Mental Health Inspection of the VA Ann Arbor Healthcare System in Michigan

Report Information

Issue Date
Report Number
25-00732-113
VISN
10
State
Michigan
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
14
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The VA Office of Inspector General’s (OIG’s) Mental Health Inspection Program evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on inpatient mental health care delivered at the VA Ann Arbor Healthcare System in Michigan. 

The facility met some VHA requirements for inpatient mental health units, such as having a plan for continued transformation to recovery-oriented services. The facility had a mental health executive council, but the council did not have veteran representation. Facility staff conducted biannual environment of care inspections; however, the OIG could not determine whether the facility had a formalized interdisciplinary safety inspection team.

The OIG observed a recovery-oriented physical environment with communal areas for socialization. Staff offered veterans the required amount of interdisciplinary programming on weekdays but not on weekends.

The OIG identified inconsistencies in the number of operating inpatient mental health beds reported in facility data and by leaders at various facility and Veterans Integrated Service Network levels. Network leaders did not ensure accurate reporting of available beds.

Facility leaders did not have written processes to monitor compliance with state laws regarding involuntary hospitalization. Staff did not document veterans’ legal commitment statuses in the required template. Not all inpatient staff completed suicide prevention or safety hazards training. 

Some electronic health records did not include evidence of timely suicide risk screening. All reviewed records included the required discharge summary; however, some summaries were not completed within two business days of discharge. Discharge instructions included difficult-to-understand language and lacked important details for appointment location follow-up and medication management.

VA concurred with the OIG’s 14 recommendations; the OIG closed 1 recommendation prior to publication. Facility leaders committed to implementing corrective actions, including written compliance processes for involuntary commitment, mental health environment of care standards, interdisciplinary weekend programming, discharge instruction improvements, and staff training completion. 
 

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

The Facility Director ensures the Mental Health Executive Council includes veteran representation.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director provides oversight and monitoring of bed utilization.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Mental Health ensures a minimum of four hours of recovery-oriented, interdisciplinary programming on weekends on the inpatient mental health unit.

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

The Facility Director develops and implements written processes to monitor and track compliance with state involuntary commitment requirements.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures staff use the required admission note template to document legal commitment status.

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

The Chief of Staff ensures documentation of discussions between prescribers and veterans on the risks and benefits of newly prescribed central nervous system medications.

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

The Chief of Staff ensures discharge summaries are completed within two business days of discharge.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures discharge instructions for veterans include appointment locations written in easy-to-understand language.

No. 9
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures discharge instructions for veterans include an explanation when both trade and generic names are used for the same medication.

No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2026

The Chief of Staff directs staff to complete and document the Columbia Suicide Severity Rating Scale within 24 hours before veterans’ discharge.

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

The Facility Director directs nonclinical staff to complete VA S.A.V.E. training requirements.

No. 12
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Facility Director ensures compliance with Veterans Health Administration requirements for the Interdisciplinary Safety Inspection Team, including an assigned lead and recording of meeting minutes and membership.

No. 13
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Facility Director implements processes to ensure the Interdisciplinary Safety Inspection Team applies Mental Health Environment of Care Checklist standards on the inpatient mental health unit.

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

The Facility Director directs inpatient unit staff and Interdisciplinary Safety Inspection Team members to complete Mental Health Environment of Care Checklist training requirements.