When a prostate-specific antigen test comes back abnormal at the VA West Texas Healthcare System in Big Spring, federal rules say the patient is to be told within seven days. In the first quarter of fiscal year 2026, the VA Office of Inspector General found, that happened 55 percent of the time. Worse, the facility had already changed its process to fix the problem, and the number went down from roughly 60 percent.
The inspection report, published October 2, 2026, contains five recommendations, one of which was closed before publication. The other four deserve more attention than the usual inventory of parking signs and ceiling tiles, because they describe a facility handed a clear mandate in 2023 whose own schedule for complying runs into 2027.
A Seven-Day Rule With a Fifty-Five Percent Pass Rate
The seven-day expectation is not a fresh invention. A 2022 OIG report applied it to an abnormal PSA case at the Hampton VA in Virginia, and the earlier version of the test-results directive dates to October 2015. The current rule, VHA Directive 1088(1), requires that results calling for action reach patients within seven calendar days.
At Big Spring, the report says, quality staff audited PSA results in fiscal year 2025 at the request of the regional network and found patients were notified in time about 60 percent of the time. Leaders acknowledged the problem and changed the notification process in July 2025. The OIG then found compliance had slipped to 55 percent in the first quarter of fiscal 2026. The facility describes two corrective action plans, including provider education, monthly chart audits, and quarterly reviews to identify providers who need retraining, and it gives itself until June 30, 2027 to finish the job.
A PSA test is used to diagnose prostate cancer, and the OIG notes that slow notification can cause important health conditions to be missed. The Hampton case shows what that can look like. There, the OIG concluded that failures to communicate and act on an abnormal PSA contributed to a delayed cancer diagnosis. That was a different facility, and nothing in the Big Spring report documents a missed diagnosis. The point is only that this is the kind of paperwork that sometimes turns out to be a person.
A Deadline Observed From a Great Distance
VHA issued the directive on July 11, 2023, and, by the OIG’s account, gave facilities six to twelve months to write a local policy and service-level workflows (the documents that say who tells the patient what). VHA amended it in September 2024 to clarify expectations for the workflows. The OIG had also published reports on other facilities flagging the same gap before it arrived in Big Spring.
It then asked Big Spring for its policy and workflows in December 2025. At the February 2026 inspection, the facility produced a draft policy dated February 1, 2026, and a single undated draft workflow. The workflow contradicted the facility’s own nursing protocols; one said registered nurses cannot communicate results unless a provider delegates the task, while the other let registered and licensed vocational nurses notify patients of normal results. The OIG said it was concerned that executive leaders took no action to comply despite multiple opportunities. The Chief of Staff said the earlier policy lacked certain required elements and that staff were revising it.
The facility’s target date for the policy and the workflows is March 31, 2027. By the arithmetic of the report’s own dates, that is about two years and eight months after the outer edge of the directive’s window closed in July 2024, and more than three and a half years after the directive was issued. The executive leaders, the report adds, all started between August 2023 and June 2024, so each arrived before that window shut.
Leaders told the OIG that the federal hiring freeze, which ran from January 20 to October 15, 2025, and the deferred resignation program raised workloads and made recruiting harder. The report shows real strain, including a domiciliary operating at a temporarily reduced capacity of 12 beds out of 40 and a Veterans Justice Program that entered no enrollment data for 11 months because of a staffing vacancy. My inference is that the freeze cannot explain the missing policy. It rests on the report’s own dates. The directive’s window closed in July 2024, six months before the freeze began, and a freeze cannot cause a deadline to have been missed in retrospect, though it may have made catching up harder.
Quality Oversight by Reply-All
The Healthcare Delivery Board is responsible for the continual review of clinical care quality and medical staff credentialing. In fiscal year 2025 it conducted 10 of its 12 meetings by email, according to the OIG, with leaders circulating material labeled as minutes for members to read and vote on. The Chief of Staff offered scheduling conflicts and nothing more. The OIG worried that this reduces interaction and robust discussion, which it called vital for accountability. The facility says it has held real-time virtual meetings for six months, and the OIG closed that recommendation before publication, which deserves credit.
The same affection for paper over presence turns up in the nursing home. In the community living center, testing evidence showed persistent positive Legionella results over several months for one communal shower and some sinks. Staff said they use a filtered communal shower. But the Water Safety Committee minutes did not clearly show how the facility responded to the repeat positives, and the inspector could not confirm that staff carried out the twice weekly fixture flushing the facility’s plan outlines for this high-risk area. The OIG said this left uncertainty about whether risk mitigation was working for a medically vulnerable population.
The report describes no Legionnaires’ disease case at the facility. The facility’s response sets a goal of 90 percent compliance with flushing dates in patient care areas and a completion target of June 30, 2027. For context, a 2023 OIG audit of VHA water safety made eight recommendations, found that VHA leaders did not receive complete water test results, and cited a CDC finding that one in four people with healthcare associated Legionnaires’ disease dies.
An Exception Would Be Easier to Explain
Big Spring would be simpler to fix if it were unusual. It is not. Among OIG reports published since February, recommendations tied to the same directive appeared at Eastern Colorado, Loma Linda, San Diego, Albuquerque, Tuscaloosa, and NY Harbor. At Loma Linda, the facility had no policy and gave the OIG no drafts. At Eastern Colorado, a leader blamed staffing turnover and competing priorities. Not everyone failed; the Indiana inspection found processes that complied with the updated directive.
What distinguishes Big Spring is the trajectory. The OIG’s language about missed opportunities, and a PSA measure that worsened after a fix, make it a useful case study in how a mandate can pass through a health system without leaving a mark.
Nor is the habit new to the building. A 2014 OIG review recommended strengthening notification of normal test results there, and the recommendation was closed as implemented. A 2023 OIG inspection of the nursing home found that its nursing staff had received no mock code training since October 2019 and that leaders had not defined staff responsibilities in a medical emergency. Both findings predate the current leadership team. My inference, resting on those dates and the report’s account of when the current leaders started, is that the pattern is institutional rather than personal, since problems at this facility have outlasted changes of management. That is a reading, not a finding, and the OIG does not make it.
The report also notes that VA is consolidating its regional networks from 18 to 5, with the new networks assuming initial operational responsibilities on July 15, 2026. A redrawn organization chart is not a compliance plan. The facility Director and the interim Health Service Area Director concurred with all five recommendations, and the OIG will follow up on the open ones until they are completed. In the meantime, a patient waiting on an abnormal PSA result has the seven-day rule to rely on, and the report suggests it is working a little over half the time. For other recent OIG findings across VHA, see the inspection of the VA Nebraska-Western Iowa Health Care System, where a Legionella case was missing from the required water-safety assessment and an infection-control problem survived its own 2023 correction, and the national roll-up on informed consent documentation failures across ten inpatient mental health facilities.
