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 VA Western Colorado Healthcare System in Grand Junction. This evaluation focused on five key content domains: • Culture • Environment of care...

The OIG conducted this review to assess the merits of two hotline complaints—one in March 2024 and one in April 2024—alleging Omaha VA Medical Center leaders manipulated the clinically indicated date for consults, thereby limiting veterans’ access to community care. The OIG substantiated the...

VA asked the OIG to conduct an audit of a contractor whose billing practices were concerning. The contractor, which provided eligible veterans with wheelchair van and other nonemergency transportation services to and from medical appointments in a certain VA healthcare system, invoiced VA about $11...

Underground storage tanks (USTs) are a critical part of the Veterans Health Administration’s healthcare facilities. The tanks store fuel for boilers and backup generators, which are essential to operations, especially during power failures. If the tanks are not properly installed and maintained, any...

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 Bronx Healthcare System in New York. This evaluation focused on five key content domains: • Culture • Environment of care • Patient safety...

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 Hampton Healthcare System in Virginia. This evaluation focused on five key content domains: • Culture • Environment of care • Patient...

In 2023, the VA OIG received several allegations that raised concerns about the management of supplies and equipment and workplace culture at the Michael E. DeBakey VA Medical Center in Houston, Texas. The OIG initiated this review to evaluate whether the Houston facility supply chain management...

The VA Office of Inspector General (OIG) assessed aspects of community care and VA direct care programs at the Montana VA Healthcare System (system) for fiscal year 2022. Among patients who received VA primary care and VA mental health care, 98.8 and 77.5 percent, respectively, did so exclusively...

The OIG’s Mental Health Inspection Program (MHIP) evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on the inpatient care delivered at the Edward P. Boland VA Medical Center, part of the VA Central Western Massachusetts Healthcare...

The VA Office of Inspector General (OIG) conducted a national review to evaluate the governance structure and responsibilities related to the Veterans Integrated Service Network (VISN) Chief Mental Health Officer (CMHO) role. The OIG found that VHA communicated inconsistent mandatory and...