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Mental Health Inspection of the VA Augusta Health Care System in Georgia

Report Information

Issue Date
Report Number
24-00675-259
VISN
7
State
Georgia
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Mental Health Inspection Program
Report Topic
Mental Health
Patient Safety
Suicide Prevention
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
21
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 (MHIP) evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on the inpatient care delivered at the VA Augusta Health Care System (HCS) in Georgia. 

Augusta HCS met some VHA requirements for inpatient mental health units, such as the presence of a mental health executive council, completion of twice-yearly environment of care inspections, and a plan for continued transformation to recovery-oriented services. A review of electronic health records indicated veterans and the interdisciplinary treatment team were involved in treatment planning, and most veterans had documented safety plans. However, some records did not include evidence of timely suicide risk screening. Discharge instructions were typically difficult to understand and lacked important details for appointment follow-up and medication management.

The OIG was concerned about access to inpatient mental health care. Specifically, the high volume of community referrals contrasted with Augusta HCS’s low bed utilization. The OIG identified communication gaps between Augusta HCS and mental health leaders regarding the explanations for beds being out of service, causes of low bed utilization, and process improvement efforts to address these concerns.

The inpatient unit’s physical environment incorporated natural sunlight in some common areas, but needed cosmetic improvements in sleeping areas and contained toilets with ligature points that posed a safety risk. Additionally, many inpatient unit staff did not have evidence of completed trainings on environment of care inspection requirements or suicide prevention strategies. 

As a result of its findings, the OIG issued 21 recommendations to Augusta HCS and Veterans Integrated Service Network 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: 2/26/2025

The VA Augusta Health Care System Director ensures that the Mental Health Executive Council includes veteran representation.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2025

The Veterans Integrated Service Network Director implements processes to strengthen oversight and monitoring of bed utilization.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2025

The VA Augusta Health Care System Associate Director for Patient Care Services ensures that inpatient mental health unit staffing supports authorized bed capacity.

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

The VA Augusta Health Care System Director develops and implements processes to incorporate veteran input for process improvements.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2025

The VA Augusta Health Care System Chief of Mental Health develops processes to ensure integration of the Local Recovery Coordinator into the inpatient mental health unit to support recovery-oriented care.

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

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

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2025

The VA Augusta Health Care System Director ensures continued implementation of a recovery-oriented environment on the inpatient mental health unit.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2025

The VA Augusta Health Care System Director ensures accurate reporting of inpatient operating beds and implements processes to monitor.

No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2025

The VA Augusta Health Care System Director identifies and addresses barriers to admission for veterans on involuntary holds for mental health treatment.

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

The VA Augusta Health Care System Director ensures alignment between involuntary commitment policies and practices, consistency with state laws, and implementation of monitoring processes.

No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2025

The VA Augusta Health Care System Chief of Staff ensures assignment of ongoing responsibilities for monitoring timely documentation of the change in veterans’ voluntary or involuntary legal status, consistent with VHA policy and state laws.

No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2025

The VA Augusta Health Care 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 improvement.

No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2025

The VA Augusta Health Care System Director ensures the development and implementation of clearly defined written processes for transition of care when veterans are discharged from the inpatient mental health unit.

No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2025

The VA Augusta Health Care System Chief of Staff ensures discharge summaries are completed within two business days of discharge and monitors for compliance.

No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2025

The VA Augusta Health Care System Chief of Staff ensures discharge instructions for veterans include appointment location and contact information in easy-to-understand language.

No. 16
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Augusta Health Care System Director ensures that medications listed in discharge instructions include the purpose for each medication and are written in easy-to-understand language.

No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2025

The VA Augusta Health Care System Chief of Staff identifies barriers to completing the Columbia-Suicide Severity Risk Scale Screener within 24 hours prior to discharge, implements processes, and monitors to ensure compliance.

No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2025

The VA Augusta Health Care System Chief of Staff ensures that safety plans address ways to make the veteran’s environment safer from potentially lethal means and monitors for compliance.

No. 19
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Augusta Health Care System Director ensures staff comply with lethal means safety training and suicide risk training requirements and monitors for compliance.

No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2025

The VA Augusta Health Care System Director ensures compliance with VHA requirements for the Interdisciplinary Safety Inspection Team, including environment of care subcommittee structure, and Mental Health Environment of Care Checklist training completion.

No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2025

The VA Augusta Health Care System Chief of Staff ensures mental health leaders update inpatient unit toilets to meet safety requirements and implement processes to reduce associated safety risks.