Only 3 of 28 VA Facilities Without Locked Mental Health Units Had Required Involuntary-Admission Agreements, OIG Found
By VA Headlines staff · Published Nov 13, 2026 · Source dated November 12, 2026 (VA Office of Inspector General)
The VA Office of Inspector General (OIG) found that only 3 of 28 VA facilities without a locked mental health acute inpatient unit reported having the required agreements for involuntary admissions and hospitalization elsewhere. OIG said that without those agreements, facilities risk delays and poor coordination of care for patients who urgently need to be admitted. The national review, report 25-00867-171, was issued November 12, 2026. OIG made 7 recommendations to the Under Secretary for Health. Acting Under Secretary for Health John Figueroa concurred with all seven. OIG considers recommendations 4, 5, and 6 closed. Recommendations 1, 2, 3, and 7 remain open.
Why OIG looked
OIG opened the review after findings from four earlier OIG reports — at Martinsburg, Augusta, North Florida/South Georgia, and Southern Nevada — raised concerns about involuntary mental health hold processes, and after congressional interest in staff knowledge of state laws and in national data collection. The review was initiated on February 26, 2025, and questionnaire results were analyzed through March 16, 2026. State laws govern involuntary mental health holds, and legal requirements and criteria vary by state. OIG did not review, or assess facility compliance with, applicable state laws.
On April 4, 2025, and again on August 4, 2025, OIG sent questionnaires to all 139 VHA facilities. Both had a 100 percent response rate. The results are point-in-time, self-reported information and reflect conditions as of the date each questionnaire was received.
Locked units and the required agreements
Eighty percent (111 of 139) of facilities reported operating a locked mental health acute inpatient unit. Of those, VHA clinicians at 101 facilities initiate involuntary holds, and clinicians at 97 of the facilities that initiate holds also admit patients on holds to their locked unit. Because of state or local laws, a small number of facilities limit those services: four place patients on holds but do not admit them to their locked unit, and ten do not place patients on holds.
The other 20 percent (28 of 139) reported that they do not operate a locked unit. VHA Directive 1160.01 requires those facilities to have agreements with appropriate agencies or hospitals so they can arrange involuntary hospitalization when clinically necessary. Only 3 of the 28 facilities (11 percent) reported having those agreements. While they did not have a formal agreement in place, the remaining facilities reported the steps they take to initiate assessment and care of patients through community resources. OIG did not find that those facilities refused patients, and it did not find that holds were illegal.
Local policies, legal review, and data tracking
VHA Directive 1160.06(1) assigns facility directors responsibility for guidelines on the involuntary commitment process and its alignment with state and local requirements. Eighty-six percent (119 of 139) of facilities reported having a local policy; of those, 113 (95 percent) said the policy aligned with applicable state laws. That leaves 14 percent of facilities without that guidance.
The same directive currently "highly recommend[s]" consulting Office of General Counsel District Counsel when developing local guidance, rather than requiring it. Only 34 percent (43 of 126) of respondents indicated that District Counsel had been consulted. Thirty-six percent of the 133 facilities that were asked reported tracking involuntary-hold data, often through manual methods, and tracking practices varied widely.
Training
The directive requires inpatient mental health staff to be trained on relevant regulations, but it does not mandate training specific to involuntary mental health hold procedures. Training in the clinical areas where holds are initiated varied by facility.
The seven recommendations
OIG made seven recommendations to the Under Secretary for Health:
Recommendation 1: Ensure all VHA medical facilities without a locked mental health acute inpatient unit have the required agreements in place to allow involuntary admissions at appropriate non-VA agencies or hospitals, in accordance with VHA Directive 1160.01. Target date: April 2027. Open.
Recommendation 2: Determine if facility guidelines should be required to include processes specific to involuntary mental health holds, admissions, and hospitalizations, in accordance with VHA Directive 1160.06(1). Target date: April 2027. Open.
Recommendation 3: Give consideration to changing Directive 1160.06(1) to require consultation with Office of General Counsel District Counsel when developing local facility guidelines for involuntary hospitalization, rather than "highly recommend" involvement as currently written. Target date: December 2026. Open.
Recommendation 4: Confirm that all VHA facilities have a designated involuntary inpatient mental health commitment point of contact and an alternate, in accordance with a July 30, 2025, VA memorandum. Closed at publication.
Recommendation 5: Take steps for full implementation of the legal status data field in the electronic health record and monitor its use, in accordance with a June 1, 2026, VA memorandum. Closed at publication.
Recommendation 6: Consider developing reports using that legal status data field to inform VHA of the number of patients across the enterprise receiving care while on an involuntary legal status. Closed at publication.
Recommendation 7: Consider whether training specific to involuntary mental health holds, including the relevant law and procedures, should be required for inpatient and outpatient staff involved with the process. Target date: November 2026. Open.
The OIG received the Under Secretary's concurrence memorandum on October 16, 2026. This is a national program-controls review. It does not name individual employees.
Related: Fayetteville VA: staff hesitated to report patient-safety concerns. Temple VA: no process to correct missed test-result notices due within seven days. 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.
Overview of Involuntary Mental Health Holds at VHA Facilities - Report 25-00867-171, November 12, 2026
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