Department of Veterans Affairs

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...

In October 2018 and January 2019, the OIG received unrelated complaints of potential irregularities regarding physician incentive compensation at two different healthcare facilities. The OIG did not substantiate either complaint.The first complainant alleged that beginning in fiscal year 2018, the...

The VA Office of Inspector General (OIG) issued a management advisory memorandum on differences in housing allowances for Post-9/11 GI Bill students attending non-college degree schools. These schools offer training programs, such as those for truck drivers, emergency medical technicians, and...

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of Veterans Integrated Service Network (VISN) 10 and 20 facilities’ COVID-19 pandemic readiness and response. This evaluation focused on emergency preparedness; supplies...

The VA Office of Inspector General (OIG) conducted an inspection in response to allegations that significant failures related to the management of view alert notifications placed patients at risk. Unaddressed view alerts do not necessarily correlate to unmanaged clinical results or administrative...