This Office of Inspector General Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the VA Northern California Health Care System, which includes the Sacramento VA Medical Center, Martinez VA Medical Center, an outpatient clinic at Travis Air Force Base, and other outpatient clinics in California. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (emergency department and urgent care center suicide prevention initiatives)The OIG issued seven recommendations for improvement in three areas:1. Medical Staff Privileging• Evaluation result documentation and reporting• Reprivileging recommendations based on service-specific Ongoing Professional Practice Evaluation data2. Environment of Care• Panic and over-the-door alarm testing in the inpatient mental health unit• Cleanliness, furnishings, and equipment• Properly stored and secured medications3. Mental Health• Timely follow-up for patients at risk for suicide discharged from the Emergency Department
| Report Date | Agency Reviewed / Investigated | Report Title | Type | Location | |
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| Department of Veterans Affairs | Comprehensive Healthcare Inspection of the VA Northern California Health Care System in Mather | Review |
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| Internal Revenue Service | Key Events of the IRS’s Planning Efforts to Implement Login.gov for Taxpayer Identity Verification | Audit | Agency-Wide | View Report | |
| Internal Revenue Service | The Enterprise Physical Access Control System Implementation and Physical Security Controls Need Improvement | Audit | Agency-Wide | View Report | |
| Department of Agriculture | COVID 19 - ReConnect Program | Other | Agency-Wide | View Report | |
| Department of Agriculture | Broadband: A Data Stroll | Other | Agency-Wide | View Report | |
| Department of Agriculture | Final Action Verification—Multi-Family Housing Tenant Eligibility | Other | Agency-Wide | View Report | |
| Department of State | OIG’s Review of the Department of State’s Evacuation of U.S. Embassy Kabul, Afghanistan | Audit | Agency-Wide | View Report | |
| Corporation for Public Broadcasting | Evaluation of KDHX-FM, Double Helix Corporation, Compliance with Selected Communications Act and General Provisions Diversity and Transparency Requirements, Report No. ECR2314-2315 | Inspection / Evaluation |
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| Board of Governors of the Federal Reserve System | Review of the Supervision of Silvergate Bank | Inspection / Evaluation | Agency-Wide | View Report | |
| Department of Labor | OSHA Needs to Do More to Address High Injury Rates of Warehouse Workers | Audit | Agency-Wide | View Report | |