Healthcare Facility Inspection of the VA Clarksburg Healthcare System in West Virginia

Report Information

Issue Date
Report Number
24-03206-21
VISN
5
State
West Virginia
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Healthcare Facility Inspection
Report Topic
Patient Safety
Supplies and Equipment
Major Management Challenges
Healthcare Services
Recommendations
3
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 Clarksburg Healthcare System in West Virginia. 

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

The OIG issued three recommendations for VA to correct identified deficiencies in two domains:
   1.    Environment of care
     •    Clean and dirty equipment storage, torn furnishings, and cleanliness
     •    Cardboard backboards
   2.    Patient safety
     •    Policy for test result communication

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)

Executive leaders ensure staff store clean and dirty equipment separately, repair torn furnishings, and keep the environment clean.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2025

Executive leaders ensure staff evaluate the cardboard backboards for pest concerns and reduce the risk of infection.

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

Executive leaders ensure the facility’s policy for test result communication aligns with the VHA directive.