Healthcare Facility Inspection of the VA Sierra Nevada Health Care System in Reno

Report Information

Issue Date
Report Number
25-00243-56
VISN
21
State
California
Nevada
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Healthcare Facility Inspection
Report Topic
Patient Safety
Supplies and Equipment
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 VA Sierra Nevada Health Care System in Reno. 

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

The OIG issued two recommendations for VA to correct identified deficiencies in two domains:
   1.    Environment of care
     •    Medical equipment storage
   2.    Patient safety
     •    Service-level workflows for test result communication

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 Medical Center Director ensures staff properly store clean medical equipment.

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

Facility leaders develop written workflows for each service to ensure timely communication of test results to providers and patients.