Healthcare Facility Inspection of the VA Louisville Healthcare System in Kentucky

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Date Issued

Friday, October 17, 2025

Submitting OIG

Department of Veterans Affairs OIG

Agencies Reviewed/Investigated

Department of Veterans Affairs

Components

Veterans Health Administration

Report Number

24-03205-235

Report Description

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Louisville Healthcare System in Kentucky. This evaluation focused on five key content domains:
•    Culture
•    Environment of care
•    Patient safety
•    Primary care
•    Veteran-centered safety net

The OIG issued 13 recommendations for VA to correct identified deficiencies in four domains:
1.    Culture
•    Telephone system improvements
2.    Environment of care
•    Exit signs
•    Detectable warning surfaces
•    Clean and safe patient care areas
•    Electrical cord management
•    Biological hazard signs
•    Biohazardous waste disposal
•    Liquid nitrogen use and storage
•    Environment of care trends, improvement plans, and outcome measures
3.    Patient safety
•    Service-level workflows for test result communications
•    Test result communication policy
•    Test result communication performance metrics
4.    Primary care
•    Panel sizes

Report Type

Inspection / Evaluation

Location

IN
United States

KY
United States

Number of Recommendations

Questioned Costs

Funds for Better Use

Report updated under NDAA 5274

External Link

https://www.vaoig.gov/reports/healthcare-facility-inspection/healthcare-facilit…

Open Recommendations

This report has 13 open recommendations.

Recommendation Number	Significant Recommendation	Recommended Questioned Costs	Recommended Funds for Better Use
01	No	$0	$0
The Executive Director oversees improvements to the telephone system to ensure identified vulnerabilities are addressed.
02	No	$0	$0
Facility leaders ensure exit signs lead to an exit.
03	No	$0	$0
Facility leaders install detectable warning surfaces anywhere a walkway transitions into a roadway.
04	No	$0	$0
The Executive Director ensures staff keep patient care areas clean and safe.
05	No	$0	$0
Facility leaders ensure staff conduct a risk assessment for electrical cord management to identify and implement any needed improvements.
06	No	$0	$0
The Executive Director ensures staff post biological hazard signs on doors where potentially infectious materials may be present and store clean and dirty items separately.
07	No	$0	$0
The Executive Director ensures prompt disposal of biohazardous waste.
08	No	$0	$0
Facility leaders ensure staff conduct a risk assessment on liquid nitrogen use and storage, to include devices in exam rooms, and implement changes accordingly.
09	No	$0	$0
The Executive Director ensures the Comprehensive Environment of Care Committee identifies at least one facility-specific environment of care trend and establishes a performance improvement plan, including outcome measures, to address it.
10	No	$0	$0
Facility leaders ensure staff develop service-level workflows for the communication of test results for each service.
11	No	$0	$0
Facility leaders review the test result communication policy to ensure it complies with the VHA requirement for communicating critical results outside of normal business hours.
12	No	$0	$0
Facility leaders develop a formal process for staff to track performance metrics for test result communication, implement improvement actions, and report compliance to an appropriate oversight committee.
13	No	$0	$0
Facility leaders manage panel sizes to ensure patients have timely access to high-quality care.