Healthcare Facility Inspection of the VA West Texas Healthcare System in Big Spring

Report Information

Issue Date
Report Number
26-00040-285
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
Maintenance and Construction
Patient Safety
Staffing
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
5
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 West Texas Healthcare System in Big Spring.

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

The OIG made five recommendations for VA to correct identified issues in two domains: 
     •    Environment of care 
       o    Legionella prevention 
     •    Patient safety 
       o    Facility policy and service-level workflows for the communication of test results 
       o    Corrective actions to address communication of test results 
       o    Oversight of clinical care quality
 

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 that staff consistently follow the facility’s Legionella prevention plan and achieve and sustain compliance with all applicable requirements in Veterans Health Administration Directive 1061(4), Prevention of Health Care-Associated Legionella Disease and Scald Injury from Water Systems to prevent contamination and maintain water quality, including testing, documentation, and mitigation actions, to protect resident safety in the community living center.

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

The Director develops and implements a written policy for communicating test results that aligns 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 develop written service-level workflows that align with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

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

The Chief of Staff and Associate Director for Patient Care Services take corrective actions to address unfavorable trends in the communication of test results in accordance with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2026

The Director evaluates the Healthcare Delivery Board and takes actions when warranted to provide proper oversight of clinical care quality in accordance with Joint Commission standards Medical Staff 16.01.01 and Leadership 11.01.01.