Healthcare Facility Inspection of the VA Boston Healthcare System in Massachusetts

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Date Issued

Thursday, July 10, 2025

Submitting OIG

Department of Veterans Affairs OIG

Agencies Reviewed/Investigated

Department of Veterans Affairs

Components

Veterans Health Administration

Report Number

24-00613-162

Report Description

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 Boston Healthcare System in Massachusetts.

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

The OIG issued 11 recommendations for improvement in two domains:
1.    Environment of care
•    Processes to prevent repeat findings
•    Biological hazard signs
•    Safe and clean patient care areas
•    Medication storage areas
o    Restricted access
o    Pharmacy staff inspections
o    Temperature and humidity
•    Urgent Care Center operates according to VHA Directive 1101.13
•    Repeat findings and sustained improvements
•    Trends, performance improvement plans, and outcome measures
2.    Patient safety
•    Test result communication policy complies with VHA directives for critical test results

Report Type

Inspection / Evaluation

Location

Boston, MA
United States

Number of Recommendations

Questioned Costs

Funds for Better Use

Report updated under NDAA 5274

External Link

https://www.vaoig.gov/reports/healthcare-facility-inspection/healthcare-facilit…

Open Recommendations

This report has 10 open recommendations.

Recommendation Number	Significant Recommendation	Recommended Questioned Costs	Recommended Funds for Better Use
01	No	$0	$0
The OIG recommends the Director ensures staff have processes to prevent repeat environment of care findings.
02	No	$0	$0
The OIG recommends the Veterans Integrated Service Network 1 Director monitors for similar or repeated environment of care findings and ensures facility staff sustain improvements.
03	No	$0	$0
The OIG recommends the Veterans Integrated Service Network 1 Director ensures facility leaders identify environment of care trends and establish performance improvement plans with outcome measures to address them.
04	No	$0	$0
The OIG recommends the Director ensures staff post biological hazard signs on doors where potentially infectious materials may be present.
05	No	$0	$0
The OIG recommends the Director ensures staff keep patient care areas clean and safe.
06	No	$0	$0
The OIG recommends the Director ensures only authorized staff have access to medication storage areas.
07	No	$0	$0
The OIG recommends the Director ensures staff conduct an inventory of all the facility’s medication storage areas, and the Chief of Pharmacy approves them.
08	No	$0	$0
The OIG recommends the Chief of Pharmacy ensures pharmacy staff inspect each approved medication storage area monthly.
09	No	$0	$0
The OIG recommends the Director ensures staff monitor temperature and humidity in medication storage areas and track possible deviations, even those that may occur when the areas are closed.
11	No	$0	$0
The OIG recommends facility leaders review the local policy to ensure it complies with VHA directives specific to which staff receive notification of critical test results.