Healthcare Facility Inspection of the VA Sioux Falls Health Care System in South Dakota

Report Information

Issue Date
Report Number
24-03420-18
VISN
23
State
Iowa
Minnesota
Nebraska
South Dakota
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Healthcare Facility Inspection
Report Topic
Maintenance and Construction
Patient Care Services Operations
Patient Safety
Major Management Challenges
Healthcare Services
Recommendations
5
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 Sioux Falls Health Care System in South Dakota. 

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

The OIG issued five recommendations for VA to correct identified deficiencies in two domains:
   1.    Environment of care
     •    Safety risk assessment permits
     •    Construction Safety Committee chair
     •    Privacy curtains in exam rooms
     •    Handrails in Community Living Center hallway
   2.    Patient safety
     •    Communication of abnormal test results

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)

Executive leaders ensure staff post safety risk assessment permits for all construction projects.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2025

The Director assigns a member of the executive leadership team as chair of the Construction Safety Committee to oversee safety activities.

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

Executive leaders ensure staff install privacy curtains in all exam rooms.

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

Executive leaders ensure staff install handrails on both sides of the hallway in the Community Living Center.

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

Executive leaders ensure staff follow the facility’s policy for communication of abnormal test results to patients.