Report Summary

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.