Comprehensive Healthcare Inspection of the Southern Arizona VA Health Care System in Tucson

Report Information

Issue Date
Closure Date
Report Number
22-00054-158
VISN
1
State
Arizona
District
Continental
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
6
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 inpatient and outpatient care provided at the Southern Arizona VA Health Care System, which includes the Tucson VA Medical Center and multiple outpatient clinics in Arizona. This evaluation focused on five key operational areas: • Leadership and organizational risks • Quality, safety, and value • Medical staff privileging • Environment of care • Mental health (emergency department and urgent care center suicide prevention initiatives) The OIG issued six recommendations for improvement in three areas: 1. Leadership and organizational risks • Sentinel events and institutional disclosures 2. Environment of care • Inspection frequency and documentation • Inspection deficiency tracking • Infectious materials signage • Environmental safety and cleanliness 3. Mental health • Patient follow-up for suicide risk

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)
Closure Date: 5/2/2024

The Director evaluates and determines any additional reasons for noncompliance and ensures leaders evaluate sentinel events and conduct institutional disclosures when criteria are met.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2024

The Director determines any additional reasons for noncompliance and ensures the Comprehensive Environment of Care Coordinator or designee schedules and ensures staff complete environment of care inspections in patient care areas at the required frequency and document the inspection results.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/2/2023
The Director determines any additional reasons for noncompliance and ensures the Comprehensive Environment of Care Coordinator or designee tracks environment of care inspection deficiencies until they are resolved.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/2/2023
The Director determines any additional reasons for noncompliance and ensures staff post signage in all areas where potentially infectious materials are present.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2024

The Director evaluates and determines any additional reasons for noncompliance and ensures staff keep patient care areas clean and furnishings and equipment safe and in good repair.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2024

The Director evaluates and determines additional reasons for noncompliance and ensures staff conduct timely follow-up for intermediate, high-acute, or chronic risk-for-suicide patients who are discharged home from the Emergency Department.