Healthcare Facility Inspection of the VA Western Colorado Healthcare System in Grand Junction

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Date Issued

Thursday, April 10, 2025

Submitting OIG

Department of Veterans Affairs OIG

Agencies Reviewed/Investigated

Department of Veterans Affairs

Components

Veterans Health Administration

Report Number

24-00595-93

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 Western Colorado Healthcare System in Grand Junction.

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

The OIG issued eight recommendations for improvement in two domains:
1.    Environment of care
•    Toxic exposure screenings
•    Fire extinguisher inspections
•    Preventive maintenance inspections
•    Wheelchair disinfection, ceiling vent dust removal, and wall repair
•    Equipment and supply access and storage
•    Video monitoring
•    Veterans Integrated Service Network oversight of the environment of care program
2.    Patient Safety
•    Patient test result notification process

Report Type

Inspection / Evaluation

Location

CO
United States

UT
United States

WY
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 8 open recommendations.

Recommendation Number	Significant Recommendation	Recommended Questioned Costs	Recommended Funds for Better Use
01	No	$0	$0
Executive leaders evaluate the toxic exposure screening process and develop a sustainable action plan to ensure staff complete secondary screenings.
02	No	$0	$0
Executive leaders ensure facility staff conduct all required monthly and annual fire extinguisher inspections, document the completion date and results, and report compliance rates to the Comprehensive Environment of Care Committee.
03	No	$0	$0
Executive leaders ensure facility staff complete preventive maintenance inspections for all medical equipment.
04	No	$0	$0
Executive leaders ensure facility staff develop and implement processes to properly disinfect wheelchairs, remove dust from ceiling vents, and repair walls.
05	No	$0	$0
Executive leaders ensure facility staff keep clean and dirty equipment and supplies separated in storage areas and ensure staff can access medical equipment when needed.
06	No	$0	$0
Executive leaders ensure facility staff use video monitors for patient safety purposes only and limit them to staff directly involved in the patients care.
07	No	$0	$0
Veterans Integrated Service Network leaders ensure facility executive leaders provide effective oversight of the environment of care program.
08	No	$0	$0
Executive leaders ensure quality management staff implement a system-wide process to monitor the effectiveness of patient notification of all urgent, noncritical test results.