Healthcare Facility Inspection of the VA Mountain Home Healthcare System in Tennessee

Report Information

Issue Date
Closure Date
Report Number
25-04252-256
VISN
3
State
Tennessee
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Healthcare Facility Inspection
Report Topic
Care Coordination
Community Care
Patient Care Services Operations
Patient Safety
Staffing
Major Management Challenges
Healthcare Services
Recommendations
1
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 Mountain Home Healthcare System in Tennessee.

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

The OIG made one recommendation for VA to correct identified issues in one domain: 
     •    Patient safety 
       o    Service-level workflows for communicating 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: 8/28/2026

Facility leaders take appropriate actions so staff develop a written workflow for each service that is consistent with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.