OIG Seal
Department of Veterans Affairs, Office of Inspector General
Michael J. Missal, Inspector General

Report Summary

Title: Combined Assessment Program Review of the San Francisco VA Medical Center, San Francisco, California
Report Number: 12-04192-97 Download
Issue Date: 1/29/2013
City/State: San Francisco, CA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CAP Reviews
Release Type: Unrestricted

The purpose of the review was to evaluate selected health care facility operations, focusing on patient care quality and the environment of care. This review focused on seven operational activities. The facility complied with selected standards in the following two activities (1) medication management – controlled substances inspections and (2) preventable pulmonary embolism. The facility’s reported accomplishments were the telehealth program and a redesigned systems improvement process. OIG made recommendations for improvement in the following five activities: (1) quality management, (2) environment of care, (3) coordination of care – hospice and palliative care, (4) long-term home oxygen therapy, and (5) nurse staffing.