Comprehensive Healthcare Inspection of the VA Greater Los Angeles Healthcare System, California

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the VA Greater Los Angeles Healthcare System, covering leadership, organizational risks, and key processes associated with promoting quality care. Focused areas were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. The facility did not have a stable leadership team. Upon review of the facility’s accreditation findings, sentinel events, and disclosures, the OIG did not identify any substantial organizational risks. However, the OIG had concerns regarding the facility’s 17 percent staff vacancies and the multiple deficiencies in the controlled substances inspections program. The OIG noted that leaders need to improve employee satisfaction and trust and patient experiences. The leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics and should continue to take actions to sustain and improve performance contributing to the facility SAIL “3-star,” Sepulveda’s CLC “5-star,” and West Los Angeles’ CLC “4-star” quality ratings. The OIG issued 25 recommendations for improvement: (1) Quality, Safety, and Value • Peer review and utilization management review processes (2) Environment of Care • Medication and environmental safety • Protection of patient information • Mental health unit panic alarm testing and bathroom faucet safety (3) Controlled Substances Inspections • Controlled substances coordinator’s reports and program oversight • Controlled substances inspectors’ appointments, competencies, and requirements • Monthly controlled substances areas and pharmacy requirements • Pharmacy operations • Override reports review (4) Antidepressant Use among the Elderly • Patient/caregiver education • Medication reconciliation (5) Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee requirements