Mental Health Inspection of the Martinsburg VA Medical Center in West Virginia

Report Information

Issue Date
Report Number
24-03520-20
VISN
5
State
West Virginia
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
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 inpatient care delivered at the Martinsburg VA Medical Center (facility) in West Virginia. 

The facility met some VHA requirements for inpatient mental health units, including aspects of a recovery-oriented physical environment, such as artwork and natural lighting, and a plan for continued transformation to recovery-oriented services. However, the facility did not include veteran representation on its Mental Health Executive Council and did not have a full-time local recovery coordinator. Recovery-oriented, interdisciplinary programming also did not consistently occur as scheduled.

The OIG identified ongoing communication issues between facility executive and mental health leaders, including executive leaders being unaware of pertinent information related to mental health staffing and processes. Staff did not perform involuntary holds or admissions due to leaders’ incorrect interpretation of West Virginia state law, and the Veterans Integrated Service Network (VISN) did not identify that the facility’s involuntary hospitalization policy was inconsistent with state laws.

Electronic health records indicated that reviewed safety plans did not consistently address making the veteran’s environment safer from potentially lethal means, and staff did not consistently document medication risk and benefit discussions. Discharge instructions were typically difficult to understand, lacking important details for medication management. 

The OIG observed safety hazards, such as unapproved window coverings in most bedrooms and potentially unsafe equipment in a shower room. The OIG also found shower room monitoring practices could compromise veterans’ privacy and dignity. 

VA concurred with the OIG’s 16 recommendations. The VISN Director committed to ensuring establishment of state-compliant involuntary hold procedures. The Facility Director agreed to implementing a range of corrective actions, including enhanced leadership oversight, expanded veteran engagement, strengthened staff training, and improved coordination and documentation practices to support safe, recovery-oriented mental health care.
 

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
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to Veterans Health Administration (VHA)

The Facility Director ensures regular communication between mental health and executive leaders regarding staffing needs and mental health processes.

No. 2
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to Veterans Health Administration (VHA)

The Facility Director ensures the Mental Health Executive Council operates in accordance with Veterans Health Administration requirements.

No. 3
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to Veterans Health Administration (VHA)

The Chief of Mental Health ensures a full-time, dedicated local recovery coordinator is integrated into the inpatient mental health unit to support recovery-oriented care.

No. 4
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to Veterans Health Administration (VHA)

The Chief of Mental Health ensures mental health leaders develop and implement written processes for staff training, education, and recovery-oriented services.

No. 5
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to Veterans Health Administration (VHA)

The Chief of Mental Health ensures staff provide a minimum of four hours of recovery-oriented, interdisciplinary mental health programming on weekdays and weekends.

No. 6
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to Veterans Health Administration (VHA)

The Facility Director ensures veterans’ privacy in the communal shower room on the inpatient mental health unit.

No. 7
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to Veterans Health Administration (VHA)

The Facility Director ensures clinicians document veterans’ capacity to consent to admission to the inpatient mental health unit.

No. 8
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to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director ensures facilities’ involuntary hold and hospitalization processes align with applicable state laws and develops processes for ongoing oversight.

No. 9
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to Veterans Health Administration (VHA)

The Facility Director consults with District Counsel to establish written involuntary hold and hospitalization processes that align with West Virginia State laws and monitors compliance.

No. 10
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to Veterans Health Administration (VHA)

The Facility Director develops and implements written care coordination processes for veterans involuntarily admitted to non-VA healthcare facilities.

No. 11
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to Veterans Health Administration (VHA)

The Chief of Staff ensures providers document discussions with veterans on the risks and benefits of newly prescribed medications and monitors for compliance.

No. 12
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to Veterans Health Administration (VHA)

The Chief of Staff ensures veterans’ discharge instructions are written in easy-to-understand language and include the follow-up appointment location, the purpose of each medication, and an explanation when both trade and generic names are used for the same medication.

No. 13
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to Veterans Health Administration (VHA)

The Facility Director ensures staff comply with suicide prevention training requirements and monitors for compliance.

No. 14
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to Veterans Health Administration (VHA)

The Facility Director ensures Interdisciplinary Safety Inspection Team members participate in Mental Health Environment of Care Checklist inspections and document membership and attendance.

No. 15
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to Veterans Health Administration (VHA)

The Facility Director ensures the Interdisciplinary Safety Inspection Team accurately identifies, documents, and addresses safety hazards within the Patient Safety Assessment Tool and monitors for compliance.

No. 16
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to Veterans Health Administration (VHA)

The Facility Director directs staff to comply with Mental Health Environment of Care Checklist training requirements and monitors for compliance.