Department of Veterans Affairs
 

Office of Inspector General
 

Healthcare Inspection
 

A Follow-Up Review of VHA Mental
 

Health Residential Rehabilitation
 

Treatment Programs (MH RRTP)
 

Report No. 10-04085-203 June 22, 2011
 VA Office of Inspector General
 

Washington, DC 20420
 
To Report Suspected Wrongdoing in VA Programs and Operations:
 

Telephone: 1-800-488-8244
 

E-Mail: vaoighotline@va.gov
 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp)
 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

Contents 

Page
 

Executive Summary ..............................................................................................i
 

Issue 1 - Review by VHA of the Utilization, Resource Allocation, and Distribution for
 

Issue 3 - Contact with and Engagement in Treatment for Patients on Waiting Lists for
 

Purpose .................................................................................................................1
 

Background ..........................................................................................................1
 

Scope and Methodology......................................................................................3
 

Results and Conclusions ....................................................................................5
 

each MH RRTP Model .................................................................................................... 5
 

Issue 2 - Special Emphasis Programming for OIF/OEF/OND Veterans......................... 6
 

Residential Programs ....................................................................................................... 7
 

Issue 4 - Documentation of Medical Screening Preceding Admission ......................... 10
 

Issue 5 - Meeting Minimum Programming Requirements 7 days Per Week ................ 13
 

Issue 6 - Formal Guidelines for Mental Health Staffing by Clinical Discipline ........... 14
 

Issue 7 - Staff Member Presence on Each Separate Unit and Floor.............................. 16
 

Issue 8 - Dispensing of Narcotic Self-Medication......................................................... 17
 

Issue 9 - Documented Orders for Medication Self-Administration .............................. 18
 

Issue 10 - Tracking and Management of Missed Appointments............................. 20
 

Issue 11 - Housing and Occupational Status at Discharge ............................................ 20
 

Appendixes 

A. Under Secretary for Health Comments.................................................................... 23
 

B. OIG Contact and Staff Acknowledgments............................................................... 30
 

C. Report Distribution................................................................................................... 31
 

VA Office of Inspector General 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

Executive Summary 

Introduction 

As directed in Public Law 110-387, the VA Office of Inspector General (OIG) conducted 

a follow-up review to evaluate any improvements made or problems remaining since 

completion of a comprehensive 2009 review of residential mental health care facilities of 

the Veterans Health Administration (VHA). The results of that inspection were 

published in the June 25, 2009 report, Healthcare Inspection Review of Veterans Health 

Administration Residential Mental Healthcare Facilities (OIG report number 08-00038-

152). In the 2009 report, we issued 10 recommendations based on identified areas of 

concern. The OIG conducted the present inspection in order to ascertain VHA’s progress 

in carrying out recommendations from the 2009 report and to evaluate whether 

improvements have occurred or deficiencies remain in these areas. Our inspection 

consisted of 3 components: (1) onsite inspection at 20 VHA Mental Health Residential 

Rehabilitation Programs (MH RRTP) sites (2) review of 907 medical records of MH 

RRTP patients treated at these 20 sites, and (3) relevant document review. 

Results 

We found significant interim progress in meeting recommendations: that VHA review 

residential program utilization, resource allocation, and distribution; that a staff member 

is present on each floor and unit of each residential program; that VHA develop formal 

guidelines for residential program mental health clinician staffing; that clinicians 

document a medical screening preceding admission, and for inclusion of OEF/OIF/OND 

(Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn) special 

emphasis programming/activities. 

We found moderate progress regarding: the presence of either a formal policy or 

consistent informal mechanism for capturing and addressing missed appointments for 

MH RRTP patients; and documentation of a progress note and prescriber’s order for 

patient safe medication management. We found mild-moderate interim progress 

regarding the provision of minimum programming hours 7 days per week-4 hours per 

day; and limiting dispensing of prescribed narcotics to up to 7 days for safe medication 

management for residential program patients (although overall compliance for this item 

was high-94%). 

We found little interim progress for: ensuring contact with patients during the time 

interval between acceptance into an MH RRTP program and program start. 

Although VHA met the requirement to develop core mental health clinical staffing 

guidelines, on this inspection we also reviewed actual staffing at MH RRTP programs 

visited. We found this to be an area of concern which is newly addressed in the 

VA Office of Inspector General i 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

recommendations section. On this inspection we also reviewed whether MH RRTP 

patients were assessed for occupational dysfunction, and if present whether they were 

referred to vocational rehabilitation services. We found that patients were assessed, but 

based on program size and urban-rural status there were differences in the percentage 

referred. In light of the emphasis on a recovery based model, this area of concern is also 

newly addressed in the recommendations. 

Table 1 summarizes the findings of the present inspection. Color coding for each item 

reflects an integrated OIG assessment of progress within the context of overall 

compliance. Of note, although we estimated 94% (high) compliance with limiting 

dispensing of narcotics to up to 7 days, and improvement since the previous review in 

2009 (89%), in light of the substantive nature of this issue, the item is shaded red. 

ISSUE 2011 OIG Review 2009 Review 

VHA Review of MH RRTP 

Program Model Utilization, 

Resource Allocation, and 

Distribution 

Met Newly Recommended in 2009 

Report 

OEF/OIF/OND Programming 70% 26% 

Contact During Interval Between 

MH RRTP Program Acceptance 

and Program Start 

73% 74% 

Medical Screening Preceding 

Admission 

89% 54% (PRRTP) -77% (DRRTP) 

Minimum Program Hours 7 Days 

per Week-4 Hours per Day 

70% of programs 55% of sites 

Formal Guidelines for Mental 

Health Clinician Staffing 

Met Newly Recommended in 2009 

Report 

Staff Member Presence on Each 

Floor and Unit 

97% of Programs 

95% of Programs 

Newly Recommended in 2009 

Report 

Limit Dispensing of Narcotics to 

up to 7 Days for Safe Medication 

Management Patients 

94% 89% 

Prescriber’s Order for Safe 

Medication Management (SMM) 

and Progress Note Assessing 

SMM 

61% 

41-96%(depending on program 

size and urban-rural status) 

45% 

82% 

Formal Policy or Consistent 

Informal Mechanism for 

Capturing and Addressing 

Missed Appointments 

82% Newly Recommended in 2009 

Report 

Table 1. Summary of findings for each issue compared with relevant findings from 2009 OIG review. 

VA Office of Inspector General ii 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

Recommendations 

We recommended that the Under Secretary for Health: 

(1) Ensure that VISN Directors ensure contact between MH RRTP staff and/or 

engagement in MH treatment for patients in the interim between their acceptance into and 

actual participation in a MH RRTP. 

(2) Ensure that VISN Directors ensure that MH RRTPs document a medical screening 

prior to MH RRTP admission. 

(3) Ensure that VISN Directors review whether MH RRTP patients assessed as having 

occupational dysfunction are referred to vocational rehabilitation when indicated and 

desired by the patient. 

(4) Ensure that the Office of Mental Health Services (OMHS) examines barriers to 

provision of weekend programming and provides further guidance to MH RRTPs 

regarding programmatic expectations during the weekend. 

(5) Ensure that VISN Directors ensure that MH RRTPs meet or exceed VHA’s core 

minimum staffing requirements. 

(6) Ensure that VISN Directors ensure that MH RRTPs comply with the MH RRTP 

Handbook regarding limiting of residential patient self-administration of controlled 

substances to a 7-day supply during the last third of a patient’s anticipated residential 

program stay. 

(7) Ensure that VISN Directors ensure documentation of a provider’s order and clinical 

note related to MH RRTP assessment for safe medication management. 

VA Office of Inspector General iii 
DEPARTMENT OF VETERANS AFFAIRS
 

Office of Inspector General
 

Washington, DC 20420
 

TO: Under Secretary for Health 

SUBJECT: Healthcare Inspection – A Follow-Up Review of VHA Mental Health 

Residential Rehabilitation Treatment Programs 

Purpose 

As directed in Public Law 110-387, the VA Office of Inspector General (OIG) conducted 

a follow-up review to evaluate any improvements made or problems remaining since 

completion of a comprehensive 2009 review of residential mental health care facilities of 

the Veterans Health Administration (VHA). The results of that inspection were 

published in the June 25, 2009 report, Healthcare Inspection Review of Veterans Health 

Administration Residential Mental Healthcare Facilities (OIG report number 08-00038-

152). In the 2009 report, we issued 10 recommendations based on identified areas of 

concern. The Acting Under Secretary (at the time of issuance) agreed with the findings 

and recommendations and provided an improvement plan. 

The OIG conducted the present inspection in order to ascertain VHA’s progress in 

carrying out recommendations from the 2009 report and to evaluate whether 

improvements have occurred or deficiencies remain in these areas. Additionally, from 

the medical record review component of this inspection, we determined documented 

housing arrangement (e.g., temporary grant-per-diem, return to own home) and 

vocational status for patients discharged from mental health residential rehabilitation 

treatment programs (MH RRTP) during the time frame of our review. 

Background 

VHA MH RRTPs provide a 24-hour therapeutic setting for veterans utilizing professional 

and peer support in a structured environment. Residential programs aim to provide 

rehabilitative and clinical care to address a range of problems experienced by eligible 

veterans. Issues encountered include medical, psychiatric, and substance use related 

conditions; homelessness; and problems that are social, vocational, and educational in 

nature. MH RRTP programs are intended to focus on Veterans’ needs, abilities, strengths, 

and preferences. Categories included in MH RRTP include; Psychosocial Residential 

Rehabilitation Treatment Programs (PRRTP), Substance Abuse Residential 

VA Office of Inspector General 1 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

Rehabilitation Treatment Program (SARRTP), Post-Traumatic Stress Disorder 

Residential Rehabilitation Treatment Program (PTSD-RRTP), Domiciliary Residential 

Rehabilitation Treatment Programs (DRRTP), Domiciliary Care for Homeless Veterans 

(DCHV), and Compensated Work Therapy/Transitional Residence (CWT/TR). 

MH RRTPs intend to identify and address goals including rehabilitation, recovery, health 

maintenance, improved quality of life, and community integration in addition to 

facilitating treatment and intervention for specific medical conditions, mental illness, 

substance use, and psychosocial stressors. Focus on patient strengths, abilities, needs, 

and preferences rather than on illness and symptoms is a core MHRRTP objective. 

MH RRTPs may provide treatment within the program itself (all inclusive residential 

model), or patients in MH RRTPs may participate in an intensive regimen of outpatient 

services (supportive residential model), which are then augmented by the MH RRTP 

component of care (supportive residential model). The residential component is intended 

to emphasize incorporation of clinical treatment gains into a lifestyle of self-care and 

personal responsibility. In an all inclusive residential model, staff dedicated to the MH 

RRTP provide virtually all treatment and rehabilitative services to patients in the 

program. In a supportive residential model, a supportive residential component is 

provided while patients receive intensive outpatient treatment from providers in other 

mental health programs (e.g., intensive outpatient substance use program, PTSD clinic). 

As of the 3rd quarter of FY 2010, there were 237 active MH RRTP programs at 104 VHA 

locations with approximately 8,457 operational beds. The following table documents 

MH RRTP utilization for FY 2008-2010. 

2008 2009 2010 

Discharges 

Cumulative Occupancy Rate 

Average Length of Stay (LOS) 

33,251 

79.6% 

63.3 

34,598 

79.0% 

65.4 

38,974 

81.7% 

63.4 

Table 2. MH RRTP discharges, average cumulative occupancy rate, and average LOS for FY 2008-2010. 

VHA Handbook 1162.02, Mental Health Residential Rehabilitation Treatment Program 

(December 22, 2010) provides procedures and reporting requirements for Mental Health 

Residential Rehabilitation Programs. The Handbook details substantive elements for MH 

RRTP’s with respect to several areas including program structure, staffing requirements, 

admission, screening, treatment planning, suicide risk assessment, medication 

management, and access and services for woman veterans among others. 

In the 2009 OIG review we recommended that the Acting Under Secretary for Health: 

1. Ensure that VHA program officials review the utilization, resource allocation, and 

distribution of general residential, PTSD focused, substance use focused, 

VA Office of Inspector General 2 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

(Domiciliary Care for Homeless Veterans (DCHV) , and Compensated Work 

Therapy (CWT) programs. 

2. Ensure that VISN Directors include programming specific for OIF/OEF/OND 

veterans in residential programs. 

3. Ensure that VISN Directors require residential program managers to ensure that 

patients on waiting lists are periodically contacted and/or engaged in treatment 

while awaiting placement in a residential program. 

4. Ensure that VISN Directors make sure that medical screening precedes admission 

for all patients in all residential programs and be documented accordingly. 

5. Ensure	 that VISN Directors require that (at least) minimum programming 

requirements are met 7 days per week 

6. Develop formal guidelines for mental health clinician staffing by mental health 

discipline for programs using an all-inclusive staffing model and for programs 

using a residential type clinical staffing model. 

7. Require the presence of at least one staff member on each separate wing and floor 

of residential programs on all shifts. 

8. Ensure that residential programs limit dispensing of narcotic self-medication to no 

more than a 7-day supply for residential program patients. 

9. Ensure that all patients on self medication have a documented order for selfadministration of medication, and documented instruction regarding medication 

self-administration. 

10. Ensure that missed appointments by residential program patients are captured, 

addressed, and case managed in a uniform manner. 

VHA Handbook 1162.02 conceptually addresses several of these recommendations. The 

following inspection evaluates VHA’s “on the ground progress” in carrying out these 

recommendations and in attending to the areas of concern intrinsic to each 

recommendation. 

Scope and Methodology 

We reviewed VHA Handbook 1162.02 (Mental Health Residential Rehabilitation 

Treatment Program), and VHA Handbook 1160.01 (Uniform Mental Health Services in 

VA Medical Centers and Clinics) and interviewed former and present VA Mental Health 

Residential Rehabilitation leadership with the Office of Mental Health Services at VA 

Central Office. We conducted a pilot onsite visit at the Hampton, Virginia VAMC. 

VA Office of Inspector General 3 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

A stratified sample design was used to select a probability-based random sample for 

onsite inspection. VHA MHRRTP sites were stratified based on bed size (small-50 beds 

or fewer, medium-51-126 beds, large-126 or more beds) and by urban versus rural status. 

Twenty locations were randomly sampled. In total, there were 50 MH RRTPs affiliated 

with these 20 locations. 

While onsite we interviewed program staff and informally spoke with program 

participants. We reviewed programming calendars for February and March 2011 looking 

for evidence that at least a minimum of 4 hours of programming was offered 7 days per 

week, and for indication of some OEF/OIF/OND veteran specific programming. After 

discussion of program calendars with staff, for further validation, we then selected 5 

medical records of patients presently in each MH RRTP at the time of the visit and 

reviewed these patient records for involvement in at least 4 hours of treatment or 

therapeutic programming per day. We observed program staffing and visited each 

building that houses an MH RRTP looking for the presence of staff or an alternate safety 

monitoring mechanism on each wing and floor of each MH RRTP at the selected 

location. We also reviewed each site’s missed appointment policies and interviewed staff 

regarding mechanisms used to monitor, address, and case manage missed appointments. 

For medical records review, a probability-based random sample of 50 patients was drawn 

from lists of all unique patients admitted from September 1, 2010, through December 30, 

2010, to MHRRTPs at the 20 sites selected for onsite visits. For locations with less than 

50 admissions during FY 2010, all patients admitted to MHRRTP’s at the site were 

included. OIG healthcare inspectors reviewed a total of 907 patient medical records for 

evidence of compliance with recommendations and/or elements from VHA Handbook 

1162.02 regarding admission screening; documentation of contact with veterans waiting 

more than 7 days to start a MHRRTP; medical screening; assessment of occupational 

function/dysfunction and vocational rehabilitation referral; documentation of suicide 

assessment as part of the biopsychosocial assessment; assessment for the ability to be in 

the safe-medication program and presence of an accompanying clinician’s order; and 

duration of narcotic prescriptions for patients on a safe-medication program. In addition, 

we reviewed documentation of vocational status and type of housing arrangements noted 

in the discharge plan. 

Additional document inspection included: review of safe medication policies for each 

location; review of required nursing-hours-per patient day (certified time sheets for each 

shift on 3 separate days); written staffing plans with roster by name and position title for 

all program staff; and a labor map for psychologists, psychiatrists, social workers, 

primary care physicians; physician assistants, and/or nurse practitioners assigned full or 

part time to MHHRTPs at each location. 

We conducted the review in accordance with Quality Standards for Inspection and 

Evaluation published by the Council of the Inspectors General. 

VA Office of Inspector General 4 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

Results and Conclusions
 

Issue 1. Review by VHA of the Utilization, Resource Allocation, and 

Distribution for each MH RRTP Program Model. 

MH RRTPs provide residential rehabilitative and clinical care to veterans with a wide 

range of problems or needs. MH RRTP bed types include: Domiciliary Residential 

Rehabilitation Treatment Programs (DRRTP), DCHV, Health Maintenance Domiciliary, 

General Domiciliary or Psychosocial Rehabilitation Treatment Programs (PRRTP), 

Domiciliary PTSD (Dom PTSD) or Post-Traumatic Stress Disorder Residential 

Rehabilitation Treatment Programs (PTSD-RRTP), Domiciliary SA (Dom SA) or 

Substance Abuse Residential Rehabilitation Treatment Programs (SARRTP), and CWTTransitional Residence (TR) programs. 

Those VAMCs that have a MH RRTP may have 1 or more MH RRTPs at one site, or 

separate programs in separate locations. In addition, within an MH RRTPs there may be 

special tracks or designated beds. For example, there may be a PTSD track or substance 

use track located with a general domiciliary program. 

MH Residential Rehabilitation leadership reported that MH RRTP utilization, resource 

allocation, and bed distribution are tracked by the VA Northeast Program Evaluation 

Center (NEPEC) on a quarterly basis. This information is sent to VISN leadership and 

directly to facility MH RRTP managers. We obtained and reviewed the MH RRTP 

quarterly bed reports, quarterly reports by MH RRTP bed type, VISN and facility level 

stoplight reports (based on cumulative occupancy rates, and related notes for FY 2010. 

Quarterly reports indicate: (1) the number of operational beds for each program modeltype at MH RRTP locations, (2) the cumulative average daily census for each program, 

(3) the cumulative occupancy rate, (4) the number of beds under development or 

construction at each location for each model type, and (5) the name and contact 

information for program coordinators at each site. 

Cumulative occupancy and cumulative average daily census data provide program 

managers and VA leadership with information to enhance decision making regarding 

utilization, resource allocation, and bed distribution. The additional notes include 

miscellaneous information on bed status changes (e.g., “they anticipate additional beds 

for TBI as soon as construction to accommodate these beds is completed”), observations 

regarding changes in occupancy rates, conversions from 1 model bed type to another 

(e.g., from General PRRTP to PTSD PRRTP), and observations regarding anomalies 

noted in the data reported to NEPEC (e.g., “VISN submitted copy of previous 

information from December 2009 making it unclear if the information is correct”). 

Each VISN except VISNs 19 and 21 have General MH RRTP operating bed types. Dom 

PTSD or PTSD-RRTP bed types are present in each VISN except for VISN’s 15, 18, and 

VA Office of Inspector General 5 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

22 which is unchanged since the June 2009 OIG report. However, the VA Eastern 

Kansas Health System, Topeka in VISN 15 does run a specialized inpatient stress 

disorders unit. Dom SA or SARRTP and DCHV bed types are operating in all VISN’s. 

CWT-TR beds operate in all VISN’s except for VISN’s 9, 19, and 22 (compared with 

VISN’s 2, 19, and 22 at the time of prior OIG report). 

Conclusion 

In conclusion, documentation review indicates that VHA program officials are engaged 

in ongoing review of the utilization, resource allocation, and distribution of general 

residential, PTSD focused, substance use focused, DCHV, and CWT programs. VHA 

tracks outcome measures (e.g., housing status, incarceration, employment status) for 

certain residential programs at 30 days post discharge. Although ongoing follow-up 

becomes more challenging as time horizons increase, VHA should consider utilizing a 

longer time frame and explore broadening the set of outcome measures as part of the MH 

RRTP evaluation process. 

Issue 2. Special Emphasis Programming for OIF/OEF Veterans 

At the 20 sites visited for our review, there were a total of 49 MH RRTP programs. 

CWT-TR programs offer therapeutic work-based residential rehabilitation services 

designed to facilitate successful community integration. In general, the main focus of the 

CWT-TR programming day consists of participation (on-site or off-site) in compensated 

work therapy which is not targeted to a specific veteran or mental health population. We 

therefore excluded the 12 CWT-TR programs from our analysis in this section of the 

report. For non-CWT, MH RRTPs, 100% had at least 1 OEF/OIF/OND veteran within 

the 2 months prior to our visit. From documentation and interview we found evidence of 

OEF/OIF/OND specific programming at 70% of the programs visited. This is improved 

compared with the 26% of programs with inclusion (different methodology) of special 

emphasis programming for OEF/OIF/OND veterans during our 2009 inspection. 

Conclusion 

Depending on the program focus and location, the number of OEF/OIF/OND veterans 

served by each particular MH RRTP varies throughout the system. Special emphasis 

programming may be impractical for programs that infrequently serve OEF/OIF/OND 

veterans but are a relevant component of the program of care for those MH RRTP’s that 

are regularly accessed by recent, returning veterans. Inclusion of OEF/OIF/OND special 

emphasis programming in MH RRTP’s significantly increased since our prior inspection. 

VA Office of Inspector General 6 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

Issue 3. Contact with and Engagement in Treatment for Patients on 

Waiting Lists for Residential Programs 

After screening and acceptance for admission to residential programs, some patients may 

begin program participation shortly following acceptance into the program, while other 

patients may experience a time delay between the time of acceptance and actually starting 

treatment in a MH RRTP. The time lag may be patient initiated (e.g., veteran taking 

college classes desires to wait until end of semester to begin program) or facility specific 

(e.g., lack of an available bed at time of acceptance, cohort model for PTSD track with 

each new cohort of patients starting at six week intervals). 

To ensure continuity of clinical monitoring of this vulnerable population during the 

period between acceptance into and starting treatment in a residential program, prudence 

dictates that residential programs maintain contact with and/or ensure interim assessment 

for veterans awaiting placement into residential programs. VHA Handbook 1160.01, 

Uniform Mental Health Services in VA Medical Centers and Clinics notes that facilities 

must ensure that waits for admission to a MH RRTP do not delay the implementation of 

care by instituting processes that include: ongoing monitoring and case management of 

referred patients, provision of treatment as needed to ensure stabilization of target 

conditions and management of co-morbidities, and/or utilizing waiting periods to provide 

pre-group preparation to enhance the experience and benefits of group treatment. 

OIG inspectors reviewed a statistically representative sample of 907 medical records of 

patients treated in MH RRTPs during FY 2010 at the 20 sites visited. Figure 1 depicts 

the relative frequency of times between MH RRTP acceptance and start for patients. 

Figure 1. Relative frequency of times between acceptance and start in MH RRTP. 

VA Office of Inspector General 7 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

Based on results from our sample, we estimated the mean number of days from 

acceptance to start for MH RRTP patients was 14.6 days [95% Confidence Interval (CI) of 

9.02-20.12 days]. 

In order to evaluate the presence and nature of clinical monitoring for patients waiting to 

start in a residential program, we focused on patients for whom the time between 

acceptance into and beginning formal participation in a MH RRTP was greater than 7 

days. We estimated that 45.1 percent of the patients began MH RRTP participation 

greater than 7 days after program acceptance. 

For VHA MH RRTP patients starting a MH RRTP 7 days or more after program 

acceptance, we estimated that overall there was interim phone or similar contact for 73% 

(CI 53.50-86.31) of these patients. Table 3 indicates estimates of the percentage of VHA 

MH RRTP patients starting a MH RRTP 7 days or more after program acceptance who 

had a mental health visit (in person or telehealth) during the relevant time frame by MH 

RRTP program size (small, medium, large) and facility urban-rural status. The data is 

presented by strata instead of an overall composite because a statistically significant 

difference was observed for small programs based on urban-rural status, and for smallurban programs compared to medium-urban and large-urban programs. 

Estimated Percentage 

Small-Rural 59.6 (CI 41.19-75.59) 

Small-Urban 97.1 (CI 86.21-99.43) 

Medium-Rural 67 (CI 34.62-88.58) 

Medium-Urban 74 (CI 66.05-80.59) 

Large-Rural 72.8 (CI 61.54-81.73) 

Large-Urban 31.4 (CI 6.13-76.20) 

Table 3. Percentage estimates of patients starting MH RRTP 7 days or more after program acceptance 

who had a mental health visit during the interim time frame by program size and urban-rural status. 

Table 4 depicts the estimated percentage of VHA MH RRTP patients who began 

participation at least 7 days after program acceptance, and had documentation in the 

record of either a mental health visit (in-person or via telehealth) or interim phone or 

other contact with the program prior to starting a residential program by program size and 

urban-rural status. A statistically significant difference was noted for small programs 

based on urban-rural status, and for small-urban programs compared with large-urban 

programs. 

VA Office of Inspector General 8 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

Estimated Percentage 

Small-Rural 76.8 (CI 63.93-86.07) 

Small-Urban 99.3 (CI 92.87-99.94) 

Medium-Rural 88 (CI 71.70-95.53) 

Medium-Urban 90 (CI 63.09-97.94) 

Large-Rural 78.2 (CI 67.16-86.35) 

Large-Urban 51.1 (CI 25.30-76.39) 

Table 4. Percentage estimates of patients starting MH RRTP 7 days or more after program acceptance 

who had either phone contact or a mental health visit during the interim time frame by program size and 

urban-rural status. 

For patients starting an MH RRTP more than 7 days after acceptance and for whom there 

was no evidence of an interim mental health visit or phone contact between the program 

and the patient, we estimated that 5.5% (CI 2.09-13.50) of these patients had a primary care 

visit during the time between acceptance and program start.1 

For MH RRTP patients for whom there was no evidence of interim phone contact or a 

mental health visit, the time frame from acceptance to start was 8-14 days for 38.2%, 15-

28 days for 33.1%, 29-42 days for 13.1% patients, and greater than 42 days for 15.6% 

patients. 

For MH RRTP patients for which there was a greater than 7-day time frame between 

acceptance and program start, we looked for evidence of a plan of care until actual 

program admission. In our 2009 review, we estimated documented presence of an 

interim plan of care for 64% of patients for whom there was a greater than 7-day time 

frame between acceptance and program start. Table 5 depicts the estimated percentage of 

MH RRTP patients with documentation of an interim plan of care by program size and 

urban-rural status. A significant difference is noted for small-urban versus small-rural 

programs; for large-urban versus large rural programs; and for small-rural versus large 

rural programs. 

1 The few patients who were on a VA inpatient unit during the time frame between acceptance into a residential 

program and participation in the MH RRTP program, were included as having had contact and a mental health visit 

while waiting to start the program. 

VA Office of Inspector General 9 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

Estimated Percentage 

Small-Rural 76.8 (CI 66.90-84.44) 

Small-Urban 97.1 (CI 86.21-99.43) 

Medium-Rural 43.9 (CI 20.08-70.90) 

Medium-Urban 88.3 (CI 58.51-97.59 ) 

Large-Rural 56.3 (CI 45.78-66.23) 

Large-Urban 91.2 (CI 84.31-95.26) 

Table 5. Estimated percentage of MH RRTP patients starting a program 7 days or more after program 

acceptance for whom there was documentation of an interim plan of care by program size and urbanrural-status. 

Conclusion 

We estimated that for MH RRTP patients with a more than 7 day gap between program 

acceptance and actual start in a program, 73% had phone contact with the MH RRTP; 

31.4-97.1% (depending on program size and urban-rural status) were engaged in a mental 

health treatment visit; and 51.1-99.3% (depending on program size and urban-rural 

status) had either phone contact or were engaged in a mental health treatment (outpatient 

or inpatient) visit. This is essentially unchanged since the 2009 OIG review during which 

we estimated that overall 74% of patients with a more than 7 day gap were followed 

clinically from the time of screening to actual admission. 

Of note, we estimated that for the sub-group of MH RRTP patients with a greater than 7 

day interval between acceptance and program start and for whom there was no evidence 

of phone contact or a mental health visit, the time frame between acceptance and program 

start was greater than 28 days for approximately 28.7% of these patients. 

Recommendation 1: We recommended that the Under Secretary for Health ensure that 

VISN Directors ensure contact between MH RRTP staff and/or engagement in MH 

treatment for patients in the interim between their acceptance into and actual participation 

in a MH RRTP. 

Issue 4. Documentation of Medical Screening Preceding Admission 

VHA Handbook 1162.02 (the MH RRTP Handbook) notes that veterans need to be 

screened for MH RRTP admission by staff capable of assessing their medical and 

psychiatric stability and their suitability for admission to the program. In addition, the 

VA Office of Inspector General 10 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

MH RRTP Handbook states that “all veterans must receive a health care screening by a 

physician or qualified health care provider prior to admission. This screening determines 

medical appropriateness for the MH RRTP and indicates areas of ongoing treatment and 

potentially urgent medical needs.” 

From medical record review, we estimated that 95.7% (CI 88.41-98.50) of medical records 

for MH RRTP patients had a screening note for the MH RRTP and 88.8% (CI 81.21-93.60) 

documented a medical screening prior to admission. 

The MH RRTP Handbook requires that veterans receive a comprehensive 

biopsychosocial assessment that is documented within 5 working days of admission to a 

residential program. The assessment includes multiple elements (e.g., living situation, 

family history, military history and trauma screening). Consistent with a rehabilitation 

model focused on improvements in function and quality of life, an assessment for 

occupational dysfunction and employment services is to be completed as part of the 

biopsychosocial assessment so that identified needs can be addressed in the rehabilitation 

plan. If needed, a referral for additional vocational rehabilitation and employment 

services may then be completed as part of the initial rehabilitation plan. 

We estimated that for 92.9% (CI 84.88-96.85) of MH RRTP patients, the biopsychosocial 

assessment included an assessment for occupational dysfunction. For MH RRTP patients 

with documentation of occupational dysfunction in the biopsychosocial assessment, table 

6 indicates the percentage estimated to have been referred to vocational services by 

program size and urban-rural status. 

Estimated Percentage 

Small-Rural 56.1 (CI 39.37-71.49) 

Small-Urban 32.7 (CI 12.72-61.88) 

Medium-Rural 97.4 (CI 97.00-97.67) 

Medium-Urban 50.4 (CI 27.37-73.30 ) 

Large-Rural 46.9 (CI 41.20-52.73) 

Large-Urban 79.7 (CI 66.02-88.79) 

Table 6. Estimated percentage of MH RRTP patients with occupational dysfunction documented in the 

biopsychosocial assessment that were referred to vocational services by program size and urban-rural 

status. 

A significant difference is noted between medium size programs based on urban-rural 

status; between large size programs based on urban-rural status; for medium-rural 

VA Office of Inspector General 11 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

programs compared to small-rural and large-rural programs; and between small-urban 

and large-urban programs. 

At one facility, all MH RRTP patients with 100% disability are referred to vocational 

rehabilitation services. As a result, there were an additional 15 patients whose 

biopsychosocial assessment did not include an assessment for occupational dysfunction, 

but who were also referred to vocational rehabilitation services. 

As per the MH RRTP Handbook, patients screened for admission to an MH RRTP are to 

be assessed for suicide risk. In addition, upon admission, all patients to an MH RRTP are 

to be screened again for suicide risk. Assessment of hopelessness, depression, suicidal 

thoughts, plan, ideation, and intention should also be ongoing through the program 

including at the time of treatment plan reviews, at times of particular concern (e.g., 

change in provider, life change etc), and prior to discharge. For this review, we 

ascertained whether a suicide assessment was included in the biopsychosocial 

assessment. We estimated that for 100% (CI 99.82-99.99) of MH RRTP patients, a second 

suicide assessment was included in the biopsychosocial assessment or a contemporaneous 

chart note. 

Conclusion 

From medical record review, we estimated that 95.7% of medical records for MH RRTP 

patients had a screening note for the MH RRTPs and 88.8% documented a medical 

screening prior to admission. This represents significant improvement compared with 

our prior review in which documentation of medical screening ranged from 54 to 77 

percent depending on historical program type.2 However, because of the substantive 

nature of this issue further progress is recommended. We estimated that for 100% of MH 

RRTP patients, a suicide assessment was included in the biopsychosocial assessment or a 

contemporaneous chart note. We estimated that for 92.9% of MH RRTP patients, the 

biopsychosocial assessment included an assessment for occupational dysfunction. For 

MH RRTP patients with documentation of occupational dysfunction in the 

biopsychosocial assessment we estimated that depending on MHRRTP program size and 

urban-rural status there was significant variation as to whether these patients were 

referred to vocational services. Considering the recovery and rehabilitative focus of MH 

RRTP programs, we believe this warrants further consideration and analysis by VHA. 

Recommendation 2: We recommended that the Under Secretary for Health ensure that 

VISN Directors ensure that MH RRTPs document a medical screening prior to MH 

RRTP admission. 

2 VHA Handbook 1162.02 unifies procedures and reporting requirements for all residential programs under the MH 

RRTP bed level of care. Prior to issuance, procedures for Domiciliary programs (DRRTP’s) and Psychosocial 

Residential Rehabilitation programs (PRRTP’s) were addressed under two separate handbooks, reflecting the 

historical organizational backgrounds from which DRRTP’s and PRRTP’s initially developed. 

VA Office of Inspector General 12 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

Recommendation 3: We recommended that the Under Secretary for Health ensure that 

VISN Directors review whether MH RRTP patients assessed as having occupational 

dysfunction are referred to vocational rehabilitation when indicated and desired by the 

patient. 

Issue 5. Meeting Minimum Programming Requirements 7 days Per 

Week-4 Hours per Day 

VHA Handbook 1162.02 notes that “MH RRTP policy requires a minimum of 4 hours 

per day of treatment or therapeutic activities, 7 days per week. Programs must provide 

therapeutic activities in the evening and on weekends. While the use of appropriate 

passes that are directly related to the accomplishment of the Veteran’s treatment and 

rehabilitation goals is encouraged, programs may not place all residents on pass for the 

weekend as a means of meeting the programming goal or due to lack of staffing 

availability. Evening and weekend activities must have a direct relationship to assisting 

the Veterans in meeting treatment and rehabilitation goals.” 

Because therapeutic work-based rehabilitation services encompass most of the 

programming day for CWT-TR programs and this handbook requirement is not 

applicable to CWT programs, we excluded these programs from our analysis for this 

section of the report. 

From documentation review and on-site interview, we found that although 95 percent of 

programs visited met minimum programming requirements on weekdays, 70% of MH 

RRTPs visited were providing at least 4 hours per day of treatment or therapeutic 

activities on weekends. This represents mild-moderate improvement compared with our 

finding (55%) in the 2009 report. 

To further explore and validate provision of at least the minimum number of 

programming hours, while on-site we randomly selected 5 medical records of patients 

presently in each MH RRTP at the time of the visit and reviewed these patient records for 

involvement in at least 4 hours of treatment or therapeutic programming per day on the 

Sunday, Tuesday, and Saturday of the week preceding our visit and queried staff with 

relevant follow-up questions as indicated. At 2 sites we looked at an additional 5 charts, 

and at 1 site we looked at a total of 5 charts rather than for each program at the site. In 

total 178 charts were reviewed on-site for involvement in 4 hours of programming 7 days 

per week. 

Documentation and follow-up discussions regarding this random sample of patient charts 

also supported meeting of minimum programming requirements during the week but not 

reliably on weekends. Forty-seven percent of charts supported patient participation in 

programming 7 days per week. Depending on the program, this number may reflect 

patient participation in weekend programming but lack of supportive documentation; 

availability of programming opportunities but variable patient participation; or lack of 

VA Office of Inspector General 13 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

weekend programming. Because this on-site patient chart sample was random but not a 

statistically representative sample, this result cannot be projected beyond the sample of 

programs and sites visited. 

Conclusion 

MH RRTPs visited were found to provide at least the minimum number of programming 

hours on weekdays but only 70% of the programs visited met this requirement 7 days per 

week. This represents mild to moderate improvement compared with our findings (55%) 

findings of our previous review. 

Recommendation 4: We recommended that the Under Secretary for Health ensure that 

OMHS examines barriers to provision of weekend programming and provides further 

guidance to MH RRTPs regarding programmatic expectations during the weekend. 

Issue 6. Formal Guidelines for Mental Health Staffing by Clinical 

Discipline 

In the 2009 OIG review of residential mental health programs, we recommended that 

VHA develop formal guidelines for mental health clinician staffing by mental health 

discipline for residential programs. Appendix A of the MH RRTP Handbook delineates 

core staffing requirements for MH RRTPs by number of beds consistent with the spirit of 

the IG recommendation. 

The minimum core requirements are intended to maintain adequate staffing to provide 

safe, appropriate clinical care. For the sites visited during the present inspection, we 

reviewed the staffing requirements, allocated staffing, and actual staffing for non-CWT 

MH RRTPs at the 20 sites visited. 

For MH RRTPs (other than CWT-TR) we reviewed staffing for the following clinical 

disciplines: 24/7 coverage; primary care physician, physicians assistant, or nurse 

practitioner for coverage of non-mental health medical and wellness issues; psychiatrist; 

psychologist; nurse; and social worker. Table 3 depicts the percentage of non-CWT 

programs visited that met core minimum staffing requirements per bed size based on 

actual staffing for the clinical disciplines reviewed. For example, a program with 41-50 

beds is required to have 2 social workers providing services to patients in the program. A 

program utilizing 2.5 social worker full time equivalents (FTE) would meet the 

requirement, while a program utilizing 1.5 FTE would not. 

VA Office of Inspector General 14 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

Position 

Percent Meeting Requirement 

Based on Actual FTE 

24/7 Coverage Staff 92% 

MD/PA/NP 73% 

Psychiatrist 68% 

Psychologist 49% 

Nurse (RN or LPN) 84% 

Social Worker 65% 

Table 7. The percentage of non-CWT MH RRTP programs that met core staffing requirements for select 

clinical disciplines at site visited. 

Sixteen percent of programs visited met requirements for all of the clinical disciplines 

reviewed. Most programs met staffing requirements for 24/7 coverage staff. In general, 

MH RRTPs at the sites visited had difficulty meeting core staffing requirements for 

psychiatrists, psychologists, and social workers. While the percentage of programs 

meeting core staffing requirements for an RN or LPN and for a primary care 

physician/physician’s assistant/nurse practitioner was greater it still deviated from the 

expected core staffing requirement. 

During our visits we also noted that less than half the programs visited met additional 

minimum requirements for vocational specialty staffing. One program did not have a 

nurse, and therefore did not accept patients who cannot self-administer their own 

medications. 

There were 12 CWT-TR programs located at 10 of the 20 sites visited by OIG inspectors. 

Consistent with the structure of CWT-TR programs, staffing focus differs from and is 

more fluid compared with other MH RRTPs. In addition, CWT’s can utilize house 

managers (non-paid former/recent participants) to help address participant needs. CWTTR staff functions include program manager, care manager, program clerk, 

physician/nurse practitioner/physician’s assistant, program evaluation, and other 

functions for CWT-TR programs visited. Because more than 1 of these functions can be 

performed by the same staff member, we focused on total minimum required FTE in 

comparison to total allocated FTE. Overall, inspectors found corresponding staffing 

arrangements for 9 of the 12 CWT-TR programs. 

Conclusion 

The 2009 OIG residential review recommended that VHA develop formal guidelines for 

mental health clinician staffing by mental health discipline for residential programs. 

Appendix A of the MH RRTP Handbook delineates core staffing requirements for MH 

RRTPs by number of beds consistent with the spirit of the IG recommendation 

VA Office of Inspector General 15 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

During the present review, 16% of programs visited met requirements for all of the 

clinical disciplines reviewed. Most programs met staffing requirements for 24/7 

coverage staff. However many programs did not meet core staffing requirements for 

psychologists, psychiatrists, social workers, RN or LPN and for a primary care 

physician/physician’s assistant/nurse practitioner. In addition, we also noted that many 

programs did not meet requirements for vocational specialty staffing. Considering the 

recovery and rehabilitative focus of MH RRTPs, we believe this warrants further 

consideration and analysis by VHA. 

Recommendation 5: We recommended that the Under Secretary for Health ensure that 

VISN Directors ensure that MH RRTPs meet or exceed VHA’s minimum core staffing 

requirements. 

7. Staff Member Presence on Each Separate Unit and Floor 

The VHA MH RRTP Handbook states that MH RRTPs “must have adequate staffing to 

provide safe, effective, and appropriate clinical care...Since onsite supervision of MH 

RRTPs is required 24/7, an employee must be physically present on the unit at all times 

that Veterans are present.” The Handbook further specifies that in MH RRTPs with 

multiple floors or buildings, a staff person must be physically present on each floor in 

each building. “For buildings where there is more than one unit on a floor, a centralized 

staff person may cover both units only if there is open and clear access to each unit and 

staff can view and hear the operation of both units.” If there is more than one unit on a 

floor and a physical barrier, a staff person must be present on each unit. 

During on-site visits, OIG inspectors went to each unit and floor of each MH RRTP to 

ascertain whether staff were physically present; and if not, whether programs were 

utilizing an alternative monitoring mechanism. For non-CWT MH RRTPs, we found 

staff present on each floor for 97% of MHRRTPs. On floors with more than one unit, 

staff or an adequate monitoring mechanism (e.g., staff situated between 2 highly visible 

units) were present on each unit for 95% of programs visited. 

At one site, there is a women’s program that is housed in a separate building. In the 

evening staff are placed on the 2nd floor where all bedrooms are located. The building is 

locked at all times. A camera is positioned to monitor the front door of the first floor. 

However, the camera/monitor was broken at the time of the OIG visit. Documentation 

indicated a work order had been placed. 

Inspectors also noted a program with units whose layout had several pockets that could 

not be easily monitored by one health tech. This concern was conveyed to program 

leadership who reported that health techs had increased the frequency of individual 

patient checks in order to compensate in part for the physical layout. 

Ninety-five percent of non-CWT MH RRTPs had an emergency management policy. 

VA Office of Inspector General 16 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

For CWT Programs, veterans are engaged in work programs and not generally present in 

the residential facility during the daytime. The presence of a staff member on each floor 

and unit is not a requirement for these programs. In the evening, a staff member or a 

current or graduate resident (“House Manager”) acting as a Without Compensation 

employee may supervise the residence with professional staff available on an emergency 

and callback basis. 

Conclusion 

In the 2009 OIG residential program review, we recommended that all sites should have 

at least one staff member available during each shift, on each separate wing, and on each 

floor of residential programs. In addition, we commented that VHA should develop more 

specific staffing guidance as it pertains to patient supervision by nursing and affiliated 

staff. The MH RRTP Handbook which published subsequent to the 2009 OIG review 

includes guidance regarding patient supervision, requires that an employee must be 

physically present on the unit at all times that Veterans are present, and further specifies 

that in MH RRTPs with multiple floors or buildings, a staff person must be physically 

present on each floor in each building. During the present review, 97% of programs 

visited were found to have a staff member present on each floor. Ninety-five percent of 

programs with multi-unit floors had presence of staff or alternative monitoring 

arrangements for each individual unit. 

Issue 8: Dispensing of Narcotic Self-Medication 

With the shift in delivery of mental health care toward a rehabilitative and recovery 

model, greater emphasis has been placed on skill development aimed at bolstering 

patients’ capacity for self-care, including self-management of medication regimens. Each 

MH RRTP must develop a local policy for Safe Medication Management (SMM). The 

MH RRTP Handbook notes that for each patient, the level of medication management 

must be assessed as dependent, semi-independent, or independent. Veterans are not to be 

denied access to an MH RRTP based on dependent or semi-independent status or on 

prescription of controlled medications. 

In terms of SMM, dependent patients (level I) require varying levels of medication 

supervision including direct involvement of nursing for observing and administering 

medication as per protocol outlined in VHA Handbook 1108.06, Inpatient Pharmacy 

Services. Semi-independent patients (level II) are able to assume partial responsibility 

for storage, security, and safe administration of medications. Program staff members 

provide varying degrees of supervision including periodic review of a patient’s safe 

medication practices, visual counts of a patient’s medications, and clinical observation of 

patient response. Patients assessed as independent (level III) are able to assume complete 

responsibility for the storage, security, and safe administration of medications. 

VA Office of Inspector General 17 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

The MH RRTP Handbook dictates that in the last third of a veteran’s length of stay and 

with at least two consecutive reassessments as independent, the independent veteran may 

be prescribed up to a 7-day supply of controlled substances for self-administration.3 The 

MH RRTP Handbook was released after issuance of our prior review of VHA residential 

mental health care facilities (2009). The present Handbook procedure limiting selfadministration of controlled substances to a 7-day supply during the last third of the 

residential stay represents a significant change from prevailing procedures in practice at 

the time of our previous OIG residential program review. 

To assess whether programs were dispensing more than a 7-day supply of controlled 

substances to MH RRTP patients for self-administration, we focused on dispensing of 

narcotic medications. From our review of medical records, we estimated that 12.4% (CI 

7.81-19.16) of patients in the sample that were on a SMM program were on a prescribed 

narcotic. We estimated that for 94.2% (CI 90.65-96.50) of MH RRTP patients on an SMM 

program who were prescribed a narcotic, the order was for up to 7 days. 

Conclusion 

New procedures outlined in the MH RRTP Handbook limit self-administration of 

controlled substances to a 7-day supply during the last third of a patient’s residential stay. 

We estimated that 94.2% of MH RRTP patients on a safe medication management 

program prescribed a narcotic, had an order for up to 7 days and 5.8% had an order for 

more than a 7-day supply. This represents improvement compared with our previous 

review in which we estimated that 11 percent of VHA residential program patients on a 

self-medication program and who were prescribed narcotics received more than a 7-day 

supply of medication. Although MH RRTPs were largely compliant with the relevant 

internal controls set forth in the MH RRTP Handbook, given the nature of this issue, we 

would expect to see 100% compliance. 

Recommendation 6: We recommended that the Under Secretary for Health ensure that 

VISN Directors ensure that MH RRTPs comply with the MH RRTP Handbook regarding 

limiting of residential patient self-administration of controlled substances to a 7-day 

supply during the last third of a patient’s anticipated residential program stay. 

Issue 9: Documented Orders for Medication Self-Administration 

A patient’s ability to safely manage medications is to be assessed by a physician, 

physician’s assistant, nurse practitioner, clinical pharmacist, clinical nurse specialist or 

registered nurse upon admission to a MH RRTP. The patient is assessed at that time for 

independent, semi-independent, or dependent medication management. The MH RRTP 

Handbook requires that proper documentation include a progress note along with a 

3 All controlled substances must be administered and recorded by licensed staff, except in CWT-TR programs. 

VA Office of Inspector General 18 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

provider’s order documented in the patient’s medical record by the staff member 

completing the assessment. SMM is to be incorporated into each patient’s individual 

treatment plan and must be reviewed as part of plan updates. 

The assessment includes patient knowledge of medication names, dose, security 

requirements, reason for taking, common side effects, and evaluation of integration of 

medications into the patient’s lifestyle, possible barriers to compliance and learning, and 

procedures for requesting a change in regimen. 

Based on medical record review, we estimated that a provider’s order for a patient to be 

on SMM was present 61.2% (CI 36.51-81.28) of the time. Table 8 depicts the estimated 

percentage of MH RRTP patients for which there was presence of a progress note 

documenting assessment of the patient’s ability to safely manage medications. 

Estimated Percentage 

Small-Rural 96.4 (CI 92.40-98.29) 

Small-Urban 87.3 (CI 78.67-92.77) 

Medium-Rural 88.9 (CI 68.20-96.78) 

Medium-Urban 91.6 (CI 74.18-97.67) 

Large-Rural 95.2 (CI 90.80-97.52) 

Large-Urban 41.3 (CI 6.00-88.58) 

Table 8. Percentage estimates of MH RRTP patients for whom there was presence of a progress note 

documenting assessment of the patient’s ability to safely manage medications by program size and urbanrural status. 

A statistically significant difference is noted comparing the relatively low estimated 

percentage for MH RRTP patients in large-urban programs to the relatively high 

percentage estimated for MH RRTP patients in large-rural programs. 

Conclusion 

The MH RRTP Handbook states that proper documentation regarding assessment of a 

patient’s ability to safely manage medications (independent, semi-independent, 

dependent) includes a progress note along with a provider’s order. We estimated the 

presence of a related provider’s order for 61.2% of MH RRTP patients. This represents 

mild to moderate improvement compared to 45% noted during our 2009 review. We 

estimated presence of a relevant progress note for 41.3-96.4% of MH RRTP patients 

depending on program size and urban-rural status. Excluding large-urban programs 

presence of a progress note documenting assessment of the patient’s ability to safely 

VA Office of Inspector General 19 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

manage medications was moderately improved compared to an overall composite rate of 

82% found during our 2009 review. 

Recommendation 7: We recommended that the Under Secretary for Health ensure that 

VISN Directors ensure documentation of a provider’s order and clinical note related to 

MH RRTP assessment for safe medication management. 

Issue 10: Tracking and Management of Missed Appointments 

During the 2009 OIG residential program review, we found significant variation in how 

and to what extent residential programs monitor and re-schedule missed appointments. 

For the present review, we ascertained on-site whether programs had a policy and/or 

mechanism in place to monitor for and to re-schedule missed patient appointments. 

Capturing and addressing missed appointments facilitates treatment adherence and 

continuity and may help optimize benefit derived by patients participating in an MH 

RRTP. 

We reviewed formal missed appointment policy documents (if existent) and discussed 

with staff mechanisms by which missed appointments are captured and addressed. 

Eighty-two percent of programs had either a formal documented policy regarding missed 

appointments or a consistent informal mechanism (e.g., daily log followed by 

documentation in a medical record progress note). 

Conclusion 

Eighty-two percent of programs visited had either a formal written policy or articulated a 

consistent informal practice for capturing and addressing missed appointments. The 

extent and mechanism by which MH RRTPs capture and address missed appointments 

appears variable and inconsistent across sites. 

Issue 11: Housing and Occupational Status at Discharge 

The MH RRTP Handbook specifies that type of housing and employment status at 

discharge should be among a list of items (e.g., reason for admission, pending 

appointments, status of goals) included in MH RRTP discharge summary note. During 

the medical record review for the present inspection, we looked at housing arrangement 

and vocational status documented at the time of discharge. The following descriptive 

results are provided for informational purposes. Figure 2 depicts estimated the postdischarge housing arrangement by relative percentage for MH RRTP patients based on 

the 816 patients for whom we could find documentation of post-discharge status. For 

clarification, patients in MH RRTPs transitioning to another MH RRTP on discharge are 

categorized in figure 2 as temporarily residing in an MH RRTP on discharge from the 

VA Office of Inspector General 20 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

first program. These patients would ultimately have other housing arrangements after 

discharge from the 2nd MH RRTP program. 

Figure 2. Estimated post-discharge housing arrangements for MH RRTP patients based on 816 patients 

for whom their was documentation of housing status at discharge. 

Figure 3 depicts the estimated vocational status for MH RRTP patients based on the 699 

patients for whom we could find documentation at discharge. 

VA Office of Inspector General 21 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

Figure 3. Estimated vocational status at discharge for MH RRTP patients based on 699 patients for whom 

it was documented. 

Conclusion 

Based on our sample of patients for who post-discharge housing arrangements were 

documented in the medical record, we estimated that approximately 37.4% were 

returning to their own apartment or house and approximately 27.1% were planning to live 

at the residence of a family member or friend. Approximately 11.4% of MH RRTP 

patients were transitioning to starting another MH RRTP (e.g., from a substance use 

focused program to a PTSD focused program). We estimated that 14.1% of MH RRTP 

patients were employed full-time, part-time or temporarily at the time of discharge. 

JOHN D. DAIGH, JR., M.D.
 

Assistant Inspector General for
 

Healthcare Inspections
 

VA Office of Inspector General 22 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

Appendix A 

Under Secretary for Health Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 June 15, 2011 

From:	 Under Secretary for Health (10) 

Subject:	 Healthcare Inspection – A Follow-Up Review of VHA Mental 

Health Residential Rehabilitation Treatment Programs 

To:	 Assistant Inspector General for Healthcare Inspections 

(54) 

1. I have reviewed the Office of Inspector General (OIG) draft report, and I 

concur with its recommendations and findings. Providing Veterans with 

effective residential rehabilitation and treatment is an important component 

of the Veterans Health Administration’s (VHA) continuum of mental health 

care. 

2. As an organization, VHA has worked diligently to provide a consistently 

high level of residential rehabilitation and treatment for all Veterans. I am 

pleased with the significant improvements that the Mental Health 

Residential Rehabilitation Treatment Programs (MH RRTP) have made 

since OIG last reviewed these programs. However, this report provides 

useful insight into areas of residential rehabilitation and treatment that can 

be further improved. 

3. As part of this continuous effort, in 2007, the National Leadership 

Board-Health Systems Committee charged VHA's Office of Mental Health 

Services (OMHS) with the task of reviewing the current status of care 

delivery in MH RRTPs in order to improve and enhance services to 

Veterans. Subsequently, OMHS developed a MH RRTP Transformation 

Plan, which includes a full review of all MH RRTPs and the development 

of a unified VHA MH RRTP Handbook. In May 2009, OMHS finalized 

VHA Handbook 1162.02, Mental Health Residential Rehabilitation 

Treatment Programs, which establishes the procedures and reporting 

requirements for the MH RRTP bed level of care. The Handbook was 

further amended in December 2010 to address issues identified in OIG’s 

VA Office of Inspector General 23 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

initial MH RRTP report dated June 25, 2009. This Handbook was 

distributed to the field earlier this year for immediate implementation. 

4. In addition, Mathematica Policy Research, Inc., a nationally recognized 

leader in independent, objective policy research and health care quality 

improvement, is currently conducting follow-up site visits to MH RRTPs to 

assess, evaluate and provide consultation on the implementation of the 

VHA MH RRTP Handbook. A final report is expected in September 2011. 

The purpose of this survey is to identify MH RRTPs that need further 

development to meet policy requirements. Medical centers are required to 

submit action plans for each item identified by Mathematica that is not in 

compliance with the VHA MH RRTP Handbook requirements. VHA’s 

Office of Mental Health Operations and OMHS will collaborate to ensure 

that there is a plan for implementation and progress monitoring in place at 

each site, as needed. 

5. Thank you for the opportunity to review the draft. An action plan to 

implement the report recommendations is attached. If you have any 

questions, please contact Linda H. Lutes, Director, Management Review 

Service (10A4A4) at (202) 461-7014. 

Robert A. Petzel, M.D. 

VA Office of Inspector General 24 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

Under Secretary for Health’s Comments 

to Office of Inspector General’s Report 

The following comments are submitted in response to the 

recommendations in the Office of Inspector General’s report: 

OIG Recommendations 

Recommendation 1: We recommended that the Under Secretary for 

Health ensure that VISN Directors ensure contact between MH RRTP staff 

and/or engagement in MH treatment for patients in the interim between 

their acceptance into and actual participation in a MH RRTP. 

VHA Comments 

Concur 

The Office of Inspector General (OIG) review found that 73 percent of 

Mental Health Residential Rehabilitation Treatment Programs (MH RRTP) 

were in contact with Veterans that had more than a 7- day gap between 

screening and admission. To improve in this effort, the Veterans Health 

Administration’s (VHA) Office of Mental Health Services (OMHS) and 

Office of Mental Health Operations (OMHO) will review and clarify 

guidelines regarding contact with Veterans waiting for MH RRTP 

admission on national conference calls with both MH RRTP program 

managers, and Veterans Integrated Service Network (VISN) and medical 

center leadership regarding contact with Veterans waiting for admission 

into a MH RRTP. The message of these national conference calls will 

emphasize the need for contact between MH RRTP staff and/or 

engagement in mental treatment for patients awaiting admission and 

system-wide documentation of such contacts. 

In Process September 30, 2011 

Recommendation 2: We recommended that the Under Secretary for 

Health ensure that VISN Directors ensure that MH RRTPs document a 

medical screening prior to MH RRTP admission. 

VHA Comments 

Concur 

VA Office of Inspector General 25 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

VHA Handbook 1162.02, Mental Health Residential Rehabilitation 

Treatment Program (MH RRTP), requires that all Veterans must receive a 

health care screening by a physician or qualified health care provider prior 

to admission. This screening determines medical appropriateness for the 

MH RRTP and indicates areas of ongoing treatment and potentially urgent 

medical needs. 

OIG found that 96 percent of medical records reviewed had a screening 

note and 89 percent documented a medical screening prior to admission to 

the MH RRTP. VHA’s OMHS and OMHO will review and clarify 

guidelines regarding medical screening requirements on national 

conference calls with MH RRTP program managers and VISN and medical 

center leadership on national conference calls. The message of these 

national conference calls will emphasize system-wide documentation of 

medical screenings prior to a Veterans’ admission into a MH RRTP. 

In Process September 30, 2011 

Recommendation 3: We recommended that the Under Secretary for 

Health ensure that VISN Directors review whether MH RRTP patients 

assessed as having occupational dysfunction are referred to vocational 

rehabilitation when indicated and desired by the patient. 

VHA Comments 

Concur 

The OIG review found that 93 percent of medical records reviewed had an 

assessment for Occupational Dysfunction and that 59 percent of the 

Veterans were referred for vocational rehabilitation services. VHA’s 

OMHS and OMHO will review VHA guidelines regarding Occupational 

Dysfunction requirements on national conference calls with MH RRTP 

program managers and with VISN and medical center leadership. 

Discussion during these calls will emphasize VHA’s requirement that MH 

RRTP patients assessed with occupational dysfunction be referred to 

vocational rehabilitation when indicated and desired by the patient. 

In Process September 30, 2011 

Recommendation 4: We recommended that the Under Secretary for 

Health ensure that OMHS examines barriers to provision of weekend 

programming and provides further guidance to MH RRTPs regarding 

programmatic expectations during the weekend. 

VA Office of Inspector General 26 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

VHA Comments 

Concur 

The OIG review found that 95 percent of the MH RRTPs provide the 

minimum number of programming hours on weekdays, but only 70 percent 

of the programs met this requirement on weekends. A review of 2009 and 

2010 Commission on Accreditation of Rehabilitation Facilities (CARF) 

accreditation surveys of MH RRTP found that approximately 10 percent of 

programs did not meet this standard. 

VHA’s OMHS will develop a list of MH RRTPs that were cited by CARF 

for not meeting this requirement and review and clarify guidelines and 

identify barriers on national conference calls with MH RRTP program 

managers. The VHA OMHO will review and clarify guidelines regarding 7 

days per week, 4 hours per day of treatment and rehabilitation services on 

national conference calls with VISN and medical center leadership. 

In Process September 30, 2011 

Recommendation 5: We recommended that the Under Secretary for 

Health ensure that VISN Directors ensure that MH RRTPs meet or exceed 

VHA’s minimum core staffing requirements. 

VHA Comments 

Concur 

Appendix A of the MHRRTP Handbook includes staffing guidelines that 

outline minimum core staffing, specialty bed section staffing requirements, 

and include discipline, full-time equivalent, and staff to bed ratio. 

VHA OMHS will review VHA’s recommended minimum staffing 

requirements on national conference calls with MH RRTP program 

managers to ensure that MHRRTPs are in compliance. The VHA OMHO 

will review the requirement to meet or exceed the core minimum staffing 

requirements on national conference calls with VISN and medical center 

leadership and will review the process for making adjustments to the core 

minimum staff for MH RRTPs. Each medical center operating an MH 

RRTP will be required to submit a local written staffing plan as outlined in 

the MH RRTP Handbook. The staffing plan will outline the core minimum 

staffing required and note the current full-time equivalent employees 

(FTEE) by discipline assigned to the unit. The staffing plan will be 

reviewed and approved by the medical center and VISN Directors and 

VA Office of Inspector General 27 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

include an action plan to address any staffing gaps in meeting or exceeding 

the core minimum staffing requirements. 

In Process September 30, 2011 

Recommendation 6: We recommended that the Under Secretary for 

Health ensure that VISN Directors ensure that MH RRTPs comply with the 

MH RRTP Handbook regarding limiting of residential patient selfadministration of controlled substances to a 7-day supply during the last 

third of a patient’s anticipated residential program stay. 

VHA Comments 

Concur 

The OIG review found 94 percent of MH RRTP patients on a safe 

medication management program prescribed a narcotic, had an order for 

less than 7 days and 6 percent had an order for more than a 7-day supply. 

Although MH RRTPs were largely compliant with the relevant internal 

controls set forth in the 

MH RRTP Handbook, given the nature of this issue, OIG is recommending 

VHA continue to work for 100 percent compliance. 

VHA’s OMHS and OMHO will review and clarify guidelines regarding 

limiting controlled medication to a 7-day supply on national conference 

calls with 

MH RRTP program managers, and VISN and medical center leadership to 

ensure safe medication management. 

In Process September 30, 2011 

Recommendation 7: We recommended that the Under Secretary for 

Health ensure that VISN Directors ensure documentation of a provider’s 

order and clinical note related to MH RRTP assessment for safe medication 

management. 

VHA Comments 

Concur 

VA Office of Inspector General 28 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

On national conference calls with MH RRTP program managers and VISN 

and medical center leadership, VHA’s OMHS and OMHO will review and 

clarify guidelines regarding the required proper documentation of a 

provider’s order and clinical note related to MH RRTP assessment for safe 

medication management. 

In Process September 30, 2011 

VA Office of Inspector General 29 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

Appendix B 

OIG Contact and Staff Acknowledgments 

OIG Contact	 For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720 

Acknowledgments	 Michael Shepherd, MD 

Lisa Barnes, MSW 

Gail Bozzelli, RN 

Elizabeth Burns, MSSW 

Shirley Carlile, BA 

Jennifer Christensen, DPM 

Limin Clegg, PhD 

Melanie Cool, LD 

Katharine Foster, RN 

Donna Giroux, RN 

Kathy Gudgell, RN, JD 

Daniel Kolb, PhD 

Karen McGoff-Yost, LCSW 

Frank Miller, PhD 

Karen Moore, RN 

Rayda Nadal, RN 

Sami O'Neill, MA 

Roxanna Osegueda, MBA 

Noel Rees, MPA 

Patrick Smith, MS

Laura Tovar, LCSW 

VA Office of Inspector General 30 
A Follow-Up Review of VHA Mental Health Residential Rehabilitation Treatment Programs 

Appendix C 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Non-VA Distribution 

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA Office of Inspector General 31