Mental Health Inspection of the VA Augusta Health Care System in Georgia

The VA Office of Inspector General’s (OIG’s) Mental Health Inspection Program (MHIP) evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on the inpatient care delivered at the VA Augusta Health Care System (HCS) in Georgia. Augusta HCS met some VHA requirements for inpatient mental health units, such as the presence of a mental health executive council, completion of twice-yearly environment of care inspections, and a plan for continued transformation to recovery-oriented services. A review of electronic health records indicated veterans and the interdisciplinary treatment team were involved in treatment planning, and most veterans had documented safety plans. However, some records did not include evidence of timely suicide risk screening. Discharge instructions were typically difficult to understand and lacked important details for appointment follow-up and medication management.The OIG was concerned about access to inpatient mental health care. Specifically, the high volume of community referrals contrasted with Augusta HCS’s low bed utilization. The OIG identified communication gaps between Augusta HCS and mental health leaders regarding the explanations for beds being out of service, causes of low bed utilization, and process improvement efforts to address these concerns.The inpatient unit’s physical environment incorporated natural sunlight in some common areas, but needed cosmetic improvements in sleeping areas and contained toilets with ligature points that posed a safety risk. Additionally, many inpatient unit staff did not have evidence of completed trainings on environment of care inspection requirements or suicide prevention strategies. As a result of its findings, the OIG issued 21 recommendations to Augusta HCS and Veterans Integrated Service Network leaders. These recommendations, once addressed, may improve the quality and delivery of veteran-centered, recovery-oriented care on the inpatient mental health unit and beyond.