Federal Reports

The VA Office of Inspector General (OIG) conducted an inspection to assess allegations regarding staff's failure to follow informed consent and against medical advice (AMA) discharge processes and that staff held a patient on the locked mental health unit involuntarily for 48 hours at the VA Southern Nevada Healthcare System (facility) in Las Vegas. The OIG identified a related concern regarding alignment of a medical center policy (MCP) with Nevada state law and Veterans Health Administration requirements.The patient presented to the Emergency Department requesting assistance with substance withdrawal and was admitted to the locked inpatient mental health unit for management of withdrawal symptoms. The OIG substantiated that staff, lacking a standardized process to follow, failed to have the required informed consent discussion to inform the patient that the unit is locked and treats patients with mental health conditions.Upon admission, the patient complained of the restrictive environment and behavior of fellow patients. After verbally requesting an AMA discharge, the patient agreed to remain. The next day, the patient completed a written AMA request and, in accordance with facility policy, was discharged within 24 hours of the request. However, Nevada law states that any patient voluntarily admitted must be released immediately after filing a written request for discharge.The OIG determined that although staff did not hold the patient involuntarily for 48 hours and followed their AMA discharge policy as written, the policy was inconsistent with state law.The OIG found the Facility Director failed to assign responsibility for ensuring the policy adhered to state laws, as required. This failure provided a gap, which may have led to the MCP not aligning with state law.The OIG made seven recommendations to the Facility Director related to the informed consent discussion process, MCP development process, and staff education on MCPs.

This is the audit of the NEA's information technology systems security. Due to security concerns, this report is not published on the internet. You can obtain a copy of this report through a freedom of information act request at the following link: https://www.arts.gov/freedom-information-act-guide.

The Office of Inspector General (OIG) evaluated concerns related to Veterans Integrated Service Network (VISN) 10 staff’s care and treatment coordination for a patient who died. The OIG reviewed the sufficiency of Veterans Health Administration (VHA) leaders’ actions prior to and following notification of the patient’s death.VA Ann Arbor Health Care System (Ann Arbor VA) staff adequately considered a posttraumatic stress disorder diagnosis and assessment for the patient and screened for toxic exposure and traumatic brain injury. However, inpatient mental health providers failed to sufficiently address the patient’s mental health condition, treatment needs, and discharge care coordination.Due to absence of documentation, the OIG was unable to determine whether a Battle Creek VA Medical Center (Battle Creek VA) staff member inaccurately verified the patient’s treatment eligibility status. Battle Creek VA staff responded appropriately to non-VA staff’s inpatient mental health unit inquiries regarding the patient’s transfer request; however, the transfer was not considered due to unavailability of beds. Battle Creek VA leaders implemented recommendations from a workgroup to improve transfer coordination.A Battle Creek VA residential treatment standard operating procedure was inconsistent with the VHA requirement to allow self-referral or non-VA agency referral. VHA leaders responded within 24 hours when notified of the patient’s transfer request and took actions to identify the patient’s treatment needs and options. VISN 10 leaders established an Interagency Reconciliation Council (IRC); however, the IRC lacked defined objectives and processes to monitor outcome progress.The OIG made one recommendation to the Ann Arbor VA Director to review the patient’s care; four recommendations to the Battle Creek VA Director regarding eligibility verification procedures, transfer coordination, and the residential treatment standard operating procedure; and one recommendation to the VISN 10 Director related to the IRC’s identification of clearly defined objectives and processes to monitor progress.

To learn how communities across the nation responded to the pandemic during the first 18 months, we initiated a multi-part review of six communities—two cities, two rural counties, and two Tribal reservations. This report is the second community-specific report and focuses on our work in Coeur d’Alene, Idaho, where we previously identified that recipients, including city government, small businesses, and individuals, received almost $314 million from 45 pandemic relief programs and subprograms. This report provides a closer look at eight pandemic programs and subprograms provided to Coeur d’Alene by seven federal departments.

The OIG evaluated concerns at the Michael E. DeBakey VA Medical Center (facility) regarding staff’s failure to arrange an evidence-based psychotherapy (EBP) referral for a patient assigned a high risk for suicide patient record flag (high-risk flag). The OIG reviewed concerns that staff did not adequately conduct lethal means safety planning or provide required high-risk flag management for the patient.Although the patient was receiving psychiatric care, the OIG found that staff failed to provide in-person EBP until over a year after the patient’s request, inconsistent with Veterans Health Administration (VHA) requirements. The OIG also found that staff did not offer the patient equipment to participate in virtual sessions or consistently document attempts to contact the patient as required.It was determined that a psychologist and psychiatrist did not sufficiently address the patient’s access to lethal means. Given the patient’s firearm access and past suicidal behavior, the OIG would have expected the psychologist to address the patient’s potential to obtain ammunition and document a discussion of risk reduction strategies. The OIG found that the psychiatrist did not document evaluation of the patient’s access to ammunition.Following high-risk flag initiation, staff did not meet with the patient, document suicide risk assessment, or update or review the patient’s safety plan, as required. Inconsistent with a VHA requirement, an Office of Mental Health and Suicide Prevention leader reported that homeless program staff are not expected to review or update safety plans during high-risk flag follow-up appointments. The OIG made one recommendation to the Under Secretary for Health to clarify requirements for suicide risk assessment completion and safety plan reviews and five recommendations to the Facility Director related to EBP consult management, timely scheduling, and documentation; VA-issued devices; lethal means safety; and high-risk flag follow-up.