Skip to main content
Source Id
324

Inadequate Care of a Patient Who Died by Suicide on a Medical Unit at the Sheridan VA Medical Center in Wyoming

2024
23-03159-204
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess an allegation of inadequate clinical care of a patient who died by suicide on the inpatient medical unit.In summer 2023, a physician admitted the patient to the facility’s medical unit, placed an order for one-to...

Mismanaged Surgical Privileging Actions and Deficient Surgical Service Quality Management Processes at the Hampton VA Medical Center in Virginia

2024
23-00995-211
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review surgical service and quality management concerns at the Hampton VA Medical Center (facility) in Virginia.The OIG found facility leaders conducted three focused clinical care reviews (FCCRs) in response to concerns...

VBA Needs to Improve the Accuracy of Decisions for Total Disability Based on Individual Unemployability

2024
23-01772-162
Review
Department of Veterans Affairs OIG
Department of Veterans Affairs

When a veteran is unable to secure and maintain a substantially gainful occupation because of service-connected disabilities, VA policy states that the veteran should be rated totally disabled—also referred to as total disability based on individual unemployability (TDIU)—for monthly compensation...

Better Collection of Family Preference Data May Minimize Risk of Burial Scheduling Delays

2024
23-01773-166
Audit
Department of Veterans Affairs OIG
Department of Veterans Affairs

The OIG received a hotline allegation in June 2022 concerning delays of over 30 days to complete burials at the Santa Fe National Cemetery. In August 2022, the executive director of the National Cemetery Administration (NCA) Pacific District substantiated the delays and attributed them to limited...

Noncompliance with Suicide Prevention Policies at the Overton Brooks VA Medical Center in Shreveport, Louisiana

2024
23-02898-195
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

The VA Office of Inspector General (OIG) evaluated facility compliance with Veterans Health Administration (VHA) suicide prevention policy at the Overton Brooks VA Medical Center in Shreveport, Louisiana, in the care of two patients, one who died by suicide and one who attempted suicide.The OIG...

Lessons Learned for Improving the Integrated Financial and Acquisition Management System’s Acquisition Module Deployment

2024
23-00151-117
Review
Department of Veterans Affairs OIG
Department of Veterans Affairs

VA has one of the largest acquisition functions in the federal government. In fiscal year 2023, VA obligated over $60.8 billion to provide health care and other benefits to veterans. To modernize its financial and acquisition processes, VA is implementing the Integrated Financial and Acquisition...

Inspection of Information Security at the VA Bedford Healthcare System in Massachusetts

2024
23-02330-127
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

The OIG conducts information security inspections to assess whether VA facilities are meeting federal security requirements. They are typically conducted at selected facilities that have not been assessed in the sample for the annual audit required by the Federal Information Security Modernization...

VA Improperly Awarded $10.8 Million in Incentives to Central Office Senior Executives

2024
23-03773-169
Investigation
Department of Veterans Affairs OIG
Department of Veterans Affairs

In September 2023, VA announced it had erroneously awarded millions of dollars in critical skill incentive (CSI) payments to senior executives at its central office. VA cancelled the payments, notified Congress, and requested the Office of Inspector General (OIG) review the matter.CSIs are a new...

Comprehensive Healthcare Inspection of the VA Finger Lakes Healthcare System in Bath, New York

2024
23-00121-158
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Finger Lakes Healthcare System, which includes the Bath and Canandaigua VA...

Comprehensive Healthcare Inspection of the VA Eastern Kansas Health Care System in Topeka

2024
23-00102-150
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Eastern Kansas Health Care System, which includes the Colmery-O’Neil VA Medical...

Subscribe to Department of Veterans Affairs