Mental Health Inspection of the VA NY Harbor Healthcare System in New York

Report Information

Issue Date
Report Number
25-00729-23
VISN
2
State
New York
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
17
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The VA Office of Inspector General (OIG) 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 Margaret Cochran Corbin VA Campus (facility) in New York.

The facility met some VHA requirements for inpatient mental health units, such as the presence of a mental health executive council and completion of twice-yearly environment of care inspections. The OIG could not confirm if the facility had a formalized interdisciplinary safety inspection team. The facility’s multiyear plan to direct veteran-centered, recovery-oriented care did not have input from the local recovery coordinator.

Some electronic health records reviewed did not include evidence of timely suicide risk screenings and documentation of medication risk and benefit discussions. Discharge instructions lacked important details for follow-up appointment locations and medication management. Consistent with prior published reports, inpatient staff did not complete the other lethal means text field in safety plans for addressing ways to make veterans’ environments safer. 

The inpatient unit physical environment incorporated recovery-oriented elements such as artwork. However, communal rooms were locked and therefore inaccessible to veterans unless there were staff to monitor. The OIG identified unit fire doors with three-point hinges that posed ligature risks and a nonfunctional panic button. Many inpatient staff did not complete training on environment of care inspection requirements or suicide prevention strategies. 

VA concurred with the OIG’s 17 recommendations. The Under Secretary for Health agreed to require staff completion of the other lethal means text field within the safety plan template. The Facility Director agreed to implement a range of corrective actions, including strengthened processes and staff training, a formalized interdisciplinary safety inspection team, and improved coordination and documentation practices to support safe, recovery-oriented mental health care on the inpatient unit.
 

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: 12/18/2025

The Associate Chief of Staff, Mental Health ensures compliance with Veterans Health Administration requirements for a full-time local recovery coordinator.

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

The Associate Chief of Staff, Mental Health ensures the implementation of written processes for staff training, education, and recovery-oriented services. 

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

The Facility Director identifies and addresses barriers to communal room access for veterans on the inpatient unit.

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

The Facility Director ensures accurate reporting of inpatient mental health beds and implements processes to monitor.

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

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

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

The Facility Director ensures staff document veterans’ legal commitment status in the electronic health record and monitors for compliance.

No. 7
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 medications and monitors for compliance.

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 the purpose for each medication listed and are free of medical abbreviations.

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

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

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

The Chief of Staff directs staff to complete suicide prevention safety plans and provide copies of the plans to veterans or caregivers and monitors for compliance.

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

The Chief of Staff directs staff to address ways to make veterans’ environments safer from potentially lethal means, beyond firearms and opioids, in safety plans and monitors for compliance.

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

The Under Secretary for Health identifies barriers to, and ensures documentation of, discussions specific to making the environment safer from identified lethal means in veterans’ safety plans. 

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

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

No. 15
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 recording of meeting minutes, membership, and attendance, and monitors for compliance.

No. 16
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 and monitors for compliance.

No. 17
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Facility Director directs inpatient unit staff and Interdisciplinary Safety Inspection Team members to comply with Mental Health Environment of Care Checklist training requirements and monitors for compliance.