Department of Veterans Affairs

The Office of Inspector General (OIG) Care in the Community healthcare inspection program examines clinical and administrative processes associated with providing quality outpatient healthcare to veterans. This report provides a focused evaluation of Veterans Integrated Service Network (VISN) 23 and...

The VA Office of Inspector General (OIG) conducted a healthcare inspection for 10 allegations related to the quality and management of patient care and the availability of resources within the Urgent Care Center at the Chillicothe VA Medical Center in Ohio.One allegation involved an urgent care...

The OIG conducted a healthcare inspection at the Charlie Norwood VA Medical Center in Augusta, Georgia (facility) to evaluate the adequacy of a patient’s outpatient care in the months prior to surgery and during preoperative and postoperative care. After surgery, the patient was admitted for...

The Veterans Health Administration (VHA) Office of Emergency Management issued the initial COVID-19 Response Plan on March 23, 2020, and then an updated version on August 7, 2020. The National Center for Organization Development created a COVID-19 rapid response consultation process for VHA leaders...

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Finger Lakes Healthcare System, which includes two medical center campuses—Bath and Canandaigua...

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA New Jersey Health Care System in East Orange. The inspection covered key clinical and...

The VA Office of Inspector General (OIG) evaluated allegations that Portland VA Medical Center (facility) staff “inappropriately discharged” a patient with “severe cognitive impairment,” then “turned away” the patient, and failed to provide the patient’s records to Adult Protective Services (APS)...

The VA Office of Inspector General (OIG) audited Post-9/11 GI Bill student enrollments that included vacation breaks because of the risk they were not being accurately processed and veterans were not getting the correct benefits.The OIG found the Veterans Benefits Administration (VBA) did not always...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate leaders’ response to the knowledge of inappropriate provider-patient relationships (inappropriate relationships) in the Mental Health Service Line at the VA Illiana Health Care System (facility) in Danville...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate OIG identified concerns related to the assessment and documentation practices of a behavioral health certified registered nurse practitioner (BHNP) and leaders’ completion of BHNPs’ ongoing professional practice...