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 VA Ann Arbor Healthcare System in Michigan.
The facility met some VHA requirements for inpatient mental health units, such as having a plan for continued transformation to recovery-oriented services. The facility had a mental health executive council, but the council did not have veteran representation. Facility staff conducted biannual environment of care inspections; however, the OIG could not determine whether the facility had a formalized interdisciplinary safety inspection team.
The OIG observed a recovery-oriented physical environment with communal areas for socialization. Staff offered veterans the required amount of interdisciplinary programming on weekdays but not on weekends.
The OIG identified inconsistencies in the number of operating inpatient mental health beds reported in facility data and by leaders at various facility and Veterans Integrated Service Network levels. Network leaders did not ensure accurate reporting of available beds.
Facility leaders did not have written processes to monitor compliance with state laws regarding involuntary hospitalization. Staff did not document veterans’ legal commitment statuses in the required template. Not all inpatient staff completed suicide prevention or safety hazards training.
Some electronic health records did not include evidence of timely suicide risk screening. All reviewed records included the required discharge summary; however, some summaries were not completed within two business days of discharge. Discharge instructions included difficult-to-understand language and lacked important details for appointment location follow-up and medication management.
VA concurred with the OIG’s 14 recommendations; the OIG closed 1 recommendation prior to publication. Facility leaders committed to implementing corrective actions, including written compliance processes for involuntary commitment, mental health environment of care standards, interdisciplinary weekend programming, discharge instruction improvements, and staff training completion.
