Department of Veterans Affairs

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

VHA’s VA Health Connect modernization initiative of 2020 was to transform medical facilities’ call centers into regionally managed units called clinical contact centers. The centers were expected to integrate operations and provide veterans 24-hour access to four core services by December 31, 2021...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to determine whether leaders and staff followed required procedures related to suspected elder abuse of a community living center (CLC) resident at the St. Albans VA Medical Center in Queens, part of the VA New York Harbor...

The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered throughout Readjustment Counseling Service (RCS). This inspection evaluated leadership stability, morbidity and mortality reviews, and the high risk...

In August 2022, the PACT Act significantly expanded veterans’ eligibility for benefits and services for conditions related to toxic exposure. The expansion added further complexity to VBA’s claims determination process, particularly given the voluminous guidance issued for nonpresumptive conditions...

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Lexington VA Healthcare System (system) in Kentucky to determine the validity of an allegation that patients seeking or receiving acute mental health treatment did not receive the care needed. The OIG substantiated...

The VA Office of Inspector General (OIG) issued this brief report to highlight a concern regarding the Veterans Health Administration’s (VHA’s) lack of national guidance regarding patients who use personally owned insulin pumps to manage their diabetes and present to emergency departments or...

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