Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducted an annual risk assessment of VA’s charge card program evaluating the three types of charge cards—purchase cards (including convenience checks), travel cards, and fleet cards—for transactions during fiscal year (FY) 2019. The OIG conducted its risk...

The OIG conducted this audit to determine whether VA implemented key elements of the Federal Information Technology Acquisition Reform Act (FITARA) consistent with the requirements for Chief Information Officer Authority Enhancements (Section 831). Specifically, the audit team evaluated two groups...

The OIG assessed the merits of a hotline complaint received in March 2019 regarding building conditions and patient safety at the Northport VA Medical Center in Northport, New York. The complainant alleged that medical center managers did not take adequate action to maintain the center’s buildings...

The OIG conducted this mandated review to assess VA’s reporting of staffing and vacancy data on its public-facing website. VA is required to release this information publicly each quarter by the VA MISSION Act of 2018 (the Act). The review team found VA partially complied with Section 505 of the Act...

The VA Office of Inspector General (OIG) conducted an inspection at the VA Northeast Ohio Healthcare System’s (the facility) Domiciliary Residential Rehabilitation Treatment Program to evaluate allegations of deficiencies in the care of a patient who died after an Emergency Department visit, as well...

The Semiannual Report to Congress summarizes the results of OIG oversight, provides statistical information, and lists all reports issued October 1, 2019 – March 31, 2020. During this reporting period, OIG audits, investigations, inspections, evaluations, and other reviews identified nearly $866.8...

This healthcare inspection assessed the delay and treatment of a patient diagnosed with leukemia (Patient A) and a failed inter-facility transfer. Inspectors also reviewed a second patient’s (Patient B’s) admission and inter-facility transfer. Facility leaders’ oversight and response to the events...

The VA Office of Inspector General (OIG) conducted this annual statutorily required review to determine whether VA complied with the requirements of the Improper Payments Elimination and Recovery Act of 2010 (IPERA) for fiscal year (FY) 2019. In FY 2019, VA reported improper payment estimates...

The VA Office of Inspector General (OIG) conducted this healthcare inspection to respond to allegations related to inadequate nurse staffing and nurse-to-patient ratios in the Critical Care Unit (CCU) purportedly resulting in poor quality of care, which included the development of pressure ulcers...

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the request of Senator Tammy Duckworth on behalf of a constituent to assess concerns regarding the appropriateness of facility leaders’ response to a radiologist’s alleged four radiologic errors. The OIG determined that...