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Report File
Date Issued
Submitting OIG
Department of Veterans Affairs OIG
Agencies Reviewed/Investigated
Department of Veterans Affairs
Components
Veterans Health Administration
Report Number
24-00551-64
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 Washington DC Healthcare System. 

This evaluation focused on five key content domains:
   •    Culture
   •    Environment of care
   •    Patient safety
   •    Primary care
   •    Veteran-centered safety net

The OIG issued four recommendations for improvement in two domains:
 1.    Environment of care
   •    Crosswalk visibility and pedestrian safety
   •    Blanket warmer temperature
   •    Electrical issue
 2.    Patient safety
   •    Identifying adverse events that warrant institutional disclosures

Report Type
Inspection / Evaluation
Location

DC
United States

MD
United States

VA
United States

Number of Recommendations
4
Questioned Costs
$0
Funds for Better Use
$0
Report updated under NDAA 5274
No
External Link
https://www.vaoig.gov/reports/healthcare-facility-inspection/healthcare-facilit…

Open Recommendations

This report has 3 open recommendations.
Recommendation Number Significant Recommendation Recommended Questioned Costs Recommended Funds for Better Use Additional Details
01 No $0 $0

The OIG recommends facility leaders improve crosswalk visibility and monitor pedestrian safety at the crosswalk between the patient parking garage and main entrance until completion.

02 No $0 $0

The OIG recommends facility leaders ensure blanket warmer temperatures do not exceed 130 degrees Fahrenheit and implement a process to inform staff about proper use of the equipment.

04 No $0 $0

The OIG recommends facility leaders reevaluate and improve their processes for identifying adverse events that warrant an institutional disclosure.

Department of Veterans Affairs OIG

United States