Mental Health Inspection of the VA Salem Healthcare System in Virginia

The OIG’s Mental Health Inspection Program (MHIP) evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on care delivered on the inpatient mental health unit at the VA Salem Healthcare System in Virginia. 

The inpatient unit had some aspects of a recovery-oriented physical environment, including artwork, natural lighting, and secure outdoor spaces. The local recovery coordinator was integrated into recovery-oriented activities and staff provided the required interdisciplinary programming on weekdays but not on weekends. 

The facility had an established local Mental Health Executive Council; however, the OIG could not verify that all required participants attended meetings. The facility had an admission procedure that addressed involuntary hospitalization but lacked a written process to monitor and track compliance with involuntary commitment state laws. 

Staff involved veterans in treatment planning, but did not comply with requirements to document medication risks and benefits discussions. Staff also did not consistently complete suicide screening within 24 hours before discharge, complete or review safety plans, or consistently address ways to make veterans’ environments safer from lethal means beyond access to firearms and opioids. Many staff did not have evidence of completed lethal means safety and suicide risk trainings. Additionally, most discharge instructions included abbreviations that could be difficult for veterans to understand.

The OIG was unable to determine whether Interdisciplinary Safety Inspection Team members completed the required environment of care training. Staff reported using a restraint chair; while the facility had a local policy on the use of restraints, it did not include the use of restraint chairs. 

As a result of its findings, the OIG issued 15 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.