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Isakson, Chambliss Demand Answers from Department of Veterans Affairs in Wake of Inspector General Report of Mismanagement at Atlanta VA Medical Center IG Report Linked Three Veteran Suicides to Deficiencies at the Atlanta VA Medical Center

By   /   June 7, 2013  /   Comments

Special to the Journal

WASHINGTON – U.S. Senators Johnny Isakson, R-Ga., and Saxby Chambliss, R-Ga., today sent two letters to Veterans Affairs Secretary Shinseki demanding answers in response to the Inspector General (IG) report that describes egregious mismanagement at the Atlanta VA Medical Center (VAMC). The IG report linked three recent suicides to these deficiencies.

In their letters, Isakson, who is a member of the Senate Veterans Affairs Committee, and Chambliss, who is a member of the Senate Armed Services Committee, asked the VA to follow up on reported problems with inpatient and contracted outpatient mental health care at the Atlanta VA Medical Center. The senators asked the VA to provide information on its progress to correct the problems identified by the IG report to ensure that veterans do not fall through cracks in the future. Sen. Richard Burr, R-N.C., who is the ranking Republican on the Senate Veterans Affairs Committee, joined Isakson and Chambliss in sending the letters to Shinseki.

The senators wrote that the IG report is “troublesome due to the number of veterans experiencing mental health conditions, the number of veteran suicides, and the lack of access to mental health services at VA medical centers.” The senators expressed that they “are deeply concerned that veterans are not receiving quality mental health services.”

The senators also stated, “With estimates that 22 veterans commit suicide each day, it is vital that we address problems at all of the VA’s mental health facilities and their partners…The men and women who have bravely served our country deserve better care than what was described in the IG report related to mental health services provided by the Atlanta VAMC.”

The full text of the senators’ two letters to Secretary Shinseki are below.

The Honorable Eric K. Shinseki
Secretary of Veterans Affairs
810 Vermont Avenue, Northwest
Washington, DC 20420

Dear Secretary Shinseki:

We are writing in response to the April 17, 2013, audit conducted by the Department of Veterans Affairs (VA) Office of Inspector General (IG), entitled Healthcare Inspection: Mismanagement of Inpatient Mental Health Care Atlanta VA Medical Center, Decatur, Georgia. This audit describes serious deficiencies at the Atlanta VA Medical Center (VAMC), which is very troublesome due to the number of veterans experiencing mental health conditions, the number of veteran suicides, and the lack of access to mental health services at VA medical centers. We are deeply concerned that veterans are not receiving quality mental health services.

The IG audit linked one veteran suicide to an unacceptable lack of appropriate oversight over the inpatient mental health unit. We fear that this lack of oversight might exist in other VAMC across the country. We believe the mismanagement of the mental health programs at the Atlanta VAMC provides an opportunity to explore the lessons learned and to ensure that the same mistakes are not repeated anywhere else in the country.

In its report, the IG substantiated allegations that the hospital did not have adequate policies and procedures in place to ensure patient safety, to supervise clinical changes in patients, or to monitor patients in the mental health unit. In response to the report, the Atlanta VAMC implemented its action plan and established policies and procedures in line with the IG’s recommendations. What metrics, benchmarks, statistics, and results does the Atlanta VAMC now use to track the performance of the inpatient mental health unit since the implementation of the action plan?

In addition, another IG recommendation called for the mental health inpatient units to be equipped with functional and well-maintained life-support equipment, which the Atlanta VAMC stated would be completed by April 15, 2013. Please provide us details on the progress that has been made to comply with this recommendation. What policies and procedures have been put in place to ensure that the equipment is fully maintained? What Veterans Health Administration (VHA) policies and procedures have been sent to the field to provide guidance on how life-support equipment is maintained at each of its facilities?

Lastly, the final IG recommendation called on the Atlanta VAMC to evaluate the care of the subject patient with Regional Counsel for any possible disclosures to the veterans’ surviving family members. Please provide us details on the progress that has been made to comply with this recommendation.

We strongly encourage VA to continuously monitor the progress at the Atlanta VAMC. However, we have serious concerns that this problem is not unique to one particular VAMC. We believe that VHA should work to ensure that other VAMCs are not facing similar challenges as the Atlanta VAMC. In response to the IG audit, VHA stated it will complete its national guidance for hazardous items, visitation, urine drug screens, and escort services for inpatient mental health units by September 30, 2013. Please provide us with information about the progress of this guidance and how it will be implemented throughout the VISNs.

The Honorable Eric K. Shinseki
Secretary of Veterans Affairs
810 Vermont Avenue, Northwest
Washington, DC 20420

Dear Secretary Shinseki:

We write today regarding the Inspector General (IG) report entitled, Healthcare Inspection: Patient Care Issues and Contract Mental Health Program Mismanagement Atlanta VA Medical Center, Decatur, Georgia, which describes the Department of Veterans Affairs (VA) egregious mismanagement of the contract with DeKalb County Community Service Board (CSB). The quality and continuity of care was greatly compromised by the lack of oversight for this contract. Clearly, VA was not able to meet its own regulations that require “all new patients requesting, or referred for, MH services …receive an initial evaluation within 24 hours, and a more comprehensive diagnostic and treatment planning evaluation within 14 days.” The lack of compliance with this simple benchmark has been the subject of several hearings held by the Senate Committee on Veterans’ Affairs, yet we continue to find veterans who “fall through the cracks.”

The IG audit linked two veteran suicides to an unacceptable lack of appropriate oversight over the contracted outpatient mental health services. This is simply unacceptable and we would like to have more details about how the Veterans Health Administration (VHA) will satisfy the IG’s recommendation to correct these deficiencies by the target date of July 31, 2013. These corrections are particularly important in light of the President’s August 31, 2012, Executive Order — Improving Access to Mental Health Services for Veterans, Service Members, and Military Families, because entities similar to the DeKalb County CSB are potential community partners that can participate in the 15 pilot projects mandated by this order. It is imperative that we understand the lessons learned from this contract to ensure these mistakes are not repeated. It is also critical that quality is assured across all VA programs, whether they are handled directly by VA or through a contracted community partner.

We ask that you provide to us in a timely manner any quality assurance processes and matrices that have been developed for these types of contracted services. We would like answers by June 14, 2013, to the following questions: What steps are being taken to provide continuous care to patients being seen under the short-term contract with the DeKalb County CSB? What processes and policies are in place to ensure a continuum of quality mental health care as contracts expire and are not renewed? Has the Southeast Regional Network conducted a review of similar contracts with other outside providers? We request VHA conduct a review across all Veterans Integrated Service Networks (VISNs) into their contracting practices. Does VA plan to standardize contracts that will be entered into for the 15 pilot projects?

With estimates that 22 veterans commit suicide each day, it is vital that we address problems at all of the VA’s mental health facilities and their partners. Even one suicide is one suicide too many. Our obligation is to conduct oversight so that VA can provide the best care to our nation’s veterans. The men and women who have bravely served our country deserve better care than what was described in the IG report related to mental health services provided by the Atlanta VAMC. We will continue to monitor the progress at the Atlanta VAMC, and will press for the same quality assurance throughout VHA. We are hopeful that this will provide the impetus that VA needs to address the problems in providing mental health care to veterans.

We understand there are constraints within which VA must work, but we want you to maximize your resources to provide the best care and services to our veterans. While we believe that VA is committed to addressing this issue, it is critically important that the Department improves significantly and quickly. We are dedicated to ensuring that no veteran falls through the cracks ever again when they seek the care they have earned and deserved. After more than a decade of war in Iraq and Afghanistan, we expect to see more than 1 million service members transition from active-duty to veteran status in the next few years. We must see to it that VA provides the best care and treatment to our service members and veterans who have shown such bravery in the face of tyranny around the world.

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