Mental Health Inspection of the Lexington VA Healthcare System in Kentucky

Report Information

Issue Date
Report Number
24-03543-78
VISN
9
State
Kentucky
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Mental Health Inspection Program
Report Topic
Care Coordination
Mental Health
Suicide Prevention
Major Management Challenges
Leadership and Governance
Recommendations
11
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The VA Office of Inspector General’s (OIG’s) Mental Health Inspection Program evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on inpatient mental health care delivered at the Lexington VA Healthcare System in Kentucky. 

Facility leaders reported that the service line leadership structure promoted a culture of collaboration. However, despite adequate leadership staffing and a low patient census, the OIG identified oversight concerns and unmet VHA requirements. Concerns included a lack of veteran representation on the Mental Health Executive Council and recovery-oriented programming not being delivered as scheduled. 

Facility policy outlined written processes for involuntary hospitalization; however, there was no formal procedure to track and monitor compliance with relevant state laws. Additionally, staff inconsistently documented required discussions regarding medication risks, and discharge instructions were often difficult to understand or incomplete. 

Staff met suicide risk screening requirements; however, some safety plans omitted strategies to reduce access to lethal means other than firearms or opioids. 
Inspections used to identify environmental hazards occurred at the required frequency; however, risk assessments for identified deficiencies were not documented. Furthermore, facility leaders did not reconcile conflicting guidance between the Veterans Integrated Service Network and the National Center for Patient Safety regarding environmental safety requirements.

Facility and Veterans Integrated Service Network leaders concurred with the 11 recommendations issued by the OIG. Leaders described plans to address recovery-oriented staffing and programming, design elements, discharge instructions, informed consent, involuntary hospitalization, safety inspections, and hazard reporting on the inpatient mental health unit.
 

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Facility Director ensures the Mental Health Executive Council operates in accordance with Veterans Health Administration requirements.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Mental Health ensures compliance with Veterans Health Administration requirements for a full-time local recovery coordinator.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Mental Health ensures a minimum of four hours of recovery-oriented, interdisciplinary programming on weekdays and weekends on the inpatient mental health unit.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Facility Director considers consulting with the Office of Mental Health to clarify guidelines for design elements such as artwork on the inpatient unit.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Facility Director considers alternatives to outdoor access for the inpatient unit, such as those identified in VA’s Design Guide for Inpatient Mental Health & Residential Rehabilitation Treatment Program Facilities.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Facility Director develops and implements written processes to monitor and track compliance with state laws for involuntary hospitalization and consults with the Office of General Counsel to ensure processes are consistent with applicable laws.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures documentation of informed consent discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures veterans’ discharge instructions are written in easy-to-understand language and include the follow-up mental health appointment location, the purpose of each medication, and how the medication is supposed to be taken.

No. 9
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Facility Director ensures the Interdisciplinary Safety Inspection Team adheres to Veterans Health Administration requirements, including recording membership and attendance for Mental Health Environment of Care Checklist inspections.

No. 10
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director implements processes to ensure the Veterans Integrated Service Network Mental Health Environment of Care Checklist Oversight Team provides facility guidance consistent with Veterans Health Administration requirements.

No. 11
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Facility Director implements processes to ensure Interdisciplinary Safety Inspection Team staff accurately identify and document safety hazards within the Patient Safety Assessment Tool.