Healthcare Inspection – Mental Health Care Concerns, Atlantic County Community Based Outpatient Clinic, Northfield, New Jersey

OIG conducted a healthcare inspection in response to requests from Senator Cory Booker, Senator Robert Menendez, and Congressman Frank LoBiondo to assess concerns that a patient’s insufficient access to timely mental health (MH) care may have contributed to the patient’s suicide and that general access to MH care was limited at the Atlantic County Community Based Outpatient Clinic (CBOC), Northfield, NJ. The patient at the center of this review received routine MH care at the CBOC for several years through the fall of 2014. The patient requested a MH appointment in late 2015, which was scheduled for 3 months later. In the interim, the patient experienced severe family and vocational stressors and ultimately completed suicide before the date of his scheduled MH appointment. The patient had not been seen by his MH providers for 11 months prior to his death. We identified failures to provide the patient a timely appointment and that instructions for overbooking were either not followed or not communicated. We found the staff failed to follow up on clinic cancellations, patient no-shows, and appointments for approved care in the community, leaving the patient without follow-up appointments and refills for prescribed medications. We found the clinical staff failed to acknowledge and document the lack of appointments and failed to reach out to re-engage the patient in therapy. In addition, staff failed to make appointments for authorized care in the community. In general, the facility did not provide appropriate supervision and oversight of clinic processes for walk-in patients, patient no-shows, clinic cancellations, non-VA care coordination consults, and patient termination.