Healthcare Facility Inspection of the VA Central Alabama Health Care System in Montgomery

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Date Issued

Wednesday, January 28, 2026

Submitting OIG

Department of Veterans Affairs OIG

Agencies Reviewed/Investigated

Department of Veterans Affairs

Components

Veterans Health Administration

Report Number

24-03419-34

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 Central Alabama Health Care System in Montgomery.

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

The OIG issued 15 recommendations for VA to correct identified deficiencies in three domains:
1.    Environment of care
•    Detectable warning surfaces
•    Training for toxic exposure screenings
•    Repeat findings
•    Biohazardous material storage
•    Clean and safe environment
2.    Patient safety
•    Communication of test results
•    Peer Review Committee attendance
•    Sentinel events and institutional disclosures
•    Action plan tracking
•    Medical emergency roles and responsibilities
•    Emergency response policy
•    Basic life support certification
3.    Primary care
•    Patients assigned to primary care teams

Report Type

Inspection / Evaluation

Location

AL
United States

GA
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 14 open recommendations.

Recommendation Number	Significant Recommendation	Recommended Questioned Costs	Recommended Funds for Better Use
01	No	$0	$0
Facility leaders install detectable warning surfaces where crosswalks transition onto a vehicle roadway.
02	No	$0	$0
Facility leaders ensure clinical staff who perform toxic exposure screenings complete mandatory training.
03	No	$0	$0
The Director ensures staff implement processes to prevent repeat environment of care findings related to dusty sprinkler heads.
04	No	$0	$0
Facility leaders evaluate all areas where biohazardous materials are located to ensure staff store clean and dirty items separately.
05	No	$0	$0
The Director ensures staff keep the environment clean and safe.
06	No	$0	$0
Facility leaders ensure their policy aligns with VHA Directive 1088(1) and develop workflows for all services that communicate test results to patients.
07	No	$0	$0
The Chief of Staff and Associate Director for Patient Care Services ensure corrective actions address unfavorable trends in communication of test result data.
08	No	$0	$0
The Director ensures the Chief of Staff chairs and attends the Peer Review Committee meetings as required by VHA.
09	No	$0	$0
The Director ensures patient safety managers identify adverse events as sentinel events when they meet criteria.
10	No	$0	$0
Facility leaders evaluate and improve processes to identify adverse events that warrant an institutional disclosure.
11	No	$0	$0
The Director implements processes to ensure staff track action plans until they are completed and report to leaders those that are outstanding.
13	No	$0	$0
The Director ensures leaders revise the emergency response policy based on recertification time frames in VHA Directive 0999(1) or sooner, if warranted.
14	No	$0	$0
Facility leaders ensure all applicable staff maintain basic life support certification and take appropriate action for those staff without it.
15	No	$0	$0
The Director ensures facility leaders manage primary care teams’ panel sizes to support patients’ access to care.