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Comprehensive Healthcare Inspection of the Columbia VA Health Care System in South Carolina

Report Information

Issue Date
Report Number
23-00009-57
VISN
7
State
South Carolina
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Mental Health
Patient Safety
Suicide Prevention
Major Management Challenges
Healthcare Services
Recommendations
4
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the Columbia VA Health Care System in South Carolina. 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 suicide prevention initiatives)

The OIG issued four recommendations for improvement in two areas:
1.    Environment of care
•    Responding to utility system disruptions
•    Safe and secure environment
2.    Mental health
•    Comprehensive Suicide Risk Evaluations
•    Reporting suicidal behaviors

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

The Director ensures staff have written procedures for responding to utility system disruptions.

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

The Director ensures staff identify, minimize, or eliminate safety and security risks in the physical environment.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures designated staff complete the Comprehensive Suicide Risk Evaluation the same calendar day, when logistically feasible and clinically appropriate, for all ambulatory care patients with a positive suicide risk screen.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures clinical staff notify the suicide prevention team when patients report suicidal behaviors during the Comprehensive Suicide Risk Evaluation.