Comprehensive Healthcare Inspection of the VA Central California Health Care System in Fresno

Report Information

Issue Date
Report Number
22-00059-157
VISN
1
State
California
District
Continental
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
2
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This Office of Inspector General Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the VA Central California Health Care System in Fresno, which includes the Fresno VA Medical Center and multiple outpatient clinics in California. This evaluation focused on five key operational areas: • Leadership and organizational risks • Quality, safety, and value • Medical staff privileging • Environment of care • Mental health (focusing on emergency department and urgent care center prevention initiatives) The OIG issued two recommendations for improvement in two areas: 1. Leadership and organizational risks • Institutional disclosures 2. Mental health • Suicide risk evaluations

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines reasons for noncompliance and ensures leaders conduct institutional disclosures for all applicable sentinel events.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines reasons for noncompliance and ensures clinicians complete the Comprehensive Suicide Risk Evaluation following a positive suicide risk screen.