Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Facilities, Fiscal Year 2021

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report highlights the results of an evaluation of VHA facilities’ mental health programs. The report describes findings from healthcare inspections performed at 44 medical facilities during fiscal year 2021 that focused on suicide risk screening and evaluation processes in emergency departments and urgent care centers. Each inspection involved interviews with key staff and reviews of clinical and administrative processes. The OIG found general compliance with most of the selected requirements. However, the OIG identified a weakness with the completion of mandatory training by staff who develop suicide safety plans and issued one recommendation. Lack of training could prevent staff from providing optimal treatment to veterans who are at risk for suicide.