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Healthcare Facility Inspection of the VA Poplar Bluff Health Care System in Missouri

Report Information

Issue Date
Closure Date
Report Number
24-00608-46
VISN
15
State
Arkansas
Missouri
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Healthcare Facility Inspection
Report Topic
Patient Care Services Operations
Patient Safety
Staffing
Major Management Challenges
Healthcare Services
Recommendations
4
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 Poplar Bluff Health Care System in Missouri. 

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

The OIG issued four recommendations for improvement in three domains:
   1.    Culture
   •    Key leadership turnover
   •    Interactions with local union leaders
   2.    Environment of care
   •    Nonoperational security camaras
   3.    Primary care
   •    Primary care team staffing

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: 1/15/2025

The OIG recommends the Veterans Integrated Service Network Director takes actions to ensure stable and consistent leadership at the facility.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2025

The OIG also recommends Veterans Integrated Service Network leaders assist facility leaders to improve interactions with local union leaders.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/23/2025

The OIG recommends the Interim Medical Center Director ensures all security cameras are operational.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/23/2025

The OIG recommends the Interim Medical Center Director ensures primary care teams are staffed according to Veterans Health Administration guidelines.