Comprehensive Healthcare Inspection of the Royal C. Johnson Veterans' Memorial Hospital in Sioux Falls, South Dakota

Report Information

Issue Date
Report Number
South Dakota
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Questioned Costs
Better Use of Funds
Congressionally Mandated



This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the Royal C. Johnson Veterans’ Memorial Hospital in Sioux Falls and multiple outpatient clinics in Iowa and South Dakota.

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 one recommendation for improvement in the mental health review area regarding completing Comprehensive 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 Chief of Staff ensures designated staff complete a 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.