Facility Leaders’ Response to Inappropriate Mental Health Provider-Patient Relationships at the VA Illiana Health Care System in Danville, Illinois

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate leaders’ response to the knowledge of inappropriate provider-patient relationships (inappropriate relationships) in the Mental Health Service Line at the VA Illiana Health Care System (facility) in Danville, Illinois. The OIG determined that while facility leaders took initial actions to address three inappropriate relationships between mental health providers (Providers A, B, and C) and mental health patients (Patients A, B, and C), multiple factors affected the effectiveness of those actions. The OIG found that effective facility leader actions to investigate and address the inappropriate relationships of Provider A and Provider B occurred only after an Office of Accountability and Whistleblower Protection complaint. Facility leaders ineffectively addressed Provider C’s inappropriate relationship before Patient C died by overdose. Facility leaders implemented action plans to prevent future occurrences of inappropriate relationships. Given the egregious nature of the providers’ behaviors, facility leaders failed to report Providers B and C to their state licensing boards in a timely manner and failed to report Provider A to the appropriate professional certification board. The OIG also determined that facility leaders did not take actions to address the circumstances that contributed to the death of Patient C who was involved in an inappropriate romantic relationship with Provider C. The OIG made one recommendation to the Veterans Integrated Service Network 12 Director related to evaluating processes that affected facility supervisors’ identification and actions to address inappropriate relationships. The OIG made two recommendations to the Facility Director related to timely reporting of providers to state licensing or certification boards, and reviewing Patient C’s care to determine if there was an adverse event and if so, whether institutional disclosure is warranted.