Healthcare Inspection – Alleged Suicides and Inappropriate Changes to Mental Health Treatment Program, Coatesville VA Medical Center, Coatesville, Pennsylvania

OIG conducted an inspection to assess the merit of allegations that two suicides may have occurred following the early termination of case management services, and two suicides may have occurred with the closure of a sub-acute psychiatric inpatient ward at the Coatesville VA Medical Center, (facility) in Coatesville, PA. The OIG also assessed allegations that the facility did not follow Veterans Health Administration (VHA) guidelines in closing or modifying other mental health care programs. We did not substantiate that any patient suicides occurred due to early termination of case management or the closure of a sub-acute psychiatric inpatient ward. We found that the facility complied with VHA policy when it closed the beds on the ward. We did not substantiate that the changes were made without regard to patient safety. We did not substantiate that the consolidation of two Domiciliary Care for Homeless Veterans (DCHV) units violated VHA policy. We substantiated the allegation that admission criteria to the DCHV program were restrictive; however, the issue was identified during a VHA site visit and corrected. We substantiated that the facility’s decision to close the Community Transition and Wellness Center violated VHA policy. We found that the facility did not transition the Community Transition and Wellness Center program to a Psychosocial Rehabilitation and Recovery Center as required by VHA policy. We recommended that the Facility Director coordinate with VHA leadership regarding the establishment of a Psychosocial Rehabilitation and Recovery Center.