Healthcare Inspection – Alleged Inadequate Mental Health Care, Iowa City VA Health Care System, Iowa City, Iowa

OIG conducted a healthcare inspection of the Iowa City VA Health Care System (system), Iowa City, IA, mental health (MH) unit admission policies and practices. We received review requests from five Members of Congress. The requests were to: examine the facts and circumstances surrounding a patient who was reportedly denied inpatient MH admission; assess whether the patient received appropriate MH care; and conduct a review of the admission policy and practice for inpatient MH. We found that the patient requested inpatient MH admission and was not admitted. The psychiatrist made efforts to re-engage the patient after he abruptly left an appointment and followed appropriate medical decision-making practices based on the information available at the time. The patient had access to and participated in extensive MH services appropriate for his diagnoses and needs. We identified system shortcomings including adherence to Veterans Health Administration (VHA) policies on no-shows, treatment planning/communication, and the use of principal MH providers (the system uses the title of “MH Treatment Coordinator” for designated principal MH providers). We also identified information during our review that, if known to VHA providers, may have altered the course of care. We found system MH admission practices were in alignment with VHA and system policies, including a plan for care when system MH beds were unavailable. Although VHA requirements for review were met, the reviews were limited in scope to the electronic health record and interviews with clinicians and next of kin. As a result, information relevant to the case was missed. We also noted opportunities for the system to proactively plan for the management of communications in similar future cases. We made four recommendations.