Deficiencies in Mental Health Care and Facility Response to a Patient’s Suicide, VA Portland Health Care System in Oregon and Treatment Program Referral Processes at the VA Palo Alto Health Care System in California

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate a patient’s mental health care at the VA Portland Health Care System (facility) including care coordination, administrative actions following the patient’s death, and non-VA community care procedures. The OIG also evaluated VA Palo Alto Health Care System (VA Palo Alto) posttraumatic stress disorder residential rehabilitation treatment program (RRTP) processes. Facility staff made reasonable efforts to accommodate the patient’s treatment preferences, completed safety planning, and conducted required military sexual trauma screening and care. Facility leaders and staff did not assign a Mental Health Treatment Coordinator (MHTC) or establish a policy as required. Facility staff did not review the patient’s high risk for suicide patient record flag timely or ensure the facility’s High Risk Review Workgroup approved flag inactivation, inadequately managed the patient’s flag, and failed to assess suicide risk following the patient’s Veterans Crisis Line call. The OIG identified Veterans Health Administration (VHA) policy and suicide behavior reporting guidance inconsistencies and facility leaders did not follow VHA staff-specific guidance. Facility staff did not complete a behavioral health autopsy timely. VA Palo Alto RRTP staff did not complete the patient’s screening within VHA expectations and did not accept patient self-referrals. RRTP staff appropriately considered the patient’s service animal request. However, inconsistent with VHA policy, RRTP policy included additional admission requirements for the service animal. The OIG made two recommendations to the Under Secretary for Health related to suicide behavior and overdose report staff-specific guidance and RRTP admission decision timeframe expectations; three recommendations to the Facility Director related to MHTC policy and assignment, suicide behavior and overdose report staff-specific guidance, and behavioral health autopsy report timeliness; and two recommendations to the VA Palo Alto Director related to aligning facility RRTP procedures and assistance dog policies with VHA requirements.