Healthcare Inspection – Follow-Up of Mental Health Inpatient Unit and Outpatient Contract Programs, Atlanta VA Medical Center, Decatur, Georgia

OIG conducted an inspection at the request of Senator Johnny Isakson to follow up on two prior reports at the Atlanta VA Medical Center (facility), Decatur, GA. We evaluated management of care on the facility’s mental health (MH) inpatient unit, and we assessed administration, management, and coordination of the facility’s contract MH program through which patients receive outpatient MH services at community service boards (CSBs). We noted overall improvements in oversight of the inpatient MH unit and contract MH care program. We found that the facility made changes in leadership that enhanced interdisciplinary collaboration and added supervisory processes previously absent from these programs. We found that the Under Secretary for Health and Operations had issued a memorandum to the field and published a Handbook to provide guidelines and requirements for inpatient MH units. The facility developed and implemented policies and procedures to address hazardous items on the unit, patient off-unit escorts, urine drug screenings, and patient visitation. The facility also established processes to strengthen documentation of patient monitoring and on-unit observation, interdisciplinary communication, leadership oversight, and rigor of the root cause analysis process. We found improvements to the facility’s administration and coordination of contract MH care with CSBs, billing, and oversight. However, challenges persist in the absence of a centralized repository for CSB patient data, tracking of patients beyond first appointments, and in the transfer of patient information between the facility and the CSBs. We recommended that the Facility Director ensure that a standardized and facility-wide repository be developed and implemented to monitor patients referred to CSBs, patients are tracked for follow-up beyond the first contract MH appointment, and that communication is strengthened to better coordinate patient care.