BIG SPRING VA: ABNORMAL PSA RESULTS SHARED ON TIME JUST 55%
By VA Headlines · Published Nov 3, 2026 · Source dated October 2, 2026 (VA Office of Inspector General)
Staff at the VA West Texas Healthcare System in Big Spring told patients about abnormal prostate-specific antigen (PSA) test results within VA's required seven days only 55% of the time in the first quarter of fiscal 2026, the VA Office of Inspector General (OIG) found. That was down from about 60% in fiscal 2025, even after the facility changed its notification process in July 2025. PSA tests are used in diagnosing prostate cancer.
OIG inspected the facility February 17-23, 2026, and published report 26-00040-285 on October 2, 2026. The system, which includes the George H. O'Brien, Jr., VA Medical Center in Big Spring and clinics in west Texas and New Mexico, cared for about 20,700 patients in fiscal 2025 on a budget of about $401 million.
Key findings
Test results: The facility had no policy or service-level workflows for communicating test results, as VHA Directive 1088(1) requires. One workflow OIG reviewed contradicted the nursing protocols.
Legionella in the nursing home unit: Routine testing of one communal shower and some sinks in the community living center (a VA nursing home) showed persistent positive Legionella results over several months. OIG could not confirm staff were doing required steps such as twice-weekly fixture flushing. Staff said residents use a communal shower with a filter that blocks bacteria. Committee minutes didn't clearly show how the facility responded to the repeat positives.
Oversight by email: The Healthcare Delivery Board, which reviews clinical care quality and medical staff credentialing, held 10 of its 12 meetings by email in fiscal 2025. OIG said that reduces real discussion. The facility has since held real-time virtual meetings, and OIG closed that recommendation.
Primary care access: Primary care panels averaged 104% of VHA's expected capacity, and 9 of 18 teams were over. New patients waited about 18 days in the third quarter of fiscal 2025 and about 25 days at the time of the February 2026 visit. Federal rules let patients be referred to community care when the wait is over 20 days. Leaders added a team at the Abilene clinic and plan one for Odessa.
Community care scheduling took 10 days on average from January through November 2025, against VA's 7-day standard. OIG noted that community care wait times were still about half the national average, so it made no recommendation there.
Staffing: Because of vacancies, leaders got approval in September 2025 to temporarily cut the domiciliary from 40 to 12 beds. It was still at 12 in June 2026.
The 5 recommendations
OIG made 5 recommendations: follow the Legionella prevention plan (target date June 30, 2027); write a test-results policy and service-level workflows (March 31, 2027); fix the unfavorable trends in test-result communication (June 30, 2027); and review the Healthcare Delivery Board (closed). The facility concurred with all of them. It says it will audit charts monthly until it keeps at least 90% compliance for six straight months.
Related: VA OIG hospital inspections 2026. Phoenix VA lab results backlog: OSC whistleblower case. Chicago VA community care wait times. More: all VA Headlines reports. How we report: Methodology & Corrections.
Healthcare Facility Inspection of the VA West Texas Healthcare System in Big Spring, Report 26-00040-285 · October 2, 2026
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VA Office of Inspector General
Full report (PDF), 26-00040-285 · October 2, 2026
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The facility concurred with all 5 recommendations. OIG considers recommendation 5 closed and will follow up on the other 4. VA Headlines reports only what official records say. Spot an error? See our corrections policy.