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 Jonathan M. Wainwright Memorial VA Medical Center in Walla Walla, Washington. 

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

The OIG issued nine recommendations for VA to correct identified deficiencies in two domains:
   1.    Environment of care
     •    Signs and maps
     •    Emergency generator and fire door inspection and testing
     •    Environment of care committee meetings
     •    Mental Health Residential Rehabilitation Treatment Program area cleanliness
     •    Hands-free sanitizer dispensers
     •    Guidance for shelter-in-place supplies
   2.    Patient safety
     •    Service-level workflows for the communication of test results
     •    Process to monitor the communication of test results
     •    Improvement actions from root cause analyses

The audit objectives were to determine whether program funds were managed in accordance with the ARC and Federal grant requirements.

Why We Did This Report

The Inspector General Act of 1978, as amended, requires each inspector general to prepare semiannual reports for Congress. As part of that reporting, the inspector general must identify all recommendations from the prior reporting period for which corrective actions have not been completed by the agency, as well as any management decisions with respect to audit, inspection, or evaluation reports issued during that prior reporting period.

Summary of Findings

For this compendium, we compiled recommendations that we had reported as resolved in the semiannual report to Congress that we issued on May 30, 2025. These 80 recommendations were originally issued to the EPA over a span of more than 15 years, from fiscal year 2008 through fiscal year 2024. As of May 31, 2025, 78 of those recommendations remained open, representing $43.3 million in potential cost savings. Of these 78 recommendations, 43 recommendations, with $33.3 million in potential cost savings, remained open after three years or will be older than three years by their expected completion dates. Additionally, 15 recommendations that were issued in reports between July 2022 and May 31, 2025, remain unresolved. We also identified 13 recommendations, 12 resolved and one unresolved, with potential monetary benefits of nearly $865.8 million, that we deem as high priority.

The OIG conducted this review after receiving a hotline allegation that the 2024 emergency department expansion and renovation at the Audie L. Murphy Memorial Veterans’ Hospital in San Antonio, Texas, did not meet standards. Some exam rooms were said to put patients at risk because the rooms were not equipped for urgent care.

The OIG confirmed the allegation. Fast-track exam rooms, used to quickly assess and treat patients with minor injuries or illnesses, did not have permanent medical air, oxygen, and vacuum outlets, nor did all the rooms have acceptable exam lights. In addition, in one room the contractor failed to install the required plumbing for permanent medical air, oxygen, and vacuum lines. The deficiencies occurred in part because the VHA directive guiding minor construction projects did not incorporate the legal requirement that the director of the Office of Construction and Facilities Management (CFM) manage and oversee the project. Other factors included the contractor’s use of the wrong template to design fast-track rooms and the project engineer’s approval of the room that lacked required plumbing.

When fast-track rooms and procedural and general exam rooms lack the necessary equipment for emergency care, patient care may be delayed while healthcare professionals locate portable equipment. VA officials agreed with the OIG’s four recommendations to ensure processes and guidance are in place for the CFM to provide appropriate oversight and management over minor construction projects, revise the VHA directive on minor construction projects to incorporate legal requirements, review emergency department exam and fast-track rooms for compliance with standards, and review a CFM assessment of emergency department for compliance with design and equipment requirements.

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 Jackson Healthcare System in Mississippi. This evaluation focused on five key content domains:
•    Culture
•    Environment of care
•    Patient safety
•    Primary care
•    Veteran-centered safety net
The OIG issued one recommendation for VA to correct an identified deficiency in one domain:
1.    Primary care
•    Panel size accuracy