Deficiencies in Managing Supply, Equipment, and Implant Inventory at the Michael E. DeBakey VA Medical Center in Houston, Texas

Report Information

Issue Date
Report Number
24-00166-35
VISN
16
State
Texas
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Audits and Evaluations
Report Type
Review
Report Topic
Supplies and Equipment
Major Management Challenges
Healthcare Services
Stewardship of Taxpayer Dollars
Recommendations
10
Questioned Costs
$0
Better Use of Funds
$1,200,000
Congressionally Mandated
No

Summary

Summary

In 2023, the VA OIG received several allegations that raised concerns about the management of supplies and equipment and workplace culture at the Michael E. DeBakey VA Medical Center in Houston, Texas. The OIG initiated this review to evaluate whether the Houston facility supply chain management staff established and maintained inventory controls in accordance with VA policy. The OIG identified deficiencies in managing supplies, equipment, and implant inventory at the Houston facility. Supply chain management staff did not ensure accurate recording and accountability of expendable supplies, nonexpendable equipment, and implants in the inventory management systems, as mandated by VHA policy. These deficiencies stemmed from inadequate oversight and failure to follow inventory procedures, risking the loss of supplies or use of expired products for patient care. The OIG made 10 recommendations to the Houston medical facility director: six recommendations to improve inventory management oversight and compliance with inventory procedures and four recommendations to improve implant management.

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: 8/19/2025

Ensure supervisors conduct monitoring activities, including periodic reviews of expendable and nonexpendable inventory and root cause analyses of identified discrepancies to strengthen controls over VA supplies.

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

Establish routine monitoring for the accountable officer to verify the required use of barcode labels to track and identify supplies and equipment and report deficiencies for barcode replacement.

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

Address all unaccepted equipment and establish a requirement for custodial officers to routinely accept equipment in Maximo.

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

Implement a mechanism for the accountable officer to routinely monitor and ensure service‑line staff who conduct physical inventory are designated in writing by the custodial officers and receive the appropriate nonexpendable inventory training annually.

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

Require the accountable officer and supply chain staff to verify and update the information in the Maximo system and create procedures to ensure all nonexpendable equipment is received through the warehouse, recorded in Maximo, delivered in a timely manner to the requesting service, and accepted by the custodial officer.

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

Address the physical security issues identified and provide recurring training on proper physical security controls and procedures to individuals with authorized access to the primary inventory point and warehouse.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2025

Ensure all biological and nonbiological implants are recorded in the approved inventory management system and are routinely reconciled with other systems used to manage implant expiration dates.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2025

Develop controls to ensure implant program staff identify and create local agreements for existing consignment implants and establish agreements for future consignment implants in accordance with national guidance.

No. 9
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Officially designate a facility implant coordinator and establish a monitoring mechanism to ensure compliance with implant coordinator roles and responsibilities.

No. 10
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Update the local implant management policy to clarify roles and responsibilities and to train staff in these roles about their implant management responsibilities.

Total Monetary Impact of All Recommendations
Open: $ 1,200,000.00
Closed: $ 0.00