Comprehensive Healthcare Inspection of the VA Palo Alto Health Care System in California

Report Information

Issue Date
Closure Date
Report Number
22-00064-172
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
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 inpatient and outpatient care provided at the VA Palo Alto Health Care System, which includes medical centers in Palo Alto, Menlo Park, and Livermore 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 suicide prevention initiatives) The OIG issued four recommendations for improvement in two areas: 1. Leadership and Organizational Risks • Institutional disclosures for sentinel events 2. Environment of Care • Preventive maintenance on medical equipment • Access to medications only by authorized staff • Clean and safe environment

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: 1/2/2024

The System Director evaluates and determines any additional 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)
Closure Date: 6/27/2024

The System Director determines any additional reasons for noncompliance and ensures staff conduct required preventive maintenance on medical equipment.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/27/2024

The Chief of Staff determines the reasons for noncompliance and ensures only authorized staff have access to medications.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/26/2024

The System Director determines any additional reasons for noncompliance and ensures leaders maintain a clean and safe environment.