Mental Health Inspection of the VA Central Western Massachusetts Healthcare System in Leeds

The 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 Edward P. Boland VA Medical Center, part of the VA Central Western Massachusetts Healthcare System (facility) in Leeds.

The facility met some VHA requirements for inpatient mental health units, including providing the required amount of interdisciplinary programming for veterans and the completion of twice-yearly environment of care inspections. The inpatient unit included some aspects of a recovery-oriented physical environment, such as soft night lighting in the nurses’ station and veterans’ rooms.

Electronic health record reviews indicated most veterans were involved with the interdisciplinary treatment team in treatment planning, and veterans had documented safety plans. However, some records did not include evidence of timely suicide risk screenings, and discharge instructions were difficult to understand, lacking important details for appointment follow-up and medication management.

The facility did not have an established local mental health executive council or an interdisciplinary safety inspection team during the review period. The facility’s admission policy did not include processes for the admission of veterans on an involuntary hold. The facility leaders lacked formal processes to monitor and track compliance with involuntary commitment state laws.

The OIG identified environment of care deficiencies such as the unit’s sally port entrance doors were not synchronized; the inpatient unit had unweighted, unsecured chairs in a group room; and facility staff did not have a policy that addressed the use of a restraint chair. Additionally, many staff did not have evidence of completed environment of care or suicide prevention trainings. 

The OIG issued 16 recommendations to facility 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.