Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Syracuse VA Medical Center (facility) to assess allegations of reduced clinical services, poor leadership communication, and staff resignations. The OIG also identified concerns about patient transfer delays and...

This report presents the results of the VA OIG’s supplemental review of service obligations for VHA’s recruitment, relocation, and retention incentives, which follows on a report published in June 2025. While completing that audit, the OIG team became aware of an issue occurring when some VA...

The VA Office of Inspector General (OIG) identified a potential patient safety risk related to the Veterans Health Administration’s (VHA’s) use of generative artificial intelligence (AI) chat tools for clinical care and documentation. Generative AI creates new, original content by learning patterns...

The VA Office of Inspector General (OIG) evaluated allegations about the care of a patient at the Marion VA Health Care System (facility) who died by suicide. The OIG reviewed concerns that the patient’s traumatic brain injury (TBI), pain, and mental health needs were not addressed. The OIG...

The VA Office of Inspector General (OIG) conducted a national review of the Veterans Health Administration’s (VHA’s) suicide risk and intervention training, suicide risk screening practices, and implementation of progressive tinnitus management (PTM) in audiology settings from October 2023 through...

The VA Office of Inspector General (OIG) Mental Health Inspection Program (MHIP) evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on inpatient care delivered at the Margaret Cochran Corbin VA Campus (facility) in New York. The...

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Gulf Coast Healthcare System in Biloxi, Mississippi. This evaluation focused on five key content domains: • Culture • Environment of care...

VHA pharmacies cannot dispense drugs that are damaged or expired or will be expiring soon. To address this issue and to recover some costs, VA contracted with Pharma Logistics LLC to provide national reverse distribution services, where manufacturers accept returned drugs in exchange for credits...

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Clarksburg Healthcare System in West Virginia. This evaluation focused on five key content domains: • Culture • Environment of care •...

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Sioux Falls Health Care System in South Dakota. This evaluation focused on five key content domains: • Culture • Environment of care •...