Healthcare Facility Inspection of the Central Virginia VA Health Care System in Richmond

Report Information

Issue Date
Report Number
25-00213-242
VISN
2
State
Virginia
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
Patient Care Services Operations
Patient Safety
Staffing
Major Management Challenges
Healthcare Services
Recommendations
2
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 Virginia VA Health Care System in Richmond.

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

The OIG made two recommendations for VA to correct identified issues in one domain: 
     •    Patient safety 
       o    Facility’s policy for the communication of test results 
       o    Service-level workflows 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: 9/30/2026

The Director takes appropriate actions so leaders update the facility’s policy for communicating test results to include how providers communicate life-changing results to patients at high risk for suicide, as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

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

The Chief of Staff and Associate Director for Patient Care Services develop workflows that describe how each team member participates in the process to communicate test results, in accordance with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.