Mental Health Inspection of the VA NY Harbor Healthcare System in New York

The VA Office of Inspector General (OIG) 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 Margaret Cochran Corbin VA Campus (facility) in New York.

The facility met some VHA requirements for inpatient mental health units, such as the presence of a mental health executive council and completion of twice-yearly environment of care inspections. The OIG could not confirm if the facility had a formalized interdisciplinary safety inspection team. The facility’s multiyear plan to direct veteran-centered, recovery-oriented care did not have input from the local recovery coordinator.

Some electronic health records reviewed did not include evidence of timely suicide risk screenings and documentation of medication risk and benefit discussions. Discharge instructions lacked important details for follow-up appointment locations and medication management. Consistent with prior published reports, inpatient staff did not complete the other lethal means text field in safety plans for addressing ways to make veterans’ environments safer. 

The inpatient unit physical environment incorporated recovery-oriented elements such as artwork. However, communal rooms were locked and therefore inaccessible to veterans unless there were staff to monitor. The OIG identified unit fire doors with three-point hinges that posed ligature risks and a nonfunctional panic button. Many inpatient staff did not complete training on environment of care inspection requirements or suicide prevention strategies. 

VA concurred with the OIG’s 17 recommendations. The Under Secretary for Health agreed to require staff completion of the other lethal means text field within the safety plan template. The Facility Director agreed to implement a range of corrective actions, including strengthened processes and staff training, a formalized interdisciplinary safety inspection team, and improved coordination and documentation practices to support safe, recovery-oriented mental health care on the inpatient unit.