Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducted a review to assess aspects of the care provided to a patient who was struck and killed by a motor vehicle following elopement from a community living center (CLC).The patient suffered from paranoid schizophrenia and was involuntarily civilly...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess responses by facility leaders to a Sterile Processing Services (SPS) employee’s failure to follow endoscope reprocessing procedures. During the review, the OIG also identified concerns related to actions taken by...

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Aleda E. Lutz VA Medical Center and multiple outpatient clinics in Michigan. The inspection...

The Federal Information Security Modernization Act (FISMA) requires annual evaluations of the information security program at each federal agency. The Department of Homeland Security and the Office of Management and Budget review the results, which are part of a report to Congress on agencies’...

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 Ann Arbor VA Medical Center and multiple outpatient clinics in Michigan and Ohio. The inspection...

The VA Office of Inspector General (OIG) evaluated allegations regarding Veterans Crisis Line (VCL) responses to a caller (caller 1) with homicidal ideation and a second caller (caller 2) with suicidal and homicidal ideation. The OIG also evaluated concerns regarding caller 1’s care at the Montana...

While reviewing the Veterans Health Administration’s (VHA) plans to document receipt and distribution of the COVID-19 vaccine, the VA Office of Inspector General (OIG) determined that VHA facilities did not consistently document the COVID-19 vaccination status of veterans living in VA’s Community...

The VA Office of Inspector General (OIG) reviewed community-based outpatient clinic (CBOC) closures that occurred due to the COVID-19 pandemic to evaluate the impact on patient care. The OIG virtually interviewed Veterans Health Administration (VHA) staff at 140 facilities that oversaw the 1,031...

The VA Office of Inspector General (OIG) conducted a national review to evaluate colonoscopy care delivered in Veterans Health Administration (VHA) multispecialty community-based outpatient clinics (CBOC). This review focused on quality indicators for CBOC colonoscopy providers’ practice evaluations...

The VA Office of Inspector General (OIG) conducted an inspection to review concerns related to the mental health care provided at the Phoenix VA Health Care System (facility) to a patient who died by suicide in 2019.The patient initially established mental health care at the facility in 2017. Upon...