Healthcare Inspection Review of Veterans Health Administration Residential Mental Health Care Facilities

As directed in Public Law 110-387, the VA Office of Inspector General (OIG) conducted a review of residential mental health care facilities, including domiciliary facilities, of the Veterans Health Administration (VHA). The review employed three components for information gathering: a web based information request, onsite inspections, and medical record reviews. OIG inspectors conducted onsite visits to a stratified probability-based random sample of 20 residential treatment program sites and reviewed a total of 933 medical records that were randomly sampled from the 20 sites. We found the following: Only 16 of 21 Veterans Integrated Service Networks (VISNs) had programs in all 5 residential program categories presented. Only 24 of 92 sites reported specific special emphasis programming for Operation Iraqi Freedom/Operation Enduring Freedom veterans. Based on our chart review we estimated that 74 percent of residential program patients placed on waiting lists were contacted or engaged in treatment while awaiting placement. All 20 sites visited, excluding the Compensated Work Therapy programs, had a staff member present in each building on all shifts. We estimated that 57 percent of patients at programs with policies on contraband had contraband searches performed on admission. Clinical treatment programming meeting VHA standards was provided on weekends at 4 of 20 sites visited. We estimated that post-discharge monitoring was not evident in 29 percent of residential patient records. In the absence of external staffing ratio standards for these unique set of programs, we believe that VHA should develop more specific staffing guidance as it pertains to patient monitoring and supervision by nursing and affiliated staff. In terms of medication issues, we estimated that 11 percent of VA residential program Self Medication Policy (SMP) patients on narcotics received more than a 7 day supply of medication, 55 percent of SMP patients had no documentation of an order for SMP nor was there consistent documentation of appropriate instruction regarding the SMP process. During site visits we found variation between programs and between sites in monitoring and re-scheduling missed appointments. We made recommendations for improvement; VHA concurred and submitted appropriate action plans.