Department of Veterans Affairs

To promote compatibility with the Department of Defense’s electronic health record system, VA is replacing its aging record system. This requires VA medical facilities to upgrade their physical infrastructure, including electrical and cabling. The OIG determined from its audit that the Veterans...

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Marion VA Medical Center in Illinois (facility) to review an allegation that a patient died due to complications from high cholesterol.The OIG substantiated that high cholesterol contributed to the patient’s death...

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 Cincinnati VA Medical Center and multiple outpatient clinics in Kentucky, Indiana, and Ohio. The...

The VA Office of Inspector General (OIG) conducted an inspection in response to allegations related to ophthalmology resident supervision and quality of care by an attending ophthalmologist (subject ophthalmologist) at the Oklahoma City VA Health Care System in Oklahoma.The OIG substantiated that...

In 2020, the Veterans Benefits Administration (VBA) processed about 1.2 million disability compensation claims and paid more than $90.8 billion in total benefits to veterans. About five million veterans were receiving these benefits as of December 31. To ensure claims decisions are accurate and...

The VA Office of Inspector General’s (OIG) Office of Investigations was contacted by the Facility Director in June 2018 who reported concerns related to the suspicious deaths of nine patients from profound hypoglycemia (low blood sugar). A criminal investigation was initiated. The OIG Office of...

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’...