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Report File
Date Issued
Submitting OIG
Department of Veterans Affairs OIG
Other Participating OIGs
Department of Veterans Affairs OIG
Agencies Reviewed/Investigated
Department of Veterans Affairs
Components
Veterans Health Administration
Report Number
21-03734-32
Report Description

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations related to the mental health care of a female patient at the VA Greater Los Angeles Healthcare System (facility) in California, which included that a psychiatry physician resident (psychiatry trainee) was inappropriate during treatment discussions with the patient. The psychiatry trainee utilized a modality called Intensive Short-Term Dynamic Psychotherapy in which a therapist seeks to understand a patient’s interpersonal difficulties, intensify and challenge resistance, analyze transference, explore conflict, and work through unconscious issues.The OIG did not substantiate that the psychiatry trainee’s behavior with the patient was inappropriate. Although the psychiatry trainee did not always engage in effective therapeutic intervention, the OIG was unable to determine that the treatment resulted in a decline in the patient’s mental health causing decreased trust and mental functioning.The OIG found the supervisor did not provide adequate supervision to the psychiatry trainee, to include the psychiatry trainee’s documentation and the supervisor’s documented oversight. The inadequate supervision may have impeded the supervisor’s ability to inform the therapy and hinder the opportunity to achieve a more desirable therapeutic outcome. In addition, the OIG substantiated that Mental Health Department leaders were not responsive to the patient’s concerns. During the inspection, the OIG identified an additional concern regarding the improper creation, storage, and disposition of video recordings and consent forms.The OIG made one recommendation to the Under Secretary for Health to assess the possible scope of current and former VA psychiatry residents being in possession of patients’ personal health information; two recommendations to the Veterans Integrated Service Network Director related to supervision, documentation, document control, and treatment protocols; and three recommendations to the Facility Director related to responses to the patient’s concerns, records, and utilization of video recordings.

Report Type
Inspection / Evaluation
Location

Los Angeles, CA
United States

Number of Recommendations
9
Questioned Costs
$0
Funds for Better Use
$0

Open Recommendations

This report has 1 open recommendations.
Recommendation Number Significant Recommendation Recommended Questioned Costs Recommended Funds for Better Use Additional Details
04 Yes $0 $0

The Under Secretary for Health conducts a review to assess the possible scope of current and former VA psychiatry residents being in possession of patients’ personal health information, to include video recorded treatment sessions and consent forms, and consults with the appropriate organizational leaders such as the Office of General Counsel on the required disposition of the recordings and forms, and takes action as needed.

Department of Veterans Affairs OIG

United States