Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Facilities, Fiscal Year 2020

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of Veterans Health Administration facilities’ selected mental health program requirements. This evaluation focused on suicide prevention coordinator processes, provision of suicide prevention care, and suicide prevention training.This report describes mental health-related findings from healthcare inspections that were initiated at 36 Veterans Health Administration medical facilities from November 4, 2019, through September 21, 2020, and electronic health record review at five additional facilities. Each inspection involved interviews with facility leaders and staff, and reviews of clinical and administrative processes. The results in this report are a snapshot of Veterans Health Administration performance at the time of the fiscal year 2020 OIG reviews.The OIG found general compliance with many of the selected requirements. However, the OIG identified weaknesses in various key mental health-related processes and issued four recommendations related to:• completion of four follow-up visits within the required time frame,• appropriate follow-up of veterans with high-risk patient record flags who do not attend mental health appointments,• suicide prevention training, and• completion of five monthly outreach activities.