Mental Health Inspection of the VA Tampa Healthcare System in Florida

The OIG’s Mental Health Inspection Program evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on the inpatient mental health care delivered at the James A. Haley Veterans’ Hospital (facility), part of VA Tampa Healthcare System in Florida. 

The facility met some VHA requirements for inpatient mental health units, such as an established Interdisciplinary Safety Inspection Team and completion of twice-yearly environment of care inspections. The facility had a mental health executive council but did not have veteran representation. Additionally, the facility did not meet the requirement for a standard operating procedure for staff training, education, and the implementation of recovery-oriented services on the unit.  

Facility leaders did not have formal written processes to monitor and track compliance with state involuntary commitment requirements. Staff completed the required documentation of legal commitment status and informed consent medication discussions. Not all inpatient staff completed suicide prevention or annual environmental safety hazards trainings.  

Most reviewed electronic health records included evidence of suicide risk screenings and safety plans. Safety plans did not address ways to make the veteran’s environment safer from potentially lethal means beyond firearms and opioids. Discharge instructions included difficult to understand language and lacked important details for appointment location follow-up.  

The OIG observed a recovery-oriented culture and veteran-centric care through staff’s presence and engagement with veterans on the inpatient unit. While veterans had unrestricted access to a day room and a large outdoor space, bedrooms lacked recovery-oriented elements such as calming paint colors. 

VA concurred with the OIG’s seven recommendations; the OIG closed two recommendations based on information provided. The Facility Director agreed to implement a range of corrective actions, including strengthened staff training, ensuring formalized written processes, and improved documentation practices to support safe, recovery-oriented mental health care on the inpatient unit.