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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
24-00595-93
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
8
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 6 open recommendations.
Recommendation Number Significant Recommendation Recommended Questioned Costs Recommended Funds for Better Use Additional Details
01 No $0 $0

Executive leaders evaluate the toxic exposure screening process and develop a sustainable action plan to ensure staff complete secondary screenings.

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.

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.

Department of Veterans Affairs OIG

United States