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Healthcare Inspection – Mental Health-Related Deficiencies and Inadequate Leadership Responsiveness, Central Alabama VA Health Care System, Montgomery, Alabama

Report Information

Issue Date
Report Number
14-04530-414
VISN
State
Alabama
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
17
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
OIG conducted a review at the Central Alabama VA Health Care System (CAVHCS), Montgomery, AL. In relation to one or more of the community based outpatient clinics (CBOCs), we substantiated: inadequate psychiatrist staffing; waiting lists to see providers; improper scheduling of patients on the Recall Reminder list; excessive wait times for ambulance transport for mental health (MH) patients requiring non-emergent hospitalization; inadequate primary care (PC)-MH integration; and non-compliance with MH staffing and medication trial requirements. We confirmed some PC providers could not enter a MH consult but found this to be an acceptable practice. We did not substantiate that: multiple MH patients committed suicide due to care delays; leaders refused to provide inpatient detoxification (detox) services; patients did not receive medical treatment for substance use disorders (SUD) and were discharged from the emergency department (ED) with only anti-anxiety medication; patients had to pay for private-sector detox; 24-hour ED observation for detox was insufficient; or the substance abuse treatment program had an inefficient admission process. We did not substantiate that the Disturbed Behavior Committee refused to issue a behavioral patient record flag but it did take an excessive amount of time to do so. We did not substantiate that providers routinely prescribed benzodiazepines to high-risk patients, but sometimes they did not document their rationales. Some medication combinations could have placed patients at risk. We found that MH treatment coordinators were not assigned consistently. We could not substantiate that CBOC providers could not be reached after hours, that MH peer reviews, were not conducted, or that there were not “enough” acute MH beds. CAVHCS leaders were aware of many issues but often did not implement timely corrective actions. We made 17 recommendations to improve operations.

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 Central Alabama VA Health Care System Director ensure adequate mental health staffing in the community based outpatient clinics to provide timely and appropriate patient care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director ensure appropriate review and scheduling of patients on the electronic wait list and Recall Reminder lists provided to management.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director ensure that staff are trained on the proper use and management of the electronic wait list and the Recall Reminder list, that recall reminder letters are sent to patients, and that compliance is monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director ensure that clinical staff and the Suicide Prevention program staff follow guidelines on the identification, tracking, treatment, and follow-up of patients at high risk for suicide.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director ensure that Substance Abuse Treatment Program patients have more timely access to residential/domiciliary beds, as needed.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director ensure that staff receive appropriate training on the policy requirements for managing disruptive behavior.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director ensure that the Disturbed Behavior Committee complies with policy on completing and documenting incident/threat assessments and initiating Patient Record Flags.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director ensure that all Disturbed Behavior Committee Alert Notes, both recent and remote, have been reviewed and appropriate actions taken, if indicated.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director ensure behavioral Patient Record Flags are re-evaluated within established timeframes.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director evaluate options available to improve the timeliness of Emergency Department clearance and acute mental health unit admission for high risk patients.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director ensure that mental health providers adequately document their clinical reasoning when their treatment decisions do not comply with VA/DoD guidelines for medication management in Post-Traumatic Stress Disorder and Substance Use Disorder patients.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director approve and issue a Mental Health Treatment Coordinator policy and train appropriate staff on same.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director ensure assignment of Mental Health Treatment Coordinators for all appropriate patients.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director monitor to ensure the Dothan Primary Care contractor complies with staffing and care specifications as outlined in the contract.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director ensure that the Dothan Primary Care contract complies with Veterans Health Administration policy on the treatment of uncomplicated psychiatric disorders.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director update the Dothan Mental Health Community Based Outpatient Clinics recorded message to instruct callers on what to do for a mental health emergency and how to access the Suicide Prevention/Crisis lines.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director reinitiate ongoing professional practice evaluation-related mental health chart reviews.