5 OF 18 ATLANTA VA SUICIDE-PREVENTION STAFF LACKED AUTHORIZATION TO PROVIDE PSYCHOTHERAPY, OIG FOUND
By VA Headlines staff · Published Nov 11, 2026 · Source dated November 10, 2026 (VA Office of Inspector General)
The VA Office of Inspector General (OIG) did not substantiate an allegation that assigning additional psychotherapy duties to suicide prevention program clinical staff at the Atlanta VA Healthcare System in Decatur, Georgia, limited those staff members' ability to meet program requirements. OIG did find, however, that 5 of the 18 staff members were not authorized through their scopes of practice to provide psychotherapy or other advanced practice procedures — mental health assessments and diagnosis — to patients at the system. OIG published report 26-00120-12 on November 10, 2026, and made 3 recommendations to the System Director. The VISN and System Directors concurred. OIG says the recommendations remain open.
Why OIG looked
OIG opened a hotline healthcare inspection on December 1, 2025, after an allegation that the added psychotherapy duties would keep staff from fulfilling program requirements. Interviews and off-site work continued through May 12, 2026. Suicide prevention is VHA's top clinical priority.
The psychotherapy assignment and program metrics
In September 2025, mental health leaders assigned each of the 18 suicide prevention program clinical staff — coordinators, case managers, and care coordinators — one general mental health patient and expected them to begin weekly, time-limited psychotherapy. Leaders did not report that the extra assignment affected completion of program duties.
OIG reviewed two key metrics for the three months before and after the assignment: Veterans Crisis Line consult closures and reviews of high-risk-for-suicide patient record flags. Under VHA Directive 1503(2), those consults are to be closed within three days. OIG found the staff remained 99–100 percent compliant with those closures and continued to review 97 percent of high-risk flags within required time frames. OIG found no indication either metric was negatively affected.
Scopes of practice: 5 of 18 lacked authorization
OIG confirmed that all 18 staff members held active licensed clinical social worker licenses, at the advanced-practice level, and held the position of senior social worker. Providing psychotherapy was an expected responsibility of that license, position, and assignment. Even so, 5 of the 18 did not have a scope of practice authorizing psychotherapy or other advanced practice procedures, and those scopes did not align with their licensure, position, or assignment. OIG found this misalignment "likely applied to a larger number of the system's social workers." OIG found two scopes of practice in use. Thirteen of the 18 staff were still on a traditional social-work-service scope; 12 of those 13 were authorized to perform advanced practice procedures, but one was not. In April 2025, the system's Medical Executive Committee approved a new scope that let individual social workers request or decline those procedures. Five staff had moved to that 2025 scope; four of the five were not authorized to provide psychotherapy or other advanced practice procedures inherent to their position.
The chief of social work reported transitioning 321 system social workers to the 2025 scope; as of May 1, 2026, 60 had transitioned. OIG learned that suicide prevention staff had been instructed not to request advanced practice procedures on that scope. VHA's National Director of Social Work told the inspection team those interventions are "relevant to their daily work" and that performing them without authorization would be practicing outside what the system had authorized, "which is a patient safety concern." After a January 22, 2026, OIG memorandum and an April 2026 inquiry, three social workers on the 2025 scope had been modified to include "psychotherapy and counseling," but not mental health assessments or formulating diagnoses. OIG remains concerned that social workers may still be practicing outside their approved scopes.
Licensed independent practitioners
OIG also found that, while recredentialing social workers as licensed independent practitioners through the medical staff structure, system leaders blended the scope-of-practice and privileging processes and limited social workers' ability to practice independently. VHA policy recognizes a social worker licensed at the independent practice level as a licensed independent practitioner. Leaders revised the medical staff bylaws to include social workers but listed them as providers who "practice under a Scope of Practice with appropriate supervision and/or collaboration." National social work and credentialing leaders told OIG those bylaws treat independently licensed social workers as dependent, inconsistent with VA and VHA policy, and could affect patients' access to timely mental health services.
The three recommendations
OIG made three recommendations to the Atlanta VA Health Care System Director, in consultation with VHA's Office of Care Management and Social Work Services (and, for recommendation 2, the Office of Credentialing and Privileging):
Recommendation 1: Take appropriate steps so licensed clinical social workers' scopes of practice align with their licensure, position classification, and clinical assignment, in accordance with VA Handbook 5005/120 and VHA Directive 1110.02.
Recommendation 2: Review the system's actions to integrate social workers into the medical staff, including the revised bylaws and scopes of practice, in accordance with VHA Directives 1110.02 and 1100.21(1).
Recommendation 3: Take appropriate steps so social workers are identified as licensed independent practitioners, either through a scope of practice or privileges, in accordance with those directives.
The System Director concurred with all three and provided action plans, with target dates of June 2026, December 2026, and March 2027. The facility said suicide prevention staff scopes have been modified to include providing psychotherapy. OIG considers recommendation 1 open until leaders submit supporting documents, and says it will follow up. The report does not allege criminal wrongdoing by any individual employee and does not name the staff.
Related: Marion VA: 2 patient-safety recommendations on test-result policy. Truman VA: nurse whistleblower case on psych admissions. VA OIG hospital inspections. Department of Veterans Affairs (VA) News. More: all VA Headlines reports. How we report: Methodology & Corrections.
Review of Suicide Prevention Program Staff Duties at the Atlanta VA Health Care System in Decatur, Georgia - Report 26-00120-12, November 10, 2026
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