Healthcare Facility Inspection of the VA Maryland Health Care System in Baltimore

Report Information

Issue Date
Closure Date
Report Number
26-00044-209
VISN
1
State
Maryland
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
Community Care
Healthcare Infrastructure
Maintenance and Construction
Patient Care Services Operations
Patient Safety
Staffing
Supplies and Equipment
VA Police
Major Management Challenges
Healthcare Services
Recommendations
5
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 Maryland Health Care System in Baltimore.

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

The OIG made five recommendations for VA to correct identified issues in four domains: 
     •    Environment of care 
       o    Emergency pull cords 
     •    Patient safety 
       o    Service-level workflows for the communication of test results 
     •    Integrated veteran care 
       o    Process to assess panel size and efficiency 
       o    Scheduling for community care consults 
     •    Veteran-centered safety net 
       o    Clinic security
 

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: 10/19/2026

The Associate Director requires bathroom and shower emergency pull cords to be present, accessible, and functional, in accordance with the National Fire Protection Association’s NFPA 99 Health Care Facilities Code.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2026

The Chief of Staff develops written workflows for each service consistent with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2026

The Chief of Staff develops and implements a standardized process to routinely assess panel size and efficiency, as required by Veterans Health Administration Directive 1406(3), Patient Centered Management Module (PCMM) for Primary Care.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2026

The Director develops and implements a process to meet the seven‑day scheduling requirement in Veterans Health Administration’s Consult Timeliness Standard Operating Procedure.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2026

The Director considers a security assessment to identify risks at the Baltimore VA Clinic, in accordance with VA Handbook 0730/4, Security and Law Enforcement.