care and identify opportunities to improve care when a suicide attempt or death by suicide has occurred. A panel that includes a mental health professional from the VA medical facility completes the quality review. Staff who were directly involved in the client’s care are not included in the panel just to ensure objectivity in the review. Across the 5 districts, there were 53 critical incidents requiring a critical incident quality review, but only 23 of these reviews were completed. We found only one zone completed all the expected reviews.
In regards to suicide prevention training, we found that it was completed for all clinical staff at only 4 of the 20 vet centers and for non-clinical staff at 12 of the 20 vet centers we inspected. Vet center directors explained that training was not always correctly assigned in the training system, and they recognized a lack of oversight for the timely completion of required training. Although we had several findings related to suicide prevention, we didn’t find any suicide risk safety concerns for the physical environment during the environment of care inspection.
Adam Roy:
Wow. What this really shows is just the importance that not only VHA, but also the VA OIG, is putting on suicide prevention and ensuring that veterans are getting the care they need. I think that’s a good story tell. Let’s change gears a little bit now and talk more about the other parts of the inspection, share some of the other components that your teams look at.
Lindsay Gold:
Sure. Another part of the inspection is the consultation, supervision, and training review. This portion of the inspection focuses on evaluating the quality of care provided at the vet centers through review of clinical oversight and collaboration, and role-based training.
Adam Roy:
So, you look at suicide prevention training. Are there any other trainings that you look at that staff is required to take?
Lindsay Gold:
Yes. We look for the completion of military sexual trauma training for clinical staff. In 1992, vet center eligibility was expanded to include veterans who experienced military sexual trauma, and vet center counselors are required to complete military sexual trauma training so they can effectively meet the counseling needs of clients healing from trauma. We found that military sexual trauma training was completed for all clinical staff at only 4 of the 20 vet centers. Vet center directors explained again that this was due to training not being assigned or being assigned incorrectly.
The final training element we reviewed was the district annual in-service training. This training is meant to provide education to vet center staff in support of their individual roles and the objectives and goals of Readjustment Counseling Services. Three of the 20 vet centers were compliant with district annual in-service training requirements. In most vet centers, the required in-service training had not been provided due to operational challenges during the COVID-19 pandemic.
Adam Roy:
I am hearing that some of the trainings were not done due to a lack of effective oversight controls. How did you look at these oversight processes?
Lindsay Gold:
Sure. RCS has several oversight processes in place to support and evaluate clinical care at the vet centers. The requirements provide a foundation, but what we found is that they often lack direction and standardization across the 300 vet centers. Two primary clinical oversight processes we evaluated are supervision and clinical record audits. Both are the primary responsibility of the vet center director with district leader oversight. At the time of our inspections, vet center directors were required to provide one hour of individual supervision to the vet center counselors each week where they would discuss client cases, clinical care, and provide feedback to those counselors.
Adam Roy:
Were these vet center directors complying with the supervision standards?
Lindsay Gold:
Unfortunately, none of the 20 vet centers was compliant with weekly supervision. Vet center directors said this was due to not tracking or documenting when supervision was done. They also indicated that supervision does not always occur due to client care needs and difficulties in rescheduling the supervision. It is important to note, I also want to share, that in January 2021 RCS implemented a new directive without a clear definition of the frequency of supervision of clinical staff.
Adam Roy:
Besides this weekly individual supervision oversight responsibility, what other responsibilities do these vet center directors have?
Lindsay Gold:
The vet center directors are also responsible for auditing charts for 10 percent of each counselor caseload. They evaluate them for completion of required clinical documentation, and generally give feedback to the counselors on a monthly basis. Again, we found that none of the 20 vet centers was compliant with completing a 10 percent chart audit for all clinical staff. A few factors contributed to the non-compliance. We found that often the vet center directors were completing chart audits, but that RCSnet report, which is used to determine caseload and track audit completions, was inaccurate. This resulted in vet center directors creating their own tracking mechanisms, which did not always capture or document all the information needed for OIG to determine if the audits completed met that 10 percent requirement.
Adam Roy:
To summarize, the VCIP team found that no vet centers were compliant with the two primary oversight requirements that the vet center directors are responsible for?
Lindsay Gold:
That’s right, Adam. We did see that supervision and audits were occurring, but they didn’t meet the RCS requirements. I think it is also important for us to discuss the role of the vet center director. They have so many responsibilities in maintaining clinical and administrative operations of the vet center. In addition to supervising staff and providing feedback, they’re responsible for maintaining the vet center leases, function, and safety. They’re responsible for updating and maintaining policies. They serve as a liaison to the VA medical facilities for clinical and administrative issues, and they also carry a clinical caseload and provide counseling to clients. Some vet center directors also manage any day-to-day operational issues and crises. They definitely have a full plate.
Adam Roy:
Absolutely agree. Earlier, Mash explained that vet centers are required to have an external clinical consultant who is a licensed credentialed mental health professional from the support VA and who also provides four hours of consultation each month. Did your team find that vet centers had this in place?
Lindsay Gold:
This is another responsibility of the vet center directors—to ensure that the external clinical consultant meets with the vet center staff for four hours each month. As Mash mentioned, the external clinical consultant provides support in managing complex and high-risk client cases. Unfortunately, Adam, we found that none of the 20 vet centers was compliant with the requirement for four hours per month of external clinical consultation. We did see that the external clinical consultation was occurring, but again we weren’t able to verify that it occurred four hours each month due to that lack of tracking and documentation of those meetings.
Adam Roy:
Is it fair to say that a lot of work is happening, the directors are very busy, but there may not be a standardized tracking and documentation system that ensures that consultation, supervision, and audits are happening?
Lindsay Gold:
Yes. We’ve gotten the sense from our interviews with district leaders and vet center directors, as well as our document reviews, that everyone involved understands the importance of the aspects of oversight, but we can’t verify or evaluate work that is not documented.
District leaders are responsible for completing clinical and administrative quality site visits annually to evaluate vet center compliance with RCS requirements. These reviews are conducted in person every other year, with virtual visits in between. A report is completed listing any identified deficiencies. The vet center director writes a remediation plan with the assistance of the associate district director who completed the inspection. From the time that the remediation plan is developed, the vet center director has 60 days to resolve the deficiencies, and that is tracked by the district leaders.
Adam Roy:
How did you evaluate whether these quality site visits took place? What did you find?
Lindsay Gold:
We reviewed documentation, and through our interviews we evaluated whether they were done, whether the remediation plans were developed, and deficiency resolution was completed timely in each zone. We didn’t evaluate or verify the deficiencies identified in the specific site visit reports. But we found most zones were compliant with completing the annual site visits and developing the remediation plans to correct those deficiencies. Unfortunately, they were non-compliant with documenting deficiency resolution. And in most cases where resolution was documented, we also weren’t able to determine if the deficiencies were resolved timely due to that lack of documentation of resolution dates and the thoroughness of that documentation.
Adam Roy:
Earlier you mentioned that the team also looks at leadership stability and organizational health. Can you talk about that?
Lindsay Gold:
Yes. Across the five districts, we found that district leadership teams had been working together from 12 months to three and a half years. Each district, on average, has four leaders as part of the leadership team including the district director, deputy district director, and associate district directors for counseling and administration. Across the five zones, one district leader position was vacant at the time of the inspection. We found that district leaders were knowledgeable about quality improvement processes and were able to identify priorities and actions taken in response to the employee feedback from the VA All Employee Survey. We also evaluated vet center client feedback.
Adam Roy:
How does the vet center obtain client feedback?
Lindsay Gold:
At the time of our inspections, RCS used the vet center service feedback form. The form has six questions evaluating how clients were treated and whether vet center appointments and locations were convenient. The feedback form also asks if the client felt better because of vet center services, if they were satisfied with care, and if they would recommend vet center services to another veteran, service member, or family member. Those surveys are only sent to clients who left care, and we found each district had relatively low response rates. But overall client feedback was positive and reflected satisfaction with vet center services. In the summer of 2021, RCS implemented a new tool, called VSignals, that surveys veterans throughout their care, rather than waiting for when they leave care. That’s something we’ll be reviewing in the future of VCIP and looking at that VSignals data in future inspections.
Adam Roy:
It is great to hear that clients are satisfied with the care that they’re receiving. It’s an example of how vet centers are meeting their mission to make care accessible to veterans, service members, and their family members. Lastly, the final part of the VCIP inspection is a review of open recommendations. Can you talk a little about that, too?
Lindsay Gold:
Sure. Prior to the inspection, we review open recommendations from previous inspections and investigations. Because VCIP is a new program and there hasn’t been a cyclical review of RCS, we haven’t had any open recommendations for our inspections. In the future, if we do identify open recommendations from previous inspections, we would evaluate and determine whether we are able to close those recommendations or if the finding is not resolved.
Adam Roy:
We’ve talked a lot about how vet center care is provided and how oversight of this care is completed. Can you tell us a little bit about where the care is provided?
Lindsay Gold:
Yes. Vet centers are unique in that they are in the community and prioritize accessibility to the vet center for the clients served. Vet centers also celebrate and recognize military service in the vet center décor, which is customized to the client population. During our environment of care inspections of selected vet centers in each zone, we evaluated the physical environment, general safety, and privacy.
Adam Roy:
What are those safety factors that you’re looking at?
Lindsay Gold:
We evaluated accessibility of the vet center for persons with disabilities. We found that all vet centers inspected had designated handicapped accessible parking spaces and building entrances. Vet centers are also required to have exits identified with tactile or braille signs. Across all zones we found three of the 20 vet centers were compliant with this requirement. In most cases, vet center directors weren’t aware of the requirement.
Another requirement for safety is that vet centers have an updated crisis and emergency plan that provides guidance to the vet center staff in the event of a disaster or emergency, such as a telephone or computer outage or disruptive behavior from staff or clients. We found 17 of the 20 vet centers were compliant with this requirement.
Adam Roy:
From what I’m hearing, it sounds like the vet centers prioritize making sure their clients can get access to them by keeping non-traditional hours, being located in the community, and maintaining access for clients with disabilities. What can the clients expect when they enter vet center?
Lindsay Gold:
The vet centers really are committed to making sure veterans can access their services. During our evaluation of the physical environment, we looked at cleanliness and presentability of the building, both interior and exterior. We found most vet center interiors and exteriors were clean and presentable. One vet center had an exterior that was not quite presentable, but we found the vet center director was actively working to correct that issue. We found that all vet centers were non-institutional spaces with clean furniture in good repair.
We enjoyed inspecting vet centers across the country and got to see individual touches the vet center staff put into place at their locations. For example, the Sarasota Vet Center in Florida had photos throughout the vet center that were taken by one of their clients. And in Midland, Texas, the vet center had a map on the wall where clients could insert pins to show where they served.
Adam Roy:
That’s really neat. Thanks for sharing those examples. What about measures to protect client privacy? Did you take a look at that?
Lindsay Gold:
Privacy of client information was evaluated by ensuring soundproofing was present for all counseling spaces, and also making sure that veteran documents and information were secured. All the vet centers we inspected had the required sound-proofed individual and group counseling spaces. Of the 20 vet centers we inspected, 15 had secure, double-locked rooms, which met the requirements for maintaining client records. During the time of the inspections, RCS was in the process of transitioning paper records to electronic records. Although most vet centers had shredded select records and were maintaining paper records, RCS still required a double-locked file room.
Adam Roy:
Earlier, Dr. Patel mentioned having to pivot to virtual inspections at the onset of COVID-19. Was there anything specific you reviewed in regard to the pandemic?
Lindsay Gold:
Yes. Rather than traveling to the vet centers, we completed the facility tours virtually because of the COVID-19 pandemic, as Dr. Patel mentioned. We assessed the impact of the pandemic on vet center operations, and the availability of cleaning supplies and personal protective equipment.
We also gathered information about screening and referral processes to determine if a client may have COVID-19 and how care was transitioned for further medical evaluation and treatment. We received feedback that there were challenges with cleaning supplies and personal protective equipment at the onset of the pandemic, but leaders worked to resolve issues as quickly as possible. Many reported that communication processes were enhanced to keep the vet center staff and clients informed of changes.
Adam Roy:
What did you see was the biggest take away in reference to how vet centers handled the onset of the pandemic?
Lindsay Gold:
The greatest standout in the responses was the quick transition of RCS from in-person services to telehealth and telework, and providing more accessibility to vet center clients.
Adam Roy:
It sounds like the inspection resulted in great information and opportunities for improvement. What were some other things that you learned during these initial inspections?
Lindsay Gold:
From a clinical perspective, there were significant concerns about counseling staff not completing suicide risk assessments during the first clinical visit. Improvements are needed for care coordination with VA medical centers when working with high-risk clients, specifically, communicating expectations for managing high-risk patients in a way that is clear and consistent for all vet center staff. RCSnet is a tool for documentation with significant limitations, we’ve learned, and in the near future it may outgrow its ability to support the growing clinical activities of vet centers. The OIG VCIP team is looking forward to assisting and supporting vet centers as they continue grow and build upon the already extensive services that they provide to our veteran population.
Adam Roy:
Wow, that’s a really great summary. Thanks a lot for sharing that, Lindsay. To conclude, what’s your overall impressions of the first inspection cycle and the staff who work there at these vet centers?
Lindsay Gold:
Overall, leaders and staff at the vet centers and district levels were engaged, interested in telling their stories and sharing how they care for veterans, and they welcomed OIG staff for the inspection. Many of the RCS staff expressed interest in wanting to make quality improvements. They had positive comments and feedback on how RCS handled the COVID 19 response and encouraged staff to work from home during the pandemic. Vet center directors shared that they wear many hats, clinical and administrative, which unfortunately deters them from being able to dedicate the time to conduct quality improvement activities.
Adam Roy:
Thank you again, Lindsay, and also thank you to Mash, Bina for spending time with me today and sharing the impactful work of the Vet Center Inspection Program. Government work can be complicated sometimes, and I think you guys did a great job just breaking down what the program is and where the program’s going.
If you’re interested, listeners, the first five VCIP reports we discussed today, part of this first inspection cycle, can be found on our VA OIG website. Go there under the publications tab, select “reports” and you can filter by selecting vet center inspection program.
That’s it for this episode of Inside Oversight. I encourage you to check out other episodes wherever you listen to podcasts. Thanks for tuning in.
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