Mental Health Inspection of the VA Central Western Massachusetts Healthcare System in Leeds

Report Information

Issue Date
Report Number
24-01859-62
VISN
1
State
Massachusetts
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Mental Health Inspection Program
Report Topic
Care Coordination
Mental Health
Suicide Prevention
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
16
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The OIG’s Mental Health Inspection Program (MHIP) evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on the inpatient care delivered at the Edward P. Boland VA Medical Center, part of the VA Central Western Massachusetts Healthcare System (facility) in Leeds.

The facility met some VHA requirements for inpatient mental health units, including providing the required amount of interdisciplinary programming for veterans and the completion of twice-yearly environment of care inspections. The inpatient unit included some aspects of a recovery-oriented physical environment, such as soft night lighting in the nurses’ station and veterans’ rooms.

Electronic health record reviews indicated most veterans were involved with the interdisciplinary treatment team in treatment planning, and veterans had documented safety plans. However, some records did not include evidence of timely suicide risk screenings, and discharge instructions were difficult to understand, lacking important details for appointment follow-up and medication management.

The facility did not have an established local mental health executive council or an interdisciplinary safety inspection team during the review period. The facility’s admission policy did not include processes for the admission of veterans on an involuntary hold. The facility leaders lacked formal processes to monitor and track compliance with involuntary commitment state laws.

The OIG identified environment of care deficiencies such as the unit’s sally port entrance doors were not synchronized; the inpatient unit had unweighted, unsecured chairs in a group room; and facility staff did not have a policy that addressed the use of a restraint chair. Additionally, many staff did not have evidence of completed environment of care or suicide prevention trainings. 

The OIG issued 16 recommendations to facility leaders. These recommendations, once addressed, may improve the quality and delivery of veteran-centered, recovery-oriented care on the inpatient mental health unit and beyond.

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)
Closure Date: 7/30/2025

The VA Central Western Massachusetts Healthcare System Director establishes a mental health executive council that operates in accordance with VHA requirements.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2025

The VA Central Western Massachusetts Healthcare System Director ensures staff consistently solicit and incorporate veteran feedback into process improvements.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/2/2025

The VA Central Western Massachusetts Healthcare System Chief of Mental Health develops written guidance to ensure staff and veteran safety during outdoor breaks.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Central Western Massachusetts Healthcare System Director ensures the development of written processes for the admission of veterans on an involuntary hold and monitors and tracks compliance with involuntary commitment requirements.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/2/2025

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures timely documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications and monitors for compliance.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures discharge instructions for veterans include follow-up appointment location and contact information in easy-to-understand language.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures discharge instructions include the purpose for each medication listed and are written in easy-to-understand language.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2025

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures staff complete the Columbia-Suicide Severity Rating Scale within 24 hours before discharge and monitors for compliance.

No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2025

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures staff address ways to make veterans’ environments safer from potentially lethal means in safety plans and monitors for compliance.

No. 10
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Central Western Massachusetts Healthcare System Director ensures staff comply with Skills Training for Evaluation and Management of Suicide requirements and monitors for compliance.

No. 11
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Central Western Massachusetts Healthcare System Director establishes an interdisciplinary safety inspection team in alignment with Veterans Health Administration requirements and ensures ongoing compliance.

No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2025

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures that the sally port inpatient unit doors are synchronized and monitors for compliance.

No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2025

The VA Central Western Massachusetts Healthcare System Director uses VHA guidelines to develop facility-specific policy for the use of restraint chairs.

No. 14
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Central Western Massachusetts Healthcare System Director ensures alignment between physical restraint policies and practices.

No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/2/2025

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures mental health leaders update inpatient unit furniture to meet safety requirements and implements processes to reduce associated safety risks.

No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2025

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures compliance with VHA requirements for Mental Health Environment of Care Checklist training completion.