The VA Office of Inspector General’s (OIG’s) Mental Health Inspection Program evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on inpatient mental health care delivered at the Lexington VA Healthcare System in Kentucky.
Facility leaders reported that the service line leadership structure promoted a culture of collaboration. However, despite adequate leadership staffing and a low patient census, the OIG identified oversight concerns and unmet VHA requirements. Concerns included a lack of veteran representation on the Mental Health Executive Council and recovery-oriented programming not being delivered as scheduled.
Facility policy outlined written processes for involuntary hospitalization; however, there was no formal procedure to track and monitor compliance with relevant state laws. Additionally, staff inconsistently documented required discussions regarding medication risks, and discharge instructions were often difficult to understand or incomplete.
Staff met suicide risk screening requirements; however, some safety plans omitted strategies to reduce access to lethal means other than firearms or opioids.
Inspections used to identify environmental hazards occurred at the required frequency; however, risk assessments for identified deficiencies were not documented. Furthermore, facility leaders did not reconcile conflicting guidance between the Veterans Integrated Service Network and the National Center for Patient Safety regarding environmental safety requirements.
Facility and Veterans Integrated Service Network leaders concurred with the 11 recommendations issued by the OIG. Leaders described plans to address recovery-oriented staffing and programming, design elements, discharge instructions, informed consent, involuntary hospitalization, safety inspections, and hazard reporting on the inpatient mental health unit.
KY
United States
