Healthcare Facility Inspection of the VA Dublin Healthcare System in Georgia

Report Information

Issue Date
Report Number
24-00592-60
VISN
7
State
Georgia
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Healthcare Facility Inspection
Report Topic
Clinical Care Services Operations
PACT Act
Patient Care Services Operations
Patient Safety
Supplies and Equipment
Major Management Challenges
Healthcare Services
Recommendations
8
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 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

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/6/2025

The OIG recommends that facility leaders review and correct any outdated navigational signage.

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

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

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

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

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

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.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

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.

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

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

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

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.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

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