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Report File
Date Issued
Submitting OIG
Department of Veterans Affairs OIG
Other Participating OIGs
Department of Veterans Affairs OIG
Agencies Reviewed/Investigated
Department of Veterans Affairs
Components
Veterans Health Administration
Report Number
23-00097-113
Report Description

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Black Hills Health Care System, which includes the Fort Meade and Hot Springs VA Medical Centers and multiple outpatient clinics in Nebraska, North Dakota, South Dakota, and Wyoming. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued four recommendations for improvement in three areas:1. Medical staff privileging• Completion of Ongoing Professional Practice Evaluations• Review of Ongoing Professional Practice Evaluation data and documents2. Environment of care• Completion of environment of care inspections3. Mental health• Completion of Comprehensive Suicide Risk Evaluations

Report Type
Inspection / Evaluation
Location

ND
United States

NE
United States

SD
United States

WY
United States

Number of Recommendations
2
Questioned Costs
$0
Funds for Better Use
$0

Open Recommendations

This report has 2 open recommendations.
Recommendation Number Significant Recommendation Recommended Questioned Costs Recommended Funds for Better Use Additional Details
01 No $0 $0

The Chief of Staff ensures service chiefs regularly complete Ongoing Professional Practice Evaluations for each licensed independent practitioner.

04 No $0 $0

The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation the same calendar day as a patient’s positive suicide risk screen in all ambulatory care settings.

Department of Veterans Affairs OIG

United States