Healthcare Facility Inspection of the VA Central California Health Care System in Fresno

Report Information

Issue Date
Report Number
25-00214-61
VISN
21
State
California
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Healthcare Facility Inspection
Report Topic
Information Technology and Security
Patient Care Services Operations
Staffing
Supplies and Equipment
Major Management Challenges
Healthcare Services
Recommendations
7
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 Healthcare Facility Inspection of the VA Central California Health Care System in Fresno. 

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

The OIG issued seven recommendations for VA to correct identified deficiencies in three domains:
   1.    Environment of care
     •    Badge holder responsibilities
     •    Signs
     •    Privacy curtains, preventive equipment maintenance, splash resistant bottom shelves
     •    Expired, damaged, and contaminated medications
     •    Pharmaceutical grade medication refrigerators
   2.    Primary care
     •    Staffing
   3.    Veteran-centered safety net
     •    Housing and Urban Development–Veterans Affairs Supportive Housing program staffing

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)

The Executive Director ensures staff receive education about badge holders’ responsibilities in preventing unauthorized access to VA facilities and computer systems and safeguarding electronic databases including electronic health care records.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2026

The Executive Director ensures signs are present and accurate throughout the facility.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2026

The Executive Director ensures staff maintain privacy curtains, preventive maintenance on medical equipment, and splash resistant bottom shelves on supply carts.

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

The Executive Director ensures staff monitor patient care areas for expired, damaged, and contaminated medications and remove them as needed.

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

The Executive Director ensures staff store medications in pharmaceutical grade refrigerators.

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

The Executive Director ensures primary care staffing is sufficient for patients to receive appropriate health care.

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

The Executive Director reviews staffing levels for the Housing and Urban Development–Veterans Affairs Supportive Housing program and takes action as needed.