Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducted an inspection to assess concerns regarding delays in clinical care and deficiencies in care coordination that led to a delay in the diagnosis of lung cancer in a patient who died at the Raymond G. Murphy VA Medical Center (facility). The OIG also...

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the leadership performance and oversight by Veterans Integrated Service Network (VISN) 1: VA New England Healthcare System in Bedford, Massachusetts, covering leadership and...

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of Veterans Integrated Service Network (VISN) 1 and 8 facilities’ COVID-19 pandemic readiness and response. This evaluation focused on emergency preparedness; supplies...

The Semiannual Report to Congress summarizes the results of VA OIG oversight, provides statistical information, and lists all reports issued from April 1 to September 30, 2021. During this reporting period, VA OIG audits, evaluations, investigations, inspections, and other reviews identified more...

The OIG conducted a review of select aspects of operations and performance at two Veterans Health Administration (VHA) facilities in the same Veterans Integrated Service Network (VISN) that historically ranged from lower performing (Facility A) to higher performing (Facility B).Facilities are...

VA manages about $10 billion each year in medical supplies and equipment inventory. In March 2019, VA directed the deployment of the Defense Department’s Defense Medical Logistics Standard Support (DMLSS) System to modernize and standardize Veterans Health Administration (VHA) supply chain...

The VA Office of Inspector General (OIG) conducted a national review of stat community care consults generated during the outset of the COVID-19 pandemic to evaluate consult processes. Patient involvement in care urgency disagreements and reporting of adverse events in community care were also...

The VA Office of Inspector General (OIG) assessed whether the Veterans Health Administration (VHA) and the Office of Electronic Health Record Modernization (OEHRM) effectively implemented the patient scheduling component of VA’s new electronic health record system at two sites in 2020. They were the...

The VA Office of Inspector General (OIG) conducted an inspection at the Southern Oregon Rehabilitation Center and Clinics in White City (facility) and Roseburg VA Health Care System (Roseburg) in Oregon to evaluate an allegation that a resident (resident 1) was admitted to the facility’s Mental...

The OIG’s administrative investigation examined whether the deputy executive director of VA’s Office of Construction and Facilities Management (OCFM), during his tenure as acting executive director, failed to respond appropriately to a 2018 audit by the office’s Quality Assurance Service (QAS). The...