Healthcare Facility Inspection of the Central Arkansas Veterans Healthcare System in Little Rock

Report Information

Issue Date
Report Number
25-00203-180
VISN
4
State
Arkansas
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Healthcare Facility Inspection
Report Topic
Appointment Scheduling and Wait Times
Care Coordination
Community Care
Healthcare Infrastructure
Maintenance and Construction
Patient Care Services Operations
Patient Safety
Staffing
Supplies and Equipment
Major Management Challenges
Healthcare Services
Recommendations
3
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 Central Arkansas Veterans Healthcare System in Little Rock.

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

The OIG made three recommendations for VA to correct identified issues in one domain: 
     •    Environment of care 
       o    Temperature and humidity monitoring 
       o    Liquid nitrogen tank storage and access to exits 
       o    Prevention of repeat findings
 

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: 9/30/2026

The Director takes appropriate action so staff conduct a risk assessment to identify areas that need temperature and humidity monitoring and implement changes accordingly to comply with Veterans Health Administration Directive 1761, Supply Chain Management Operations.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2026

The Director takes appropriate action so staff secure liquid nitrogen tanks, maintain unobstructed access to exits, conduct a risk assessment on safe liquid nitrogen storage options to increase safety, and implement changes accordingly to align with the National Fire Protection Association’s Compressed Gases and Cryogenic Fluids Code NFPA 55, Health Care Facilities Code NFPA 99, and Code of Federal Regulations title 29, section 1926.34.

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

The Director takes appropriate action so staff improve processes to prevent repeat environment of care findings as required by Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.