The OIG’s Mental Health Inspection Program (MHIP) evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on inpatient care delivered at the Martinsburg VA Medical Center (facility) in West Virginia.
The facility met some VHA requirements for inpatient mental health units, including aspects of a recovery-oriented physical environment, such as artwork and natural lighting, and a plan for continued transformation to recovery-oriented services. However, the facility did not include veteran representation on its Mental Health Executive Council and did not have a full-time local recovery coordinator. Recovery-oriented, interdisciplinary programming also did not consistently occur as scheduled.
The OIG identified ongoing communication issues between facility executive and mental health leaders, including executive leaders being unaware of pertinent information related to mental health staffing and processes. Staff did not perform involuntary holds or admissions due to leaders’ incorrect interpretation of West Virginia state law, and the Veterans Integrated Service Network (VISN) did not identify that the facility’s involuntary hospitalization policy was inconsistent with state laws.
Electronic health records indicated that reviewed safety plans did not consistently address making the veteran’s environment safer from potentially lethal means, and staff did not consistently document medication risk and benefit discussions. Discharge instructions were typically difficult to understand, lacking important details for medication management.
The OIG observed safety hazards, such as unapproved window coverings in most bedrooms and potentially unsafe equipment in a shower room. The OIG also found shower room monitoring practices could compromise veterans’ privacy and dignity.
VA concurred with the OIG’s 16 recommendations. The VISN Director committed to ensuring establishment of state-compliant involuntary hold procedures. The Facility Director agreed to implementing a range of corrective actions, including enhanced leadership oversight, expanded veteran engagement, strengthened staff training, and improved coordination and documentation practices to support safe, recovery-oriented mental health care.
WV
United States
