Inspectors made seven recommendations following a site visit that revealed persistent issues with equipment management, storage, and cleanliness.

The Department of Veterans Affairs Office of Inspector General (OIG) identified multiple deficiencies in medical equipment and facility upkeep at the VA North Florida/South Georgia Veterans Health System in Gainesville, Fla, in a report published this week following a June 2024 site visit. 

The OIG report flagged issues with medical equipment management, inappropriate oxygen tank storage, expired supplies, unsecured medications, and unclean storage areas, among others. Many of the problems mirrored deficiencies noted in a 2022 Joint Commission evaluation, raising concerns about recurring and unresolved risks.

One issue involved overdue preventive maintenance on cardiac monitors. Inspection stickers indicated services had not been completed on time. This finding was also listed among the top 10 deficiencies in the facility’s fiscal year 2023 environment of care annual report.

The inspection also found that broken equipment was not consistently labeled or clearly separated from equipment available for patient care. The OIG notes that staff had no reliable way to tell which devices were safe to use. According to the report, the health system’s chief of facility management said limited storage space led staff to place broken items in any available room, where they were often forgotten or left without repair tags due to time constraints.

To assess the facility’s challenges, the OIG reviewed a range of data, including repeated work orders, environment of care inspection findings, and concerns reported by patient advocates. They also examined previous OIG recommendations to identify persistent gaps in compliance.

The inspection resulted in seven recommendations:

  1. The associate director of operations ensures staff maintain, inspect, and test medical equipment.
  2. The deputy chief of staff ensures staff secure all medications from unauthorized access.
  3. The associate director of patient care services ensures staff appropriately store oxygen tanks.
  4. The associate director ensures staff clean all food storage areas.
  5. The associate director of operations ensures staff remove expired supplies from storage areas.
  6. The associate director of operations ensures staff mark equipment that needs repair and separate it from equipment available for use and remove dirty items from clean storage areas.
  7. Facility leaders ensure sustained compliance with Joint Commission accreditation standards.

The findings, from a June 4-6, 2024 site visit, were published May 20, 2025. The inspection was part of the OIG’s cyclical review program in which teams routinely evaluate VHA medical facilities on an approximately three-year cycle.

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