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Report File
Date Issued
Submitting OIG
Department of Veterans Affairs OIG
Agencies Reviewed/Investigated
Department of Veterans Affairs
Components
Veterans Health Administration
Report Number
24-00592-60
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 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

Report Type
Inspection / Evaluation
Location

GA
United States

Number of Recommendations
8
Questioned Costs
$0
Funds for Better Use
$0
Report updated under NDAA 5274
No

Open Recommendations

This report has 7 open recommendations.
Recommendation Number Significant Recommendation Recommended Questioned Costs Recommended Funds for Better Use Additional Details
02 No $0 $0

The OIG recommends facility leaders define and assign roles and responsibilities to toxic
exposure screening navigators and ensure program oversight.

03 No $0 $0

The OIG recommends the Director ensures staff keep patient care areas safe and clean.

04 No $0 $0

The OIG recommends the Director ensures biohazard storage areas display proper signage, have appropriate hand-washing supplies and equipment available, and do not contain housekeeping supplies.

05 No $0 $0

The OIG recommends the Associate Director ensures staff identify one or more facility environment of care trends and establish a performance improvement plan, including outcome measures, to address them.

06 No $0 $0

The OIG recommends that facility leaders continue to develop and implement administrative processes to ensure ordering providers promptly communicate and document test results.

07 No $0 $0

The OIG recommends that facility leaders ensure staff maintain and reference current VHA requirements and update facility-level policies and standard operating procedures to comply with them.

08 No $0 $0

The OIG recommends facility leaders ensure homeless program staff have access to appropriate vehicles to conduct their work.

Department of Veterans Affairs OIG

United States