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Healthcare Inspection – Alleged Clinical and Administrative Issues, VA Loma Linda Healthcare System, Loma Linda, CA

Report Information

Issue Date
Report Number
12-01758-40
VISN
State
California
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
2
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General Office of Healthcare Inspections conducted an evaluation to determine the validity of allegations related to Behavioral Medicine Service (BMS) staffing, workload management, patient evaluations, and supervision at the VA Loma Linda Healthcare System (the facility) in Loma Linda, CA. We substantiated that the facility needed more psychiatrists, psychologists, and social workers to meet the increased mental health (MH) workload demands. We did not substantiate that patient evaluations were inadequate or that the social workers’ schedules were not kept full. We could not confirm or refute that workload rules were not applied fairly. We determined that supervision for the social work staff was adequate and that unlicensed social work staff had appropriate supervision. We found that MH patients did not consistently receive timely evaluations. We concluded that the Chief, BMS, provided adequate supervision and oversight. However, we determined that the facility needs to establish a MH Executive Council (MHEC). We recommended that MH patients receive timely care and that a MHEC be established as required by VHA.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that MH patients receive timely care, including initial evaluations within 24 hours and comprehensive evaluations within 14 days.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director establish a MH Executive Council as required by VHA.