OIG Seal
Department of Veterans Affairs, Office of Inspector General
Michael J. Missal, Inspector General

Report Summary

Title: Healthcare Inspection – Patient Care Issues and Contract Mental Health Program Mismanagement, Atlanta VA Medical Center, Decatur, Georgia
Report Number: 12-02955-178 Download
Issue Date: 4/17/2013
City/State: Decatur, GA
Atlanta, GA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted

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.