Comprehensive Healthcare Inspection Summary Report: Evaluation of High-Risk Processes in Veterans Health Administration Facilities, Fiscal Year 2021

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report highlights the results of a focused evaluation of VHA facilities’ high-risk processes. The report describes findings from healthcare inspections performed at 45 medical facilities during fiscal year 2021 that focused on selected management of disruptive and violent behavior requirements. Each inspection involved interviews with key staff and reviews of clinical and administrative processes.The OIG found general compliance with many of the selected requirements. However, the OIG identified weaknesses with and issued three recommendations related to• required members’ attendance at disruptive behavior committee or board meetings,• patient notification of Orders of Behavioral Restriction, and• completion of required training.