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Healthcare Inspection – Mental Health Service Concerns at the Knoxville VA Outpatient Clinic, James H. Quillen VA Medical Center, Mountain Home, Tennessee

Report Information

Issue Date
Report Number
14-04435-265
VISN
State
Tennessee
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
OIG conducted an inspection at the request of Senator Lamar Alexander and Congressman John Duncan to assess allegations of mental health service concerns at the Knoxville VA Outpatient Clinic, Knoxville, TN, which is part of the James H. Quillen VA Medical Center (facility), Mountain Home, TN. We substantiated the allegation that facility managers did not have Peer Support Services (PSS) available to veterans at the Clinic for several years. We did not substantiate the allegation that the PSS Specialist hired by the Clinic was expected to provide PSS related functions for groups hosted by the Knoxville Regional Mental Health Council (Council). We substantiated that patients were discharged from a non-evidence based Post Traumatic Stress Disorder group without immediate PSS follow-up. We substantiated the allegation that facility managers delayed hiring a Veterans Justice Outreach (VJO) Specialist to service veterans in Knox County and surrounding counties. We did not substantiate the allegation that medication confirmation requests take 3–5 days for incarcerated veterans. We did not substantiate the allegation that facility and Clinic managers failed to uphold agreements with the Council regarding (1) providing meeting space for the group hosted by the Council, (2) sponsoring PSS facilitator training for members of the Council, and (3) providing travel pay for Council group members. We recommended that the Facility Director improve processes for communicating with community-based consumer-run groups that provide mental health services to veterans enrolled at the Clinic and ensure the Clinic’s VJO Specialist provides comprehensive services including outreach for veterans in Knox County and surrounding counties in accordance with Veterans Health Administration policy.

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 improve processes for communicating with community-based consumer-run groups that provide mental health services to veterans enrolled at the Knoxville VA Outpatient Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that the Clinic’s Veterans Justice Outreach Specialist provides comprehensive services including outreach for veterans in the Knox and surrounding counties in accordance with Veterans Health Administration policy.