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Healthcare Facility Inspection of the VA Eastern Colorado Health Care System in Aurora

Report Information

Issue Date
Report Number
25-00200-48
VISN
19
State
Colorado
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Healthcare Facility Inspection
Report Topic
Community Care
Patient Safety
Staffing
Supplies and Equipment
Major Management Challenges
Healthcare Services
Recommendations
10
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 Eastern Colorado Health Care System in Aurora. 

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

The OIG issued 10 recommendations for VA to correct identified deficiencies in three domains:
   1.    Environment of care
     •    Liquid nitrogen storage
     •    Expired supplies
     •    Multidose medication labels
     •    Clean and dirty storage
     •    Repeat findings
   2.    Patient safety
     •    Test result communication policy and workflows
     •    Radiology staffing
     •    Community care imaging results
     •    Root cause analyses
   3.    Primary care
     •    Staffing and panel sizes

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 direct staff to conduct a risk assessment on liquid nitrogen storage, to include the small devices stored in examination rooms, and implement changes if needed.

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

Facility leaders determine appropriate supply storage locations and, for any supplies stored outside of the defined locations, implement a process to ensure staff identify and remove expired supplies.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Facility leaders ensure staff label opened multidose medications with expiration dates.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Facility leaders ensure staff store clean and dirty items separately.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures staff implement processes to prevent repeat environment of care findings.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The OIG recommends facility leaders ensure the facility has a policy for the communication of test results and staff develop service-level workflows that align with VHA requirements.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Veterans Integrated Service Network 19 leaders assess the staffing needs for the facility’s radiology service and provide additional resources to ensure services are readily available to patients.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Veterans Integrated Service Network 19 leaders evaluate the reasons for delays in uploading images and reporting test results and assist the facility’s community care leaders to mitigate future delays.

No. 9
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Executive leaders monitor root cause analysis improvement actions through completion, monitor outcome measures, and ensure staff implement processes to sustain the improvements.

No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2026

Facility leaders attain appropriate primary care staffing and manageable panel sizes to ensure patients have timely access to high-quality care.