Healthcare Inspection – Review of Complaints Regarding Mental Health Services Clinical and Administrative Processes, VA St. Louis Health Care System, St. Louis, Missouri

OIG conducted an inspection pursuant to a June 2014 request from Senator Bernie Sanders, then Chairman of the Senate Veterans Affairs Committee, to assess allegations regarding deficiencies in Mental Health (MH) Services clinical processes including productivity, data reporting, access, quality of assessments and care, and administrative processes at the VA St. Louis Health Care System, St. Louis, MO. Of 19 allegations, 6 were substantiated, 13 were not substantiated; and we identified 8 additional findings. We found: Outpatient psychiatrists had fewer-than-expected appointment slots and encounters in fiscal year (FY) 2013; Outpatient psychiatrists’ productivity data were inconsistent with the number of daily encounters; Some outpatient psychiatrists’ coding error rates exceeded VHA’s minimum accuracy standards for the period May through August 2013 and VHA-required follow-up was not completed; Inadequate consult management of ancillary group treatment referrals for two patients; Outpatient MH and Post Traumatic Stress Disorder Clinics treatment delays averaged 3 days in FY 2013; A MH Clinic nurse did not adequately assess an unscheduled patient’s treatment needs; A former staff member did not provide timely military sexual trauma treatment or follow-up; Outpatient Post Traumatic Stress Disorder staff failed to provide timely care to a walk-in patient or include a second patient in treatment planning involving transfer to the MH clinic; The “public” facsimile machine used for Veterans Benefits Administration Vocational Rehabilitation and Employment referrals was not reliable or attended to properly; Two Compensation & Pension evaluators entered erroneous information in a veteran’s electronic health record; The facility insufficiently investigated two of three MH patient deaths. We made nine recommendations.