Temple VA Lacked a Process to Correct Missed Test-Result Notices Due Within Seven Days, OIG Found
By VA Headlines staff · Published Nov 13, 2026 · Source dated November 13, 2026 (VA Office of Inspector General)
The VA Office of Inspector General (OIG) found that the VA Central Texas Healthcare System in Temple "did not have a process to ensure staff implemented corrective actions for identified issues related to test result communication data," including communicating test results that require action to patients within seven days. OIG published healthcare facility inspection 26-00061-13 on November 13, 2026, and made 3 recommendations in two domains. The VISN Director and facility Director concurred. OIG considers recommendation 2 closed; recommendations 1 and 3 remain open.
The inspection
OIG inspected the highest-complexity system from April 21 through 23, 2026. The system includes the Olin E. Teague Veterans' Center in Temple, the Doris Miller VA Medical Center in Waco, a stand-alone multispecialty clinic in Austin, and eight community-based outpatient clinics. In fiscal year 2025, it had a medical care budget of approximately $1.6 billion, 500 operating beds, and provided direct care to about 120,600 patients. The evaluation covered five domains. OIG made no recommendations on culture, integrated veteran care, or the veteran-centered safety net.
Environment of care: supply-room monitoring
Inspectors found that the proper staff were not notified of supply-room temperature and humidity changes, as required by VHA Directive 1761, Supply Chain Management Operations.
Recommendation 1: The Director takes appropriate actions so the proper staff members are notified of supply-room temperature and humidity changes, as required by that directive. The facility concurred. Target date: February 28, 2027. Open.
Patient safety: test-result policy, workflows, and missed notices
OIG found that the facility's policy for test-result communication had not been updated to align with VHA Directive 1088(1), Communicating Test Results to Providers and Patients. The facility also lacked service-level workflows and did not have a process to ensure staff implemented corrective actions for identified issues related to test-result communication data, as required by the directive, including communicating test results that require action to patients within seven days.
Recommendation 2: The Director updates the facility's policy for test-result communications and develops service-level workflows to comply with VHA Directive 1088(1). The facility concurred. OIG considers this recommendation closed.
Recommendation 3: 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 VHA Directive 1088(1). The facility concurred. Target date: April 30, 2027. Open.
The report is a cyclical healthcare facility inspection. It does not allege misconduct by a named employee.
Related: Only 3 of 28 VA facilities without locked mental health units had required involuntary-admission agreements. Fayetteville VA: staff hesitated to report patient-safety concerns. Marion VA: 2 patient-safety recommendations on test-result policy. VA OIG hospital inspections. Department of Veterans Affairs (VA) News. More: all VA Headlines reports. How we report: Methodology & Corrections.
Healthcare Facility Inspection of the VA Central Texas Healthcare System in Temple - Report 26-00061-13, November 13, 2026
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