Healthcare Facility Inspection of the VA San Diego Healthcare System in California

Report Information

Issue Date
Report Number
25-00253-156
VISN
22
State
California
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Healthcare Facility Inspection
Report Topic
Patient Care Services Operations
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 San Diego Healthcare System in California.

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:

1. Environment of care 
     •    Separation of soiled and clean equipment 
     •    Ice machine cleanliness 
     •    Properly labeled and stored oxygen tanks

2. Patient safety 
     •    Facility policy for the communication of test results
 

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: 7/16/2026

Facility leaders ensure staff follow procedures to properly separate and store soiled and clean equipment.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2026

Facility leaders ensure environmental management services staff clean ice machines daily to help prevent infection risk.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2026

Facility leaders ensure staff properly label and store oxygen tanks.

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

Facility leaders ensure staff update the facility policy to include all elements to communicate test results to patients, as required in Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.