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Unauthorized Community Care Dental Procedures Risked Improper Payments

Report Date: 8/8/2024

Agency Reviewed / Investigated: Department of Veterans Affairs

Type: Audit

Country: Agency-Wide

Deficiencies in Informed Consent for Admission and Against Medical Advice Discharge Processes for a Patient at the VA Southern Nevada Healthcare System in Las Vegas

Report Date: 8/1/2024

Agency Reviewed / Investigated: Department of Veterans Affairs

Type: Inspection / Evaluation

Country: United States

Location:

Delays and Deficiencies in the Mental Health Care of a Patient at the Michael E. DeBakey VA Medical Center in Houston, Texas

Report Date: 7/31/2024

Agency Reviewed / Investigated: Department of Veterans Affairs

Type: Inspection / Evaluation

Country: United States

Location:

VBA Did Not Always Properly Implement Compensation Cost-of-Living Adjustments

Report Date: 7/25/2024

Agency Reviewed / Investigated: Department of Veterans Affairs

Type: Other

Country: Agency-Wide

Inadequate Care of a Patient Who Died by Suicide on a Medical Unit at the Sheridan VA Medical Center in Wyoming

Report Date: 7/25/2024

Agency Reviewed / Investigated: Department of Veterans Affairs

Type: Inspection / Evaluation

Country: United States

Location:

Mismanaged Surgical Privileging Actions and Deficient Surgical Service Quality Management Processes at the Hampton VA Medical Center in Virginia

Report Date: 7/23/2024

Agency Reviewed / Investigated: Department of Veterans Affairs

Type: Inspection / Evaluation

Country: United States

Location:

VBA Needs to Improve the Accuracy of Decisions for Total Disability Based on Individual Unemployability

Report Date: 7/17/2024

Agency Reviewed / Investigated: Department of Veterans Affairs

Type: Review

Country: Agency-Wide

Better Collection of Family Preference Data May Minimize Risk of Burial Scheduling Delays

Report Date: 7/16/2024

Agency Reviewed / Investigated: Department of Veterans Affairs

Type: Audit

Country: Agency-Wide

Noncompliance with Suicide Prevention Policies at the Overton Brooks VA Medical Center in Shreveport, Louisiana

Report Date: 7/10/2024

Agency Reviewed / Investigated: Department of Veterans Affairs

Type: Inspection / Evaluation

Country: United States

Location:

Lessons Learned for Improving the Integrated Financial and Acquisition Management System’s Acquisition Module Deployment

Report Date: 7/10/2024

Agency Reviewed / Investigated: Department of Veterans Affairs

Type: Review

Country: Agency-Wide

Review of Perceived Barriers in Coordinating Veteran Maternity Care

Report Date: 6/27/2024

Agency Reviewed / Investigated: Department of Veterans Affairs

Type: Review

Country: Agency-Wide

VBA Did Not Identify All Vietnam Veterans Who Could Qualify for Retroactive Benefits

Report Date: 6/27/2024

Agency Reviewed / Investigated: Department of Veterans Affairs

Type: Review

Country: Agency-Wide

Leaders at the VA Eastern Colorado Health Care System in Aurora Created an Environment That Undermined the Culture of Safety

Report Date: 6/24/2024

Agency Reviewed / Investigated: Department of Veterans Affairs

Type: Inspection / Evaluation

Country: United States

Location:

Extended Pause in Cardiac Surgeries and Leaders’ Inadequate Planning of Intensive Care Unit Change and Negative Impact on Resident Education at the VA Eastern Colorado Health Care System in Aurora

Report Date: 6/24/2024

Agency Reviewed / Investigated: Department of Veterans Affairs

Type: Inspection / Evaluation

Country: United States

Location:

Potential Weaknesses Identified in the VISN 20 Personnel Suitability Program

Report Date: 6/20/2024

Agency Reviewed / Investigated: Department of Veterans Affairs

Type: Review

Country: Agency-Wide

Deficiencies in Oversight and Leadership Response to Optometry Concerns at the Cheyenne VA Medical Center in Wyoming

Report Date: 6/18/2024

Agency Reviewed / Investigated: Department of Veterans Affairs

Type: Inspection / Evaluation

Country: United States

Location:

Ineffective Use and Oversight of Medical Surgical Prime Vendor Program Led to Increased Spending

Report Date: 6/11/2024

Agency Reviewed / Investigated: Department of Veterans Affairs

Type: Audit

Country: Agency-Wide

Financial Efficiency Inspection of the VA North Texas Health Care System

Report Date: 6/6/2024

Agency Reviewed / Investigated: Department of Veterans Affairs

Type: Inspection / Evaluation

Country: Agency-Wide

Inspection of Information Security at the VA Bedford Healthcare System in Massachusetts

Report Date: 6/5/2024

Agency Reviewed / Investigated: Department of Veterans Affairs

Type: Inspection / Evaluation

Country: United States

Location:

Follow-up Information Security Inspection at the VA Financial Services Center in Austin, Texas

Report Date: 5/30/2024

Agency Reviewed / Investigated: Department of Veterans Affairs

Type: Inspection / Evaluation

Country: United States

Location:

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