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Healthcare Inspection – Patient Care Issues and Contract Mental Health Program Mismanagement, Atlanta VA Medical Center, Decatur, Georgia

Report Information

Issue Date
Report Number
12-02955-178
VISN
State
Georgia
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 OIG conducted an inspection to assess the merit of allegations of mismanagement and lack of oversight of a mental health (MH) contract. We substantiated mismanagement in the administration of the contract, and also substantiated additional allegations that there was inadequate coordination, monitoring, and staffing for oversight of contracted MH patient care. Facility managers did not provide adequate staff, training, resources, support, and guidance for effective oversight of the contracted MH program. MH Service Line managers and staff voiced numerous concerns including challenges in program oversight, inadequate clinical monitoring, staff burnout, and compromised patient safety. The lack of effective patient care management and program oversight by the facility contributed to problems with access to MH care and contributed to “patients falling through the cracks.” We recommended that the Under Secretary for Health rectify the deficiencies described in this report with respect to the provision of quality MH care and contract management, with the goal that veterans receive the highest quality medical care from either the VA or its partners. The Under Secretary for Health and the Veterans Integrated Service Network and Facility Directors concurred with our recommendations and provided an acceptable action plan. We will follow up on the planned actions until they are completed.

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 Under Secretary for Health take note and rectify the deficiencies described in this report with respect to the provision of quality mental health care and contract management, with the goal that veterans receive the highest quality medical care from either the VA or its partners.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director evaluate the care of patients discussed in this report with Regional Counsel for possible disclosure(s) to the appropriate surviving family member(s) of the patients.