Healthcare Facility Inspection of the VA Texas Valley Coastal Bend Healthcare System in Harlingen

Report Information

Issue Date
Report Number
25-00189-199
VISN
17
State
Texas
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Healthcare Facility Inspection
Report Topic
PACT Act
Patient Care Services Operations
Patient Safety
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 Texas Valley Coastal Bend Healthcare System in Harlingen. 

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
     •    Toxic exposure screenings
   2.    Patient safety
     •    Service-level workflows for test result communication
     •    Peer Review Committee meeting attendance

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)

Facility leaders identify barriers to providers completing toxic exposure screenings and implement actions to ensure providers complete screenings within 30 days of initiation.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/21/2025

Facility leaders ensure each service has a service-level workflow for test result communication that is consistent with VHA requirements.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/21/2025

The Director ensures the Chief of Staff attends Peer Review Committee meetings.