Mental Health Inspection of the South Texas Veterans Health Care System in San Antonio

Report Information

Issue Date
Report Number
25-03943-269
VISN
4
State
Texas
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
Healthcare Services
Leadership and Governance
Recommendations
13
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The VA Office of Inspector General (OIG) reviewed acute inpatient mental health care at the South Texas Veterans Health Care System in San Antonio. Inspectors evaluated care in five areas, provided preliminary observations to leaders, and later issued 13 recommendations. 

The Mental Health Executive Council included required veteran representation. OIG inspectors identified inaccurate and delayed bed availability reporting, lack of formal processes for complying with involuntary commitment laws, and no program specific procedures for treatment planning on the unit. 

The physical environment did not incorporate natural lighting, warm paint colors, or artwork. Weekend programming hours were inconsistent, though staff provided the required interdisciplinary programming on weekdays. Despite environmental limitations, inspectors observed veteran-centric care with staff presence and engagement in shared areas.

The facility lacked a policy governing video monitoring on the unit and did not have signage informing veterans of its use. Contrary to VA policy, VA police used cameras on the unit to monitor and record veterans.

Most reviewed electronic health records did not include required documentation that prescribers and veterans discussed medication risks and benefits. Veterans were typically offered discharge instructions with follow-up appointment details that were difficult to understand. All reviewed records reflected timely suicide risk screening and safety planning. Some inpatient unit staff and safety inspection team members did not complete the annual Mental Health Environment of Care Checklist training.

Not all safety inspection members attended biannual inspections and attendance was not recorded or provided to the identified committee. Not all appeals were resubmitted within the required time frame.

In response to the OIG’s recommendations, the Facility Director described plans to address inpatient mental health treatment planning, involuntary commitment legal compliance, use of video monitoring, therapeutic programming, documentation practices, the recovery environment, safety inspections, and staff training. Facility leaders reported updating note templates for informed consent medication discussions.

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 Associate Chief of Staff, Mental Health develops and implements written processes to ensure treatment planning on the inpatient mental health unit aligns with Veterans Health Administration Directive 1160.01, Uniform Mental Health Services in VHA Medical Points of Service requirements. 

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

The Associate Chief of Staff, Mental Health requires a minimum of four hours of recovery-oriented, interdisciplinary programming on weekends on the inpatient mental health unit, in alignment with Veterans Health Administration Directive 1160.06(1), Inpatient Mental Health Services.

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

The Facility Director ensures implementation of a recovery-oriented environment on the inpatient mental health unit, consistent with Veterans Health Administration’s Design Guide for Inpatient Mental Health & Residential Rehabilitation Treatment Program Facilities.

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

The Facility Director develops and implements a written standard operating procedure for the use of video monitoring on the inpatient mental health unit, as required by Veterans Health Administration Office of Mental Health Standard Operating Procedure 1160.06.1, “Standard Operating Procedure for Maintaining Safety and Security on Inpatient Mental Health Units under VHA [Veterans Health Administration] Directive 1160.06.”

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

The Chief of Staff ensures that only healthcare staff have access to video monitoring in treatment areas and that video equipment is used for monitoring, not recording, in accordance with Veterans Health Administration Directive 1078, Privacy of Persons Regarding Photographs, Digital Images and Video or Audio Recordings.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/14/2026

The Facility Director posts signage to notify veterans of video monitoring on the inpatient mental health unit, as required Veterans Health Administration Directive 1078, Privacy of Persons Regarding Photographs, Digital Images and Video or Audio Recordings.

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

The Facility Director develops and implements written processes to ensure compliance with state involuntary commitment requirements in Veterans Health Administration Directive 1160.06(1), Inpatient Mental Health Services.

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

The Chief of Staff requires documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications prior to administrationand develops a plan to monitor for sustained compliance, in accordance with Veterans Health Administration Directive 1004.01(3), Informed Consent for Clinical Treatments and Procedures.

No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/14/2026

The Chief of Staff ensures discharge instructions include appointment locations in easy-to-understand language, consistent with Veterans Health Administration’s “Clinic Profile Management Business Rules.”

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

The Facility Director requires all Interdisciplinary Safety Inspection Team members attend biannual inspections and record attendance consistent with Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Units Treating Suicidal Patients.  

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

The Facility Director directs the Interdisciplinary Safety Inspection Team to provide biannual inspection attendance to the Comprehensive Environment of Care Committee, as required by Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Units Treating Suicidal Patients.

No. 12
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Facility Director ensures staff complete appeals within the required time frame in accordance with Veterans Health Administration Office of Mental Health Standard Operating Procedure 1167.1, “Standard Operating Procedure for Submission of MHEOCC [Mental Health Environment of Care Checklist] Inspections and Appeals Under VHA [Veterans Health Administration] Directive 1167.”

No. 13
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Facility Director directs staff to complete the required Mental Health Environment of Care Checklist training as required by Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Units Treating Suicidal Patients.