Mental Health Inspection of the VA Kansas City Healthcare System in Missouri

The VA Office of Inspector General (OIG) evaluated acute inpatient mental health care at the Kansas City VA Medical Center (facility) across five domains: leadership and organizational culture, recovery-oriented principles, clinical care coordination, suicide prevention, and safety. Inspectors shared preliminary observations with leaders during the inspection and later issued eight recommendations.

The mental health leaders relied on collaboration and shared responsibilities across several managers, and the Mental Health Executive Council met the requirement for veteran representation. The inpatient unit supported recovery-oriented care by offering daily interdisciplinary programming and providing access to natural light, a sensory room, and spacious communal areas. 

Inspectors identified gaps in clinical care coordination, such as bed availability not always being reported accurately, which could affect access to the unit. The facility did not have a written process for monitoring compliance with state involuntary commitment laws. Staff did not consistently document discussions about medication risks and benefits, and discharge instructions sometimes used unclear abbreviations or did not explain the purpose of medications, factors that may hinder follow-up care.

Staff routinely completed required suicide risk screenings, but safety plans were not always completed or reviewed before discharge. Environmental safety processes also had deficiencies. Not all safety inspection team members attended biannual inspections, and attendance records were not submitted to the required committee. Appeals were not resubmitted within required timeframes. Some staff had not completed mandatory safety training, which may limit their ability to identify hazards.

In response to the OIG’s recommendations, the Facility Director described plans to address mental health care to veterans on medical units, involuntary commitment legal compliance, documentation practices, interdisciplinary safety inspection team requirements, and staff completion of safety training. Facility leaders reported updating note templates for informed consent medication discussions.