Insufficient Veterans Crisis Line Management of Two Callers with Homicidal Ideation, and an Inadequate Primary Care Assessment at the Montana VA Health Care System in Fort Harrison

The VA Office of Inspector General (OIG) evaluated allegations regarding Veterans Crisis Line (VCL) responses to a caller (caller 1) with homicidal ideation and a second caller (caller 2) with suicidal and homicidal ideation. The OIG also evaluated concerns regarding caller 1’s care at the Montana VA Health Care System (facility). The OIG substantiated a VCL responder failed to assess caller 1’s homicidal risk factors, address lethal means restriction, complete an adequate risk mitigation plan, communicate critical information to a supervisor, and take actions to prevent a family member’s death. VCL leaders did not consider an administrative investigation board to review the responder’s potential misconduct. The OIG substantiated that two social service assistants (SSAs) failed to dispatch local emergency services for caller 2 following a responder’s rescue request. The OIG identified deficiencies in SSA oversight. VCL leaders did not fully adhere to Veterans Health Administration (VHA) policies related to reporting and disclosure of adverse events. A facility primary care provider failed to include caller 1’s mental health diagnosis in the assessment and plan of care. Also, the primary care provider did not submit caller 1’s non-VA medical records for scanning into the electronic health record or document a review of the records, as expected by VHA policy. The OIG made two recommendations to the Executive Director, Office of Mental Health and Suicide Prevention, related to the establishment of quality management and disclosure processes. The OIG made seven recommendations to the VCL Director related to a review of the callers’ contacts, administrative investigation board procedures, quality management processes, responders’ communication, and SSA oversight. The OIG made two recommendations to the Facility Director related to providers’ assessment and care plans and documentation of patients’ non-VA health records.