Report Summary

Title: Combined Assessment Program Review of the VA Central California Health Care System, Fresno, California
Report Link: http://www.va.gov/oig/pubs/VAOIG-13-01975-292.pdf
Report Number: 13-01975-292
Issue Date: 8/27/2013
City/State: Fresno, CA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CAP Reviews
Release Type: Unrestricted
Summary: The purpose of the review was to evaluate selected health care facility operations, focusing on patient care quality and the environment of care. During the review, OIG provided crime awareness briefings to 249 employees. This review focused on seven operational activities. The facility’s reported accomplishments were the Systems Redesign collaborative, a safety program, and an end-of-life program. OIG made recommendations for improvement in all seven of the following activities: (1) quality management, (2) environment of care, (3) medication management – controlled substances inspections, (4) coordination of care – hospice and palliative care, (5) pressure ulcer prevention and management, (6) nurse staffing, and (7) construction safety.