Healthcare Facility Inspection of the VA Central Texas Healthcare System in Temple

Report Information

Issue Date
Report Number
26-00061-13
VISN
4
State
Texas
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
Patient Care Services Operations
Patient Safety
Supplies and Equipment
System Development and Implementation
VA Police
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 Central Texas Healthcare System in Temple.

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

The OIG made three recommendations for VA to correct identified issues in two domains: 
     •    Environment of care 
       o    Supply room temperature and humidity changes 
     •    Patient safety 
       o    Facility policy and service-level workflows for the communication of test results 
       o    Communicating test results that require action to patients
 

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)

The Director takes appropriate actions so the proper staff members are notified of supply room temperature and humidity changes, as required by Veterans Health Administration Directive 1761, Supply Chain Management Operations.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2026

The Director updates the facility’s policy for test result communications and develops service-level workflows to comply with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

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

The Chief of Staff and Associate Director for Patient Care Services work with service-level leaders to take corrective action when staff do not communicate test results that require action to patients within seven days, as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.