The VA Office of Inspector General (OIG) is committed to helping VA deliver high-quality health care.
The OIG reviewed acute inpatient mental health care at the South Texas Veterans Health Care System in San Antonio. Inspectors evaluated care in five areas, provided preliminary observations to leaders, and later issued 13 recommendations.
The Mental Health Executive Council included required veteran representation. OIG inspectors identified inaccurate and delayed bed-availability reporting, a lack of formal processes for complying with involuntary commitment laws, and no program-specific procedures for treatment planning on the unit.
The physical environment lacked natural light, warm paint colors, and artwork. Weekend programming hours were inconsistent, though staff provided the required interdisciplinary programming on weekdays. Despite these environmental limitations, inspectors observed veteran-centric care, with staff present and engaged in shared areas.
The facility lacked a policy governing video monitoring on the unit and did not have signage informing veterans of its use. Contrary to VA policy, VA police used cameras on the unit to monitor and record veterans.
Most reviewed electronic health records did not include required documentation that prescribers and veterans discussed medication risks and benefits. Veterans were typically offered discharge instructions with follow-up appointment details that were difficult to understand. All reviewed records reflected timely suicide risk screening and safety planning. Some inpatient unit staff and safety inspection team members did not complete the annual Mental Health Environment of Care Checklist training.
Not all safety inspection members attended biannual inspections, and attendance was not recorded or provided to the identified committee. Not all appeals were resubmitted within the required time frame.
In response to theOIG’ss recommendations, the Facility Director described plans to address inpatient mental health treatment planning, involuntary commitment legal compliance, use of video monitoring, therapeutic programming, documentation practices, the recovery environment, safety inspections, and staff training. Facility leaders reported updating note templates for informed consent and medication discussions.