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

VA Office of Inspector General · Report 25-00213-242 · September 30, 2026 · Office of Healthcare Inspections

What the OIG found

The OIG performed a focused inspection of the Central Virginia VA Health Care System in Richmond, examining culture, environment of care, patient safety, primary care, and the veteran-centered safety net. The findings requiring correction were in patient safety and centered on communication of test results. The OIG made two recommendations: revise the facility’s test-result policy, including how providers communicate life-changing results to patients at high risk for suicide as VHA Directive 1088(1) requires, and establish service-level workflows for communicating test results.

Who it concerns

Central Virginia VA Health Care System in Richmond, Virginia

Why it matters to a family

How a life-changing test result is delivered matters enormously to a veteran and to the family who will help carry that news; this report found the Richmond facility’s policy did not fully cover communicating such results to patients at high risk for suicide.

The official report

The OIG’s report page · Full report (PDF)

Summary ours; the report is the OIG’s. Read it at vaoig.gov →