Insufficient Mental Health Treatment and Access to Care for a Patient and Review of Administrative Actions in Veterans Integrated Service Network 10 

The Office of Inspector General (OIG) evaluated concerns related to Veterans Integrated Service Network (VISN) 10 staff’s care and treatment coordination for a patient who died. The OIG reviewed the sufficiency of Veterans Health Administration (VHA) leaders’ actions prior to and following notification of the patient’s death.

VA Ann Arbor Health Care System (Ann Arbor VA) staff adequately considered a posttraumatic stress disorder diagnosis and assessment for the patient and screened for toxic exposure and traumatic brain injury. However, inpatient mental health providers failed to sufficiently address the patient’s mental health condition, treatment needs, and discharge care coordination.

Due to absence of documentation, the OIG was unable to determine whether a Battle Creek VA Medical Center (Battle Creek VA) staff member inaccurately verified the patient’s treatment eligibility status. Battle Creek VA staff responded appropriately to non-VA staff’s inpatient mental health unit inquiries regarding the patient’s transfer request; however, the transfer was not considered due to unavailability of beds. Battle Creek VA leaders implemented recommendations from a workgroup to improve transfer coordination.

A Battle Creek VA residential treatment standard operating procedure was inconsistent with the VHA requirement to allow self-referral or non-VA agency referral. 

VHA leaders responded within 24 hours when notified of the patient’s transfer request and took actions to identify the patient’s treatment needs and options. VISN 10 leaders established an Interagency Reconciliation Council (IRC); however, the IRC lacked defined objectives and processes to monitor outcome progress.

The OIG made one recommendation to the Ann Arbor VA Director to review the patient’s care; four recommendations to the Battle Creek VA Director regarding eligibility verification procedures, transfer coordination, and the residential treatment standard operating procedure; and one recommendation to the VISN 10 Director related to the IRC’s identification of clearly defined objectives and processes to monitor progress.