Healthcare Facility Inspection of the VA Asheville Health Care System in North Carolina

Report Information

Issue Date
Report Number
25-04052-222
VISN
2
State
North Carolina
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Healthcare Facility Inspection
Report Topic
Maintenance and Construction
Patient Safety
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) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Asheville Health Care System in North Carolina.

This evaluation focused on five key domains: 
     •    Culture 
     •    Environment of care 
     •    Patient safety 
     •    Integrated veteran care 
     •    Veteran-centered safety net

The OIG made four recommendations for VA to correct identified issues in two domains: 
     •    Environment of care 
       o    Clean and safe eyewash stations 
       o    Unobstructed walkways and exit routes 
     •    Patient safety 
       o    Written policy for test result communications 
       o    Service-level workflows for test result communications
 

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)

Facility leaders implement measures to keep all eyewash stations clean and safe for emergency use.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Facility leaders implement measures to keep walkways free of obstructions to maintain clear exit routes.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2026

The Director updates the facility’s written policy for test result communications to comply with requirements in Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2026

The Chief of Staff and Associate Director of Patient Care Services/Nurse Executive develop and implement written workflows for each service that comply with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.