Comprehensive Healthcare Inspection of the VA Southern Nevada Healthcare System in North Las Vegas

Report Information

Issue Date
Closure Date
Report Number
22-00062-139
VISN
21
State
Nevada
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Medical Staff Privileging Credentialing
Patient Safety
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
3
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 Southern Nevada Healthcare System, which includes the North Las Vegas VA Medical Center and multiple outpatient clinics in Nevada. 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 suicide prevention initiatives) The OIG issued three recommendations for improvement in three areas: 1. Leadership and organizational risks • Institutional disclosures 2. Medical staff privileging • Ongoing Professional Practice Evaluations 3. Environment of care • Electrical receptacles and switches in compliance with applicable requirements

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: 1/29/2024

The Director evaluates and determines 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: 1/29/2024

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with similar training and privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/14/2023

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures electrical receptacles and switches in the mental health unit are covered by metal plates, secured by tamper-resistant screws, and receptacles are flush to the wall.