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.