Review of Environment of Care Conditions at Mississippi VA-Contracted Clinics

Report Information

Issue Date
Report Number
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Questioned Costs
Better Use of Funds
Congressionally Mandated


The VA Office of Inspector General (OIG) conducted a rapid response healthcare inspection after an OIG Comprehensive Healthcare Inspection Program review identified several significant environment of care (EOC) deficiencies at the McComb Community Based Outpatient Clinic (CBOC) on May 23, 2018. The purpose of the inspection was to assess EOC conditions at the remaining six contract CBOCs under the auspices of the G.V. (Sonny) Montgomery VA Medical Center (Facility) in Jackson, Mississippi. On May 30, three OIG teams conducted unannounced inspections at the Columbus, Greenville, Hattiesburg, Kosciusko, Meridian, and Natchez, Mississippi, CBOCs. OIG inspectors did not identify deficiencies related to general privacy requirements or the availability of medical equipment and supplies. The OIG inspectors found general safety, medication safety and security, infection prevention and environmental cleanliness, and information technology deficiencies. While OIG inspectors did not find that those conditions placed patients or staff at risk, corrective actions were needed to ensure a clean, healthy, and safe environment for patients and staff. The OIG team found inconsistencies between the requirements for Veterans Health Administration oversight as described in the respective CBOC contracts, the Contracting Officer’s Representative expectations, and Facility managers’ approach to CBOC site visits. In addition, when Facility managers conducted CBOC inspections, they did not consistently keep written records of what was reviewed, deficiencies found, or required dates for correction. The OIG team briefed Facility leaders on the results of the inspection findings on June 7, 2018. The OIG made two recommendations related to Facility comprehensive reviews of environment of care issues and consistent oversight of the CBOC operations.

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)
The Facility Director requires a team of subject matter experts to complete comprehensive reviews of the community based outpatient clinics’ compliance with environment of care and other contract requirements, and initiate corrective action plans, as needed
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Facility Director ensures that responsible managers and team members provide consistent oversight of community based outpatient clinics operations in accordance with contract requirements.