Federal Reports

The VA Office of Inspector General (OIG) conducted a review of Veterans Health Administration (VHA) inpatient mental health unit (mental health unit) suicide risk identification processes, suicide prevention safety plans, mental health treatment coordinator (MHTC) role requirements, and discharge care coordination procedures.

Given patients’ increased suicide risk after discharge, continuity of care is critical to mitigating risk. VHA requires that every patient receiving mental health services be assigned a principal mental health provider to support care coordination.

Staff failed to document required suicide risk screening for 27 percent of patients and did not complete safety plans for 12 percent of discharged patients. The OIG concluded that failure to complete suicide risk identification processes may result in an underestimation of patients’ risk, and failure to complete a safety plan can contribute to diminished utilization of coping strategies and supportive resources.

Over 30 percent of facilities lacked an MHTC policy and mental health unit staff failed to assign an MHTC for nearly 40 percent of patients. Over half of surveyed patients with an assigned MHTC could not identify the MHTC and more than 25 percent of MHTCs were uninvolved in discharge care coordination or the transition to outpatient care. 

While most patients, regardless of MHTC assignment, attended at least one outpatient mental health appointment within 90 days, over half of surveyed patients identified self-motivation and 20 percent identified encouragement from a family member or friend as contributing to appointment attendance. The OIG concluded that the MHTC model failed to effectively facilitate care coordination and MHTC assignment was not associated with a patient’s likelihood of attending post-discharge treatment engagement.

The OIG made eight recommendations to the Under Secretary for Health related to suicide risk identification and safety planning; MHTC written guidance, assignment, and effectiveness; post-discharge mental health appointment scheduling; and post-discharge treatment engagement.

The VA Office of Inspector General (OIG) conducted a national review to evaluate the Veterans Health Administration’s (VHA’s) suicide risk screening and evaluation training, adherence, and oversight procedures. VHA’s standardized Suicide Risk Identification Strategy (Risk ID) process requires annual screening using the Columbia-Suicide Severity Rating Scale (screening) and comprehensive suicide risk evaluation (evaluation) in response to a positive screening. VHA also recognized the need for screening beyond annual screening and implemented setting-specific Risk ID requirements in 10 clinical settings.

The OIG found that VHA’s required suicide prevention training does not include Risk ID processes or requirements. Training related to Risk ID responsibilities is available. However, the training is optional and not monitored.

VHA has not established annual or setting-specific Risk ID performance benchmarks and has conveyed inconsistent expectations to facility leaders and staff. In fiscal year 2023, annual screening and evaluation adherence was 55 and 82 percent, respectively. In a November 2020 memorandum, VHA expected 100 percent adherence, while other VHA documents reference expectations ranging from 81 to 95 percent. Furthermore, except for emergency department and urgent care settings, VHA does not monitor setting-specific Risk ID adherence.

The OIG determined that staff encountered barriers to completing Risk ID screening and evaluation, which included (1) limited engagement of facility clinical staff, (2) lack of facility leaders’ support, (3) limitations of performance data, and (4) unclear delineation of responsibilities.

The OIG made six recommendations to the Under Secretary for Health related to suicide risk and intervention training, suicide screening and evaluation performance benchmarks, setting-specific Risk ID monitoring, effectively addressing barriers to Risk ID non-adherence, non-mental health clinical specialty leaders’ awareness of Risk ID requirements, and clear identification of Risk ID monitoring and oversight responsibilities.

The audit objectives were to determine whether program funds were managed in accordance with the ARC and Federal grant requirements.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to determine the validity of an allegation that select therapists do not maintain optimal utilization of individual mental health clinics and clinic administrative processes related to the Choose My Therapy (CMT) program, creating barriers to patients receiving care, timely care, or follow-up care at the Hinesville VA Clinic (Clinic).

The OIG substantiated that therapists’ clinic utilization rates were not optimal. Analysis of clinic utilization data revealed that Clinic therapists who provided individual psychotherapy generally had clinic utilization rates ranging from 32–68 percent, which was below the lowest target of 80 percent recommended by the Veterans Health Administration (VHA). The Clinic mental health section chief (section chief) acknowledged awareness of low utilization rates since 2022 but cited competing priorities as barriers to change.

The OIG analyzed data of 285 unique patients who received a diagnostic evaluation and found that patients experienced delayed access to mental health care. Specifically, a median wait time of at least three weeks between three subsequent individual psychotherapy sessions. Delayed initiation of mental health treatment may put patients at risk for negative outcomes, and VHA expects sessions to occur weekly. Further analysis of the data showed a progressive loss of patients engaged in treatment.

The OIG learned that Clinic mental health staff utilized a prohibited waitlist. The section chief confirmed the waitlist was discontinued in April 2023 and reported that patients’ care requests have since been tracked through clinical consults in electronic health records.

The OIG made six recommendations to the Facility Director related to optimizing clinic utilization, accurate use of current procedural terminology codes, consult management and patient scheduling processes, review of patients who experienced individual therapy delays and were on the discontinued waitlist, and evaluation of CMT programs operating in other facility locations.

Objective: To determine whether the Social Security Administration issued payments to beneficiaries who were deceased according to New York City’s vital statistics records.