Federal Reports

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 Dublin Healthcare System in Georgia. 

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

The OIG issued eight recommendations for improvement in three domains:
 1.    Environment of care
   •    Navigational signage
   •    Toxic exposure program oversight and screening navigator roles and responsibilities
   •    Clean and safe patient care areas
   •    Biohazard storage area contents, signage, and hand-washing supplies and equipment
   •    Environment of care trends, performance improvement plans, and outcome measures
 2.    Patient safety
   •    Ordering providers communicate and document test results
   •    Facility-level policies and standard operating procedures comply with VHA requirements
 3.    Veteran-centered safety net
   •    Homeless program staff have appropriate vehicles

The VA Office of Inspector General (OIG) conducted a healthcare inspection to determine how surgical instruments that were not suitable for service (nonconforming instruments) were used during a patient procedure at the Carl Vinson VA Medical Center (facility) in Dublin, Georgia. The OIG identified Sterile Processing Service (SPS)-related deficiencies as well as a continuation of previously identified deficiencies.

The OIG determined that SPS and operating room staff failed to remove nonconforming surgical instruments from a rectal tray that was used during a patient procedure. Moreover, the OIG found additional surgical instruments in nonconforming condition and that, contrary to policy, the reprocessing and use of nonconforming instruments was a permitted practice at the facility.

Additionally, facility leaders failed to establish a preventative maintenance program for the sharpening, repair, or replacement of surgical instruments prior to May 30, 2024.

The OIG also identified a continuation of previously identified deficiencies that included: the failure of facility leaders to fully implement an electronic surgical instrument tracking system known as CensiTrac, address concerns of the CensiTrac coordinator’s performance, and resolve concerns related to the intended use of an SPS conference and training room. Frequent changes in staff assigned to leadership positions, along with leaders’ failures identified above, likely contributed to the continued SPS deficiencies.

The OIG made two recommendations to the Facility Director related to ensuring staff’s compliance with identification and disposition of nonconforming surgical instruments and training operating room staff to recognize nonconforming surgical instruments. The OIG made three recommendations to the Veterans Integrated Service Network Director related to reviewing patients potentially affected by nonconforming instruments, evaluating whether administrative action is warranted for individuals regarding SPS deficiencies at the facility, and performing oversight of the facility’s implementation of facility-level action plans and sustainability of identified outcomes. 

We contracted with Williams, Adley & Company-DC, LLP (Williams Adley) to examine the effectiveness of the CFTC’s ERM process as well as its maturity. Williams Adley conducted the audit in accordance with Generally Accepted Government Auditing Standards (GAGAS) and is responsible for the attached audit report and the conclusions expressed therein.1 The OIG monitored the auditor’s progress throughout the performance audit and reviewed the respective audit report and related documentation.

The Veterans Health Administration (VHA) Grant and Per Diem (GPD) program funds community-based transitional housing for veterans experiencing homelessness. An OIG administrative investigation examined VHA’s oversight of the Veterans Village of San Diego (VVSD), a GPD program grantee providing drug treatment and other services. 

The OIG found that staff at the VA San Diego Healthcare System (the VA facility) responsible for local oversight of VVSD were aware that in 2021 and through most of 2022, issues with drug sales by non-VA residents, drug use, and insufficient staffing increased risks to veterans co-located there. However, VA facility staff did not take timely or effective action to ensure VVSD remediated these issues. Local facility staff lacked important information related to residents at VVSD who were funded by non-VA entities. Also, a regional official responsible for GPD oversight did not provide adequate support. Finally, the OIG found that the GPD National Program Office could have provided clearer guidance on key issues, such as when certain grantee enforcement measures should be used and how to redress recurrent grant noncompliance issues.

The OIG followed up the initial investigation with a limited review of VHA oversight of VVSD through September 2024, prompted in part by reports that improvements may not have taken hold. The investigation revealed that issues related to veteran care and safety, and a lack of information about co-located non-VA residents, recurred or persisted at VVSD. 

VHA concurred with the OIG’s finding and five recommendations to improve governing policies, training, or other guidance, and appropriate follow-up for GPD-funded residents at VVSD who lost access to drug treatment services there. VHA provided acceptable action plans and completion timelines. The OIG will monitor VA’s progress until sufficient documentation has been received to close the recommendations as implemented.