Department of Veterans Affairs

The VA Office of Inspector General (OIG) initiated a healthcare inspection on September 2, 2025, in response to anonymous allegations received regarding the integrity of the peer review process at the VA Caribbean Healthcare System (facility) in San Juan, Puerto Rico. The OIG conducted an...

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Western North Carolina VA Health Care System (system) to assess concerns brought forward in October 2025 by an OIG Healthcare Facility Inspection team regarding issue briefs related to sentinel events and falls at the...

The VA Office of Inspector General (OIG) sought to assess whether Veterans Benefits Administration (VBA) claims processors were appropriately overriding warnings and calculator results within the Veterans Benefits Management System for Rating (VBMS R). The review focused on overrides processed...

The VA OIG’s information security inspection program assesses whether VA facilities are meeting federal security requirements related to three high-risk control areas: configuration management, security management, and access. For this inspection, the OIG selected the VA Saginaw Healthcare System in...

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...