Report Summary

Title: Deficiencies in the Administration of Emergent Mental Health Services at Coatesville VA Medical Center, Pennsylvania
Report Number: 19-08374-112 Download
Issue Date: 3/25/2020
City/State: Coatesville, PA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspection
Release Type: Unrestricted

The VA Office of Inspector General (OIG) conducted an inspection related to a patient’s emergent mental health services, medication management, and emergency procedures at the facility. The inspection team identified an additional concern related to the Recovery and Engagement and Coordination for Health—Veterans Enhanced Treatment (REACH VET) program.

The patient was a former service member who was granted 90 days of Veterans Health Administration (VHA) emergent mental health services due to other than honorable discharge (OTH) status.

The OIG found that VHA did not provide written guidance on expected timeframes and patient notification processes regarding emergent mental health services extension requests. Facility staff notified the patient of the extension request denial two days prior to the patient’s eligibility ending. The Chief of Staff failed to review treatment notes and submit the extension request to the Veterans Integrated Service Network Chief Medical Officer, as required.

The OIG team did not substantiate that facility providers discontinued the patient’s Suboxone® and other medications without a taper or transition to another program.

Grant and Per Diem Program staff were instructed to call 911 rather than facility code blue for patients with OTH discharge status, which may result in disparity of care.

The OIG reviewed the care of five patients with OTH discharge status who were also identified by the REACH VET program. Facility staff failed to follow up with one patient who was identified by the REACH VET program twice after the emergent mental health services eligibility ended. The patient died by suicide approximately three months later.

The OIG made two recommendations to the Under Secretary for Health related to emergent mental health services and the REACH VET program and two recommendations to the Facility Director related to emergent mental health services and medical emergency procedures.