The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate concerns related to Ralph H. Johnson VA Medical Center (facility) staff’s management of a patient’s reported perpetration of intimate partner violence (IPV). The OIG also evaluated concerns related to the IPV Assistance Program (IPVAP) implementation at the facility.The OIG found that despite the patient’s and spouse’s IPV reports, inpatient mental health unit staff did not consult with the IPVAP point of contact or ensure the spouse felt safe with the patient returning home upon discharge. The inpatient psychiatry resident did not timely complete a progress note addendum, which resulted in other clinicians not having access to critical IPV related information for 34 days. Facility staff failed to consider consultation with the Office of Chief Counsel although the Veterans Health Administration (VHA) advises employees to “work with your Office of Chief Counsel” regarding state reporting requirements for victims of IPV. Outpatient mental health staff did not consult with the IPVAP point of contact or document discussion of IPV resources or treatment options, as the OIG would have expected. The Facility Director did not ensure development of an IPVAP protocol, as required, and although a licensed independent provider was appointed as the IPVAP coordinator, facility staff and leaders did not identify the assigned IPVAP coordinator as a resource at the time of the patient’s care in 2019. The OIG also found that VHA guidance about IPV training responsibilities was unclear.The OIG made one recommendation to the Under Secretary for Health related to IPV training guidance and three recommendations to the Facility Director related to staff consultation with the IPVAP coordinator, timely clinical documentation, and consultation with the Office of General Counsel to determine reporting requirements.
Charleston, SC
United States
