Healthcare Facility Inspection of the VA Atlanta Healthcare System in Decatur, Georgia

Report Information

Issue Date
Report Number
24-00606-137
VISN
7
State
Georgia
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Healthcare Facility Inspection
Report Topic
Appointment Scheduling and Wait Times
Care Coordination
Patient Care Services Operations
Patient Safety
Major Management Challenges
Healthcare Services
Recommendations
7
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

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 Atlanta Healthcare System in Decatur, Georgia. 

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

The OIG issued seven recommendations for improvement in five domains:
   1.    Culture
     •    Infrastructure issues
     •    Unanswered veteran phone calls
   2.    Environment of care
     •    Parking garage emergency call boxes
   3.    Patient safety
     •    Local test result policies and memorandums
     •    Institutional disclosures for adverse events
   4.    Primary care
     •    Panel sizes and access to care
   5.    Veteran-centered safety net
     •    Medical clearances for veterans in the Compensated Work Therapy program

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The OIG recommends facility leaders develop and implement a plan to resolve infrastructure issues that affect patient care.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The OIG recommends facility leaders develop and implement a plan to resolve veterans’ unanswered phone calls and inability to reach staff.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The OIG recommends facility leaders replace the emergency call boxes in the parking garage to ensure they are active and functioning.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The OIG recommends facility leaders update local policies and memorandums related to communication of test results.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2025

The OIG recommends the Director ensures the Chief of Staff conducts institutional disclosures for applicable adverse events.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The OIG recommends facility leaders take additional actions to obtain manageable panel sizes per VHA guidelines and ensure patients have access to high-quality care.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The OIG recommends facility leaders evaluate and improve processes for medical clearance of veterans who participate in the Compensated Work Therapy program.