Department of Veterans Affairs

The VA Office of Inspector General’s (OIG’s) Mental Health Inspection Program evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on inpatient mental health care delivered at the VA Ann Arbor Healthcare System in Michigan. The facility...

The VA Office of Inspector General reviewed acute inpatient mental health care at the Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin. Inspectors evaluated care in five areas. The OIG inspection team provided preliminary observations to leaders and later issued seven recommendations...

The VA Office of Inspector General (OIG) reviewed whether the Veterans Benefits Administration’s (VBA) automated Pension and Fiduciary Service decisions correctly granted survivors’ entitlement to service-connected death benefits from September 2023 through August 2024. The OIG found legal and...

The VA OIG reviewed whether the Veterans Benefits Administration (VBA) had sufficient procedures to verify the continued eligibility of beneficiaries (including both veterans and survivors) aged 100 years or older who were receiving recurring benefits as of May 31, 2025. Overall, the OIG found that...

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to an inquiry from Congressman Pete Aguilar and a complaint regarding patient care involving a nurse practitioner (NP) and physician assistant (PA) in the hematology/oncology section at the VA Loma Linda...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess the coordination and scheduling of community care for a patient with a lung mass suspicious for cancer at the VA Fayetteville Coastal Healthcare System (system) in North Carolina. The inspection followed a complaint...

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

The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered at vet centers. This inspection report evaluated three randomly selected vet centers throughout North Atlantic district 1 zone 4: Prince George’s County...

The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered at vet centers. This inspection report evaluated three randomly selected vet centers throughout North Atlantic district 1 zone 1: New Haven, Connecticut...

The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered at vet centers. This inspection report evaluated three randomly selected vet centers throughout North Atlantic district 1 zone 2: Buffalo, Nassau, and...