Department of Veterans Affairs
 

Office of Inspector General
 

Healthcare Inspection
 

Post Traumatic Stress Disorder
 

Counseling Services at Vet Centers
 

Report No. 10-00628-170 May 17, 2011
 VA Office of Inspector General
 

Washington, DC 20420
 
To Report Suspected Wrongdoing in VA Programs and Operations: 

Telephone: 1-800-488-8244 

E-Mail: vaoighotline@va.gov 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp) 
Post Traumatic Stress Disorder Counseling Services at Vet Centers 

Contents 

Page
 

Executive Summary ..............................................................................................i
 

Introduction ..........................................................................................................1
 

Purpose............................................................................................................................. 1
 

Background...................................................................................................................... 1
 

Scope and Methodology .................................................................................................. 2
 

Results and Conclusions ....................................................................................4
 

Issue 1: Post Traumatic Stress Disorder Counseling Services ........................................ 4
 

Issue 2: Staff Training and Education ............................................................................. 8
 

Appendixes 

A. Under Secretary for Health Comments...................................................................... 9
 

B. Sites Opened in 2009 and 2010................................................................................ 12
 

C. Randomized RCS Vet Center Sites ......................................................................... 13
 

D. Primary Care PTSD Screen ..................................................................................... 14
 

E. PTSD Check List...................................................................................................... 15
 

F. DSM Multi-Axial System......................................................................................... 16
 

G. OIG Contact and Staff Acknowledgments .............................................................. 17
 

H. Report Distribution .................................................................................................. 18
 

VA Office of Inspector General 
Post Traumatic Stress Disorder Counseling Services at Vet Centers 

Executive Summary
 

The VA Office of Inspector General (OIG), Office of Healthcare Inspections (OHI) 

completed an inspection of the Readjustment Counseling Service (RCS) Vet Centers’ 

post traumatic stress disorder (PTSD) counseling services. The purpose of our 

inspection was to assess the quality of RCS Vet Centers’ PTSD counseling services to 

determine: (1) how Vet Centers screen clients for PTSD, (2) if documentation of clients’ 

treatment is in compliance with policy, and (3) if providers are trained to provide PTSD 

counseling services according to policy. 

In a previous OIG review of the RCS Vet Centers’ operational services provided during 

FY 2008 (Report No. 08-02589-171, dated July 20, 2009), we found that documentation 

in client treatment records and staff PTSD counseling training needed improvement. As 

part of this review, we evaluated whether any improvements had occurred in these 

areas. 

We found that RCS Vet Center counselors utilized appropriate tools to screen clients for 

PTSD. Client treatment case file documentation improved from our FY 2009 report. 

Staff training also improved. Approximately 85 percent of Vet Center providers had 

attended RCS’ required training on PTSD, and 53 percent of the providers had attended 

Veterans Health Administration-sponsored PTSD training. In addition, some Vet Center 

providers received supplemental training in Evidence-Based Therapy (EBT), and most 

Vet Centers were providing EBT to PTSD clients. 

Although RCS made improvement from our previous review, we found that the Team 

Leaders were not consistently providing supervision and consultation to the Vet Center 

providers in accordance with RCS policy. 

We recommended that the Under Secretary for Health, in conjunction with the RCS 

Chief Officer: 

	 Ensure that Vet Center Team Leaders perform monthly provider’s record 

reviews, and provide supervision and consultation to providers in compliance 

with RCS policy. 

	 Ensure that corrective action is taken when supervision and consultation issues 

are identified through the annual clinical quality reviews. 

VA Office of Inspector General i 
Post Traumatic Stress Disorder Counseling Services at Vet Centers 

Comments 

The Under Secretary for Health concurred with the findings and recommendations. The 

implementation plan is acceptable, and we will follow up until all actions are complete. 

JOHN D. DAIGH, JR., M.D.
 

Assistant Inspector General for
 

Healthcare Inspections
 

VA Office of Inspector General ii 
Post Traumatic Stress Disorder Counseling Services at Vet Centers 

Introduction 

Purpose 

The purpose of our inspection was to assess the quality of Readjustment Counseling 

Service (RCS) Vet Centers’ post traumatic stress disorder (PTSD) counseling services 

to determine: (1) how Vet Centers screen clients for PTSD, (2) if documentation of 

clients’ treatment is in compliance with policy, and (3) if providers are trained to provide 

PTSD counseling services according to policy. 

Background 

During the period 1969 through 1979, Congressional hearings were held which 

identified the presence of readjustment difficulties in some veterans returning from duty 

during the Vietnam era. In 1979, Congress passed legislation that required VA to 

provide readjustment counseling services to eligible combat veterans.1 In response, the 

Veterans Health Administration (VHA) established a nation-wide system of communitybased programs separate from VA medical centers. 

In 1981, VA initiated a new organizational element, the RCS, to administer the Vet 

Centers and the provision of readjustment counseling services. The goal of the RCS 

Vet Center program is to provide a broad range of counseling, outreach, and referral 

services to eligible veterans from post-war readjustment to civilian life. Services 

provided by Vet Centers range from assistance with basic needs, therapeutic 

counseling for drug and alcohol abuse, sexual trauma, and PTSD. 

PTSD is usually tied to a particular traumatic life experience referred to as a stressor or 

cause agent. In order to make a diagnosis, the person must actually meet the “stressor” 

criterion, which means that they have been exposed in the past to a traumatic event. 

Screening tools (brief questionnaires) are used by VHA to aid in identifying and 

assessing individuals with PTSD. Primary Care-PTSD (PC-PTSD)2 screen consists of 

four questions. Current research suggests that the results of this screening tool should 

be considered “positive” if a patient answers “yes” to any two items.3 At VA facilities, 

positive screens should be assessed further; and a more structured interview for PTSD 

should be done. Diagnostic and Statistical Manual of Mental Disorders (DSM)4 is also 

utilized by providers in the diagnosis of PTSD. DSM describes the symptoms for all 

mental disorders, as well as the criteria that must be met to receive a diagnosis of each 

disorder. 

1 Public Law 96-22, Title I, § 103 (a) (1), 38 U.S.C. 1712A.
 2 The PC-PTSD is a four-item screen that includes an introductory sentence to cue respondents to traumatic events.
 

See Appendix D.

3 VA/DoD, Clinical Practice Guideline for the Management of Post-Traumatic Stress, Version 1.0, Appendix C,
 

PTSD Screening Tools.

4 The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) is the official manual listing psychiatric and
 

psychological disorders published by the American Psychiatric Association. See Appendix F.
 

VA Office of Inspector General 1 
Post Traumatic Stress Disorder Counseling Services at Vet Centers 

The Office of Inspector General previously conducted a review of the RCS Vet Centers 

(Report No. 08-02589-171, dated July 20, 2009), and found that over 40,000 veterans 

received counseling for PTSD, with over 700,000 visits during fiscal year (FY) 2008. 

Our report identified areas that RCS could improve. 

We found the documentation in client case files were incomplete. Our review of 136 

client records disclosed various deficiencies in record keeping, to include inadequate 

documentation of treatment plans, military histories, progress notes, and missing 

closing summaries. 

We found that 19 (9 percent) of the 203 Vet Centers did not have an External Clinical 

Consultant to help counselors manage complex treatment issues. RCS regional 

managers reported that some positions were difficult to fill due to the site location. 

We also found the staff training records showed a lack of documentation of specific 

training on the assessment and counseling for PTSD and other co-existing conditions. 

In the previous inspection, we recommended that: 

	 Vet Center counselors appropriately document in RCS client case files and that 

corrective action is taken when documentation problems are identified. 

	 All Vet Centers have an External Clinical Consultant. 

As a follow-up to our previous report, we assessed whether any improvements had 

occurred in these areas. 

Scope and Methodology 

Our review focused on compliance with VHA and RCS policies for the documentation of 

client treatment and staff training records. We reviewed all Vet Center providers’ 

training records for specific evidence of PTSD training. We also requested RCS’ FY 

2009 Clinical Quality Review Report for each Vet Center. We aggregated various data 

elements from this report to compare to our findings. 

Statistical Methodology. The first study population of VA Vet Centers was used to 

answer questions about Vet Center providers training in PTSD treatments. It excluded 

Vet Centers opened in 2009 and 2010 as well as Vet Centers where pilot reviews were 

conducted. The second study population containing PTSD patients at Vet Centers was 

used to answer questions about compliance of therapies and treatments for PTSD. 

The Vet Center study population included 229 facilities. For the sample of the Vet 

Centers, we randomly drew 28 facilities, stratified by region. Four Vet Centers were 

sampled from each of the seven regions. One5 of the sampled facilities was excluded 

because it had only two active PTSD clients. 

5 St. Thomas Vet Center 

VA Office of Inspector General 2 
Post Traumatic Stress Disorder Counseling Services at Vet Centers 

For the PTSD patients, the sample design consisted of two stages. The first stage of 

sampling was the selection of the 28 facilities, as described above. In the second stage 

of sampling, we randomly sampled 30 patients from each of the 27 Vet Centers. Thus, 

a sample of 810 patients was selected from the patient study population, with 

stratification and unequal probability of selection. 

Statistical Analysis. We estimated percentages of provider training at the Vet center 

facilities and the compliance percentages for PTSD treatment. Horvitz-Thompson 

sampling weights were used to account for the unequal probability sampling. The 

jackknife6 method was used to obtain sampling errors for the estimates. 

A confidence interval gives an estimated range of values (being calculated from a given 

set of sample data) that is likely to cover the true population value (parameter). The 

95 percent confidence interval (95% CI) indicates that among all possible samples we 

could have selected of the same size and design, 95 percent of the time the parameter 

would have been somewhere in the computed intervals. 

Percentages can take only non-negative values from zero to 100, but their logits7 have 

no such restriction. We calculated the confidence intervals for percentages on the logit 

scale and then transformed them back to the original scale to ensure that the calculated 

confidence intervals contained only the proper range of zero to 100 percent. SAS 

statistical software, version 9.2 (Cary, North Carolina) was used for data analyses. 

This review was conducted in accordance with Quality Standards for Inspection and 

Evaluation published by the Counsel of the Inspectors General on Integrity and 

Efficiency. 

6

Cochran, W. G. (1977), Sampling Techniques, Third Edition, New York: John Wiley & Sons. 7

Function used in mathematics, especially in statistics. 

VA Office of Inspector General 3 
Post Traumatic Stress Disorder Counseling Services at Vet Centers 

Results and Conclusions 

Issue 1: PTSD Counseling Services 

VHA requires that all new clients are screened for symptoms of PTSD. Early 

identification of PTSD could potentially improve the client’s outcome. PTSD can be 

treated by a variety of forms of psychotherapy (talk therapy) and pharmacotherapy 

(medication). PTSD counseling is designed to combat the symptoms of the disorder. 

Once the therapist determines the best type of therapy for the client, both the client and 

the therapist should decide on the treatment goals. Treatment goals should be specific 

to each client. 

A. Client Treatment Record 

RCS had established standards for Vet Center client case files. Case files must contain 

specific elements to ensure that counselors properly document the care provided to 

clients. RCS policy8 states that Team Leaders or clinical coordinators are required to 

conduct monthly reviews of 10 randomly selected client treatment records for each fulltime provider. Monthly reviews are to ensure that documentation is complete and 

quality counseling is performed. 

Treatment Record Reviews. We reviewed 771 client treatment records9 to determine 

the inclusions of the required elements. A summary of our findings are listed in Table 1. 

Sample 

Frequencies 

VA 

Estimates 

95% CI Limits 

Questions Total Clients 

Yes 

Response 

Weighted 

Percent 

Lower Upper 

Psychosocial Assessment 

Completed 771 659 86.7 81.91 90.37 

Client’s Presenting 

Problem Documented 659 654 99.8 99.30 99.94 

History of Presenting 

Problem Documented 659 653 99.6 98.59 99.88 

Treatment Plan Present 659 569 89.7 81.86 94.35 

Specific Type of 

Counseling/Therapy 

Documented 569 567 99.7 98.41 99.95 

Client Expected Outcomes 567 494 80.8 64.10 90.87 

Table 1. Client Treatment Records Review 

8 RCS Policy Memorandum No. 3-10, Review of Clinical Records, October 2002. 9 Thirty-nine client treatment records were excluded from the original random sampling of 810 records for the 

following reason(s): 1) not enough visits to complete the psychosocial assessment or no documentation found in 

record, 2) unable to locate the record, 3) client not seen in 2010, 4) not a PTSD (clinical case) client, or 5) record 

was closed. 

VA Office of Inspector General 4 
Post Traumatic Stress Disorder Counseling Services at Vet Centers 

Approximately 87 percent of the Vet Centers had completed psychosocial assessments 

in the client records. We found three Vet Centers that were below the 95% CI for 

completed psychosocial assessments. Two Vet Centers were at 66.7 and one was 53.3 

percent compliance. Completion of psychosocial assessments improved from our FY 

2009 report, where only 74 percent of the assessments were completed. 

Client treatment plans are developed following the completion of the psychosocial 

assessments. If the psychosocial assessment was missing or incomplete, we did not 

continue the record review; therefore, our denominator changed from 771 to 659. 

Treatment plans should include the following: 

 Specific actions/steps to be pursued by counselor. 

 Type of counseling or therapy. 

 Anticipated duration of counseling or therapy. 

 Expected outcomes. 

RCS policy10 required that treatment plans be reviewed during the first five visits and at 

least every six months thereafter. We found that 569 (approximately 89.7 percent) had 

current treatment plans. This represented an increase from the FY 2009 report 

(77.1 percent). However, we found five Vet Centers’ treatment plans were below the 

95% CI. These Vet Centers’ compliance ranged from 5.0–65.4 percent. 

Of the 569 records that had treatment plans present, 494 (approximately 81 percent) 

had identified expected outcomes. All Vet Centers fell within the 95% CI. 

Annual Clinical Quality Reviews. RCS regional staff conduct annual clinical quality 

reviews at all Vet Centers within their region. We reviewed the FY 2009 Annual Clinical 

Quality Reports for 26 of the 27 Vet Centers (one Vet Center did not have an annual 

review performed). The clinical quality reviews included evaluation of organizational 

quality and record keeping. The aggregated results of the reviews are displayed in 

Table 2. 

Required Elements Vet Centers Meeting 

Requirements 

Psychosocial Assessments (Psychosocial, Sexual Trauma, and 

Military History Data) Are Complete and Appropriate 

20 (77 percent) 

Treatment Plans Are Current, Measurable, and Relate to Identified 

Focus Areas 

13 (50 percent) 

Course of Treatment Is Reflected in the Progress Notes 21 (81 percent) 

Table 2. Results From RCS’ FY 2009 Annual Clinical Quality Reviews 

10 RCS Policy Memorandum No. 3-9, Content of Vet Center Files and Counseling Notation, October 2002. 

VA Office of Inspector General 5 
Post Traumatic Stress Disorder Counseling Services at Vet Centers 

RCS managers continue to identify documentation in the client records as needing 

improvement. 

Team Leader Supervision and Consultation. Team Leaders at 18 (69 percent) of the 

26 Vet Centers were consistently providing monthly supervision and consultation to 

providers. We found evidence that Team Leaders at 19 (73 percent) of the 2611 Vet 

Centers were consistently performing monthly client case file reviews according to 

policy. In the RCS’ FY 2009 Annual Clinical Quality Reports, RCS staff found that in 

12 (approximately 67 percent) of the 18 reports (8 report did not assess supervision and 

consultation), appropriate supervision was provided. 

RCS policy12 states that Team Leaders or clinical coordinators are required to conduct 

monthly reviews of 10 randomly selected client counseling records for each full-time 

provider. These reviews are designed to ensure complete and quality counseling 

documentation, as well as compliance with the “Minimal Clinical Notations” 

requirements. Team Leaders or designees are required to cosign the assessment and 

treatment plan to indicate the case was reviewed. Approximately 80 percent of the 

treatment plans were cosigned. 

B. PTSD Screening 

The Team Leaders reported utilizing PTSD screening tools to include DSM, PC-PTSD, 

PCL,13 and Combat Exposure Scale.14 We found that most veterans were assessed for 

PTSD utilizing solely DSM (10 Vet Centers) or a combination of DSM and PCPTSD/PCL (5 Vet Center). One Vet Center screened clients utilizing PC-PTSD and 

seven Vet Centers used the PCL. Two Vet Center identified other means of screening 

clients, while two did not identify how they screened clients for PTSD. 

C. Evidence-Based Therapy 

Evidence-based therapy (EBT) is supported by research, and those findings provide 

evidence that it is effective. Cognitive-behavioral Therapy (CBT), an EBT, is a well 

researched psychotherapeutic approach. Cognitive Processing Therapy (CPT),15 

Exposure Therapy (ET),16 and Prolonged Exposure (PE)17 are specific types of CBTs. 

There are different types of CBTs used in the treatment of PTSD. According to VHA 

11 One Team Leader was in the position for five weeks prior to our onsite visit; therefore, the Vet Center was not
 

included.
 12 RCS Policy Memorandum No. 3-10, Review of Clinical Records, October 2002.
 13 PCL is a 17-item checklist for self reporting PTSD symptoms. See Appendix E.
 14 Combat Exposure Scale (CES) is a 7-item self-report measure that assesses wartime stressors experienced by
 

combatants.
 15 CPT has four main parts: (1) learning about your PTSD symptoms, (2) becoming aware of thoughts and feelings,
 

(3) learning skills, and (4) understanding changes and beliefs. 16 ET reduces the fear associated with experiences through repetitive, therapist-guided confrontation of feared
 

places, situations, memories, thoughts, and feelings.

17 PE reduces the level of fear and anxiety connected with traumatic event reminders.
 

VA Office of Inspector General 6 
Post Traumatic Stress Disorder Counseling Services at Vet Centers 

policy,18 all veterans with PTSD must have access to CPT or PE at VHA facilities. 

Since some veterans utilize Vet Centers for PTSD counseling services, we assessed if 

these modalities were instituted; although, it is not a requirement for RCS Vet Centers. 

Vet Centers also offer more non-specified CBT. VHA policy also requires that all 

veterans with depression or anxiety disorders have access to CBT, acceptance and 

commitment therapy [ACT], or interpersonal therapy. Team Leaders reported (selfassessment questionnaire) that 21 (approximately 78 percent) of the 27 Vet Centers 

were providing clients one or more forms of EBT. 

D. External Clinical Consultant 

Each Vet Center is required to have an External Clinical Consultant. The consultants 

are required to perform at least 4 hours of monthly clinical consultation. We found 25 

(93 percent) of the 27 Vet Centers had an assigned External Clinical Consultant at the 

time of our inspection. Two Vet Centers did not have an External Clinical Consultant; 

however, both Vet Centers were in the process of recruiting for these positions. The 

current number of External Clinical Consultants demonstrated an improvement from our 

previous report. 

Conclusions 

RCS Vet Center counselors utilized appropriate tools to screen clients for PTSD. Most 

Vet Centers were providing EBTs to PTSD clients. We found improvement in the client 

record documentation, and an External Clinical Consultant was assigned to most of the 

Vet Centers we inspected. However, Team Leader’s supervision and consultation 

continues to require improvements. We found that RCS managers have identified 

similar findings in the FY 2009 Annual Clinical Quality Report. Improved supervision 

and consultation would ensure counselors were initiating the appropriate counseling 

services to help clients reach their goals and were properly documenting the care 

provided to clients. 

We recommended that the Under Secretary for Health, in conjunction with the RCS 

Chief Officer. 

Recommendation 1: Ensure that Vet Center Team Leaders perform monthly 

provider’s record reviews and provide supervision and consultation to providers in 

compliance with RCS policy. 

Recommendation 2: Ensure that corrective action is taken when supervision and 

consultation issues are identified through the annual clinical quality reviews. 

18 VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics, September 11, 

2008. 

VA Office of Inspector General 7 
Post Traumatic Stress Disorder Counseling Services at Vet Centers 

Issue 2: Staff Training and Education 

We reviewed all 97 Vet Center providers’19 training records for evidence of RCS’ 

mandatory training specific to assessment and counseling for PTSD. We also looked 

for evidence of participation in any VHA-sponsored PTSD training. Table 3 shows the 

number of providers that completed RCS’ mandatory training and participating in VHAsponsored training for PTSD, as well as providers with supplemental training in EBTs. 

95% CI Limits
 

Employment/Training Providers
 Percent Lower Upper 

Sample 

Frequencies 

VA 

Estimates 

Total YES Weighted 

Responses 

Employed >1 Year/ Veterans 

Adjustment Problems 

Employed > 1 Year/PTSD 

Assessment and Counseling 

Employed > 1 Year/ Counseling 

Psychotherapy Techniques 

All Employees/VHA Sponsored 

PTSD Training 

Employed 1 Year or Greater (>) 97 83 85.5 75.89 91.73 

83 82 98.8 91.99 99.83 

83 82 98.8 91.99 99.83 

83 82 98.8 91.99 99.83 

97 51 50.0 36.40 63.60 

All Employees/EBT-CBT 97 36 36.6 24.51 50.73 

All Employees/EBT-CPT 97 12 12.3 5.83 24.26 

All Employees/EBT-PE 97 5 5.1 1.72 14.05 

All Employees/EBT-ET 97 3 2.9 0.64 12.01 

Table 3. Providers Completing RCS’ Mandatory, VHA-Sponsored, and EBT Training 

Staff training in the assessment and counseling of clients with PTSD improved from the 

FY 2009 report. We found that approximately 98 percent of the 83 providers employed 

for at least one year had attended RCS’ mandatory training specific to assessment and 

counseling for PTSD. We also found that 51 of the 97 providers (approximately 50 

percent) had attended VHA-sponsored training for PTSD. This was an improvement 

from our previous review, which showed that staff training was 69 percent or less. In 

addition, Vet Center providers had received supplemental training in EBT modalities, 

and most Vet Centers were providing EBTs to PTSD clients. Therefore, we made no 

recommendations. 

19 For the purpose of our review, Vet Center providers include: social workers, clinical psychologists, mental health 

counselors, professionally trained counselors, and counseling therapists. 

VA Office of Inspector General 8 
Post Traumatic Stress Disorder Counseling Services at Vet Centers 

Appendix A 

Under Secretary for Health Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 May 11, 2011 

From:	 Under Secretary for Health (10) 

Subject:	 OIG Draft Report: Healthcare Inspection: Post-Traumatic 

Stress Disorder Counseling Services at Vet Centers 

(VAIQ 7015481) 

To:	 Assistant Inspector General for Healthcare Inspections (54) 

1. I have reviewed the draft report and concur with the report’s 

two recommendations. Attached is the Veterans Health 

Administration’s corrective action plan for the report’s 

recommendations. 

2. Thank you for the opportunity to review the draft report. If 

you have any questions, please contact Linda H. Lutes, 

Director, Management Review Service (10B5) at (202) 461-

7014. 

Robert A. Petzel, M.D. 

Attachment 

VA Office of Inspector General 9 
_____ 

Post Traumatic Stress Disorder Counseling Services at Vet Centers 

VETERANS HEALTH ADMINISTRATION (VHA)
 

Action Plan
 

OIG Draft Report: Healthcare Inspection: Post-Traumatic Stress 

Disorder Counseling Services at Vet Centers (VAIQ 7015481) 

Date of Draft Report: April 25, 2011 

Recommendations/ Status Completion 

Actions Date _____ 

OIG Recommendations 

Recommendation 1. We recommended that the Under Secretary for 

Health, in conjunction with the RCS Chief Officer, ensure that Vet Center 

Team Leaders perform monthly provider’s record reviews, and provide 

supervision and consultation to providers in compliance with RCS policy. 

VHA Comments 

Concur 

VHA Handbook 1500.01, Readjustment Counseling Service (RCS) Vet 

Center Program, published on September 8, 2010, identifies Vet Center 

Team Leaders (TL) as responsible for clinical supervision: 

The TL, or clinical designee (if the TL is not a VHA Mental Health 

Professional) is responsible for providing individual counseling 

supervision to Vet Center counselors on an ongoing and regular 

basis. It is the responsibility of the individual staff member to 

maintain a professional license in situations when it is a condition of 

employment. 

To ensure accountability, a performance goal will be added to the Team 

Leader Performance Plans for Fiscal Year 2012 that specifies the required 

standards for clinical supervision and consultation in Vet Centers. 

Additionally, the list of Vet Centers found to be deficient for clinical 

supervision and consultation, by OIG Healthcare’s recent audit, will be 

provided to the RCS regional managers and team leaders to ensure that 

identified deficiencies are corrected. 

In Process September 30, 2011 

Recommendation 2. We recommended that the Under Secretary for 

Health, in conjunction with the RCS Chief Officer, ensure that corrective 

VA Office of Inspector General 10 
Post Traumatic Stress Disorder Counseling Services at Vet Centers 

action is taken when supervision and consultation issues are identified 

through the annual clinical quality reviews. 

VHA Comments 

Concur 

A performance goal was included in the Regional Manager Fiscal Year 

2011 Performance Plans that requires remediation plans for areas 

needing improvement. To more effectively monitor future deficiencies 

noted on clinical site visits, RCS will establish an electronic template to 

report and track identified deficiencies and resolution dates. The data 

provided by OIG Healthcare regarding Vet Center site visit reports with 

unresolved deficiencies will be used for the purposes of following up on 

any clinical supervision and consultation areas needing improvement. 

In Process September 30, 2011 

Veterans Health Administration 

May 2011 

VA Office of Inspector General 11 
Post Traumatic Stress Disorder Counseling Services at Vet Centers 

Appendix B 

RCS Vet Centers Opened in 2009 and 2010 

Toms River Vet Center 

Annapolis Vet Center 

Marietta Vet Center 

Huntsville Vet Center 

Jupiter Vet Center 

Dade City Vet Center 

Clearwater Vet Center 

Daytona Beach Vet Center 

Pontiac Vet Center 

Orland Park Vet Center 

Aurora Vet Center 

Green Bay Vet Center 

Lawton Vet Center 

Spring Vet Center 

San Antonio NW Vet Center 

Mesquite Vet Center 

Arlington Vet Center 

West Valley Vet Center 

Citrus Heights Vet Center 

Henderson Vet Center 

Bakersfield Vet Center 

Antelope Valley Vet Center 

South Orange County Vet Center 

Temecula Vet Center 

High Desert Vet Center 

Chula Vista Vet Center 

Minneapolis Vet Center 

VA Office of Inspector General 12 
Post Traumatic Stress Disorder Counseling Services at Vet Centers 

Appendix C 

Randomized RCS Vet Center Sites 

RCS 

Station Vet Center Name Region 

0101V Boston Vet Center 1A 

0117V Hartford Vet Center 1A 

0118V So. Burlington Vet Center 1A 

0135V Watertown Vet Center 1A 

0220V McKeesport Vet Center 1B 

0231V Beckley Vet Center 1B 

0232V Princeton Vet Center 1B 

0233V Wheeling Vet Center 1B 

0410V Chicago Vet Center 2 

0432V Manhattan Vet Center 2 

0434V Escanaba Vet Center 2 

0402V Detroit Vet Center 2 

0308V St. Thomas Vet Center* 3A 

0311V Fort Lauderdale Center 3A 

0331V Gainesville Vet Center 3A 

0333V Macon Vet Center 3A 

0708V Fort Worth Vet Center 3B 

0710V Houston Vet Center 3B 

0714V Lubbock Vet Center 3B 

0718V Oklahoma City Vet Center 3B 

0512V Wasilla Vet Center 4A 

0515V Albuquerque Vet Center 4A 

0530V Las Cruces Vet Center 4A 

0532V Provo Vet Center 4A 

0645V Grants Pass Vet Center 4B 

0650V Modesto Vet Center 4B 

0615V San Jose Vet Center 4B 

0638V Sacramento Vet Center 4B 

*Excluded: Vet Center had only two active PTSD 

clients 

VA Office of Inspector General 13 
Post Traumatic Stress Disorder Counseling Services at Vet Centers 

Appendix D 

Primary Care PTSD Screen (PC-PTSD) 

In your life, have you ever had any experience that was so 

frightening, horrible, or upsetting that, in the past month, you: 

1. Have had nightmares about it or thought about it when you did not want 

to? 

YES NO 

2. Tried hard not to think about it or went out of your way to avoid situations 

that reminded you of it? 

YES NO 

3. Were constantly on guard, watchful, or easily startled? 

YES NO 

4. Felt numb or detached from others, activities, or your surroundings? 

YES NO 

Current research suggests that the results of the PC-PTSD should be considered 

"positive" if a patient answers "yes" to any two items. 

Sources: VA/DoD, Clinical Practice Guidelines for the Management of Post-Traumatic Stress, 

Appendix C, Version 1.1. 

VA Office of Inspector General 14 
Post Traumatic Stress Disorder Counseling Services at Vet Centers 

Appendix E 

PTSD Check List – Civilian Version (PCL-C) 20 

Instruction to patient: Below is a list of problems and complaints that veterans sometimes have in 

response to stressful life experiences. Please read each one carefully, put an “X” in the box to 

indicate how much you have been bothered by that problem in the last month. 

1. 

2. 

3. 

4. 

5. 

6. 

7. 

8. 

9. 

10. 

11. 

12. 

13. 

14. 

15. 

16. 

Response: Not at 

all (1) 

A little 

bit (2) 

Moderately 

(3) 

Quite a 

bit (4) 

Extremely 

(5) 

Repeated, disturbing memories, 

thoughts, or images of a stressful 

experience from the past? 

Repeated, disturbing dreams of 

a stressful experience from the 

past? 

Suddenly acting or feeling as if a 

stressful experience were 

happening again (as if you were 

reliving it)? 

Feeling very upset when something 

reminded you of a stressful 

experience from the past? 

Having physical reactions (e.g., heart 

pounding, trouble breathing, or 

sweating) when something 

reminded you of a stressful 

experience from the past? 

Avoid thinking about or talking about a 

stressful experience from the past or 

avoid having feelings related to it? 

Avoid activities or situations because they 

remind you of a stressful experience 

from the past? 

Trouble remembering important 

parts of a stressful experience from 

the past? 

Loss of interest in things that you 

used to enjoy? 

Feeling distant or cut off from other 

people? 

Feeling emotionally numb or being 

unable to have loving feelings for those 

close to you? 

Feeling as if your future will 

somehow be cut short? 

Trouble falling or staying asleep? 

Feeling irritable or having angry 

outbursts? 

Having difficulty concentrating? 

Being “super alert” or watchful on 

guard? 

17. Feeling jumpy or easily startled? 

20 Weathers, F.W., Huska, J.A., Keane, T.M., PCL-S for DSM-IV, Boston: National Center for PTSD-Behavioral 

Science Division, 1991. 

VA Office of Inspector General 15 
Post Traumatic Stress Disorder Counseling Services at Vet Centers 

Appendix F 

DSM Multi-Axial System 

The DSM-IV organizes each psychiatric diagnosis into five dimensions (axes) 

relating to different aspects of disorder or disability: 

	 Axis I: Clinical disorders, including major mental disorders, and learning 

disorders 

	 Axis II: Personality disorders and intellectual disabilities (although 

developmental disorders, such as Autism, were coded on Axis II in the 

previous edition, these disorders are now included on Axis I) 

	 Axis III: Acute medical conditions and physical disorders 

	 Axis IV: Psychosocial and environmental factors contributing to the 

disorder 

	 Axis V: Global Assessment of Functioning or Children's Global 

Assessment Scale for children and teens under the age of 18 

VA Office of Inspector General 16 
Post Traumatic Stress Disorder Counseling Services at Vet Centers 

Appendix G 

OIG Contact and Staff Acknowledgments 

OIG Contact	 For more information about this report, please contact 

the Office of Inspector General at (202) 461-4720. 

Acknowledgments	 Wachita Haywood, RN 

Marisa Casado, RN 

Lin Clegg, PhD 

Audrey Collins, RN 

Darlene Conde-Nadeau, NP 

Jeffrey Joppie, BS 

Tishanna, McCutchen, NP 

Simonette Reyes, RN 

Annette Robinson, RN 

Michael Shepherd, MD 

Patrick Smith, MS 

Marilyn Stones, BS 

VA Office of Inspector General 17 
Post Traumatic Stress Disorder Counseling Services at Vet Centers 

Appendix H 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Under Secretary for Health (10) 

Readjustment Counseling Service Chief Officer (0015) 

Non-VA Distribution 

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, 

and Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, 

and Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA Office of Inspector General 18