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Deficiencies in a Behavioral Health Provider’s Documentation and Assessments, and Oversight of Nurse Practitioners at the VA Pittsburgh Healthcare System in Pennsylvania

Report Information

Issue Date
Report Number
21-01712-144
VISN
4
State
Pennsylvania
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Suicide Prevention
Medical Staff Privileging Credentialing
Mental Health
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
5
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate OIG identified concerns related to the assessment and documentation practices of a behavioral health certified registered nurse practitioner (BHNP) and leaders’ completion of BHNPs’ ongoing professional practice evaluations (OPPEs) at the VA Pittsburgh Healthcare System (facility) in Pennsylvania. During the inspection, the OIG found that the BHNP did not perform thorough suicide risk assessments for a patient who died by suicide. The OIG identified multiple deficiencies in a BHNP’s assessment and documentation practices including absence of comprehensive suicide risk assessments, failure to complete abnormal involuntary movement and metabolic assessments for patients prescribed certain antipsychotic medication, missing informed consent or a risk-benefit discussion when prescribing off-label medications, failure to resolve rule-out diagnoses, and substantial copy and paste use. The OIG found adverse clinical outcomes for one of eight patients for whom the BHNP did not document a comprehensive suicide risk assessment, as required by The Joint Commission. The OIG concluded that the Nurse Manager evaluated BHNPs as satisfactory in the OPPE elements of copy and paste use for fiscal year 2018 through the first half of fiscal year 2021, and safety plan completion for high risk for suicide patients for February 2020 through the first half of fiscal year 2021, without these elements being evaluated. The OIG made five recommendations to the Facility Director related to a comprehensive review of the BHNP’s assessment practices regarding the patient who died by suicide, a review of the BHNP’s overall assessment and documentation practices, alignment of facility policy and leaders’ expectations related to the assessment and documentation of abnormal involuntary movements and metabolic problems for patients prescribed antipsychotic medications, Behavioral Health managers’ verification of BHNPs’ OPPEs review, and a review of managers’ oversight of BHNPs’ OPPEs.

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)

The VA Pittsburgh Healthcare System Director ensures a comprehensive review of the Behavioral Health Nurse Practitioner’s assessment practices related to Patient 8’s suicide and homicide risk and Recovery Engagement and Coordination for Health – Veterans Enhanced Treatment status; and consults with the appropriate Human Resources and General Counsel Offices to determine whether personnel action is warranted and takes action, as appropriate.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The VA Pittsburgh Healthcare System Director ensures a comprehensive review of the Behavioral Health Nurse Practitioner’s assessment and documentation practices including suicide risk assessments, assessment of antipsychotic medication health factors and side effects, informed consent for off-label medication use, resolution of rule-out diagnoses, and use of copy and paste, and provides training as needed.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The VA Pittsburgh Healthcare System Director aligns VA Pittsburgh Healthcare System Memorandum TX-154, Use of Psychopharmacologic Agents, December 20, 2018, with leaders’ expectations for the assessment and documentation of abnormal involuntary movements and metabolic problems for patients prescribed an antipsychotic medication.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The VA Pittsburgh Healthcare System Director makes certain that behavioral health managers verify that all elements of the behavioral health nurse practitioner ongoing professional practice evaluation are reviewed.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The VA Pittsburgh Healthcare System Director ensures a comprehensive review of managers’ oversight of behavioral health nurse practitioners’ ongoing professional practice evaluations and consults with the appropriate Human Resources and General Counsel Offices to determine whether personnel action is warranted and takes action, as appropriate.