Issues Related to an Administrative Investigation Board at the VA Black Hills Health Care System in Fort Meade and Hot Springs, South Dakota

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA Black Hills Health Care System (facility) in Fort Meade and Hot Springs, South Dakota, to evaluate how facility leaders addressed an administrative investigation board’s (AIB) findings and recommendations. The OIG received complaints alleging failures in leadership and management, and misconduct and inappropriate relationships between leaders and staff and between clinical staff and patients within the Mental Health Service. In response, the former Facility Director convened an AIB and detailed two leaders out of the Mental Health Service, in compliance with VA policy. Prior to retirement, the former Facility Director met with the acting Facility Director to discuss the AIB report and advised that two action items required follow-up. The former Facility Director did not share the AIB report with other senior facility leaders, citing not enough time before retirement. As a result, a lapse of understanding and follow-up of the AIB’s recommendations occurred when the former Facility Director retired. After being contacted by the OIG, the acting Facility Director and other senior facility leaders read the AIB report and developed an action plan to address the 11 recommendations. The OIG confirmed that facility leaders were addressing each recommendation and taking steps to address the mental health leader and a staff member, who was a student at the time, identified within the AIB report as having inappropriate relationships with patients. The facility reported the mental health leader to the state licensing board. The facility did not independently verify that the student self-reported the inappropriate relationship to the state licensing board. The OIG made two recommendations to the Facility Director related to completing the action plan, and independently determining if the state licensing board should be notified.