Department of Veterans Affairs

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...

The VA Office of Inspector General (OIG) conducted a healthcare inspection regarding allegations that a radiologist made gross errors resulting in treatment delays and placed misleading report addenda in records, and that leaders were tolerant of this practice. During the inspection, the OIG found...

VA faces tremendous challenges modernizing its electronic health records system and connecting it to a similarly implemented Department of Defense (DoD) system to create a comprehensive, lifetime health record for service members. The VA Office of Inspector General (OIG) examined whether...

The OIG conducted a review of VA’s planned launch of a new electronic health record (EHR) system at the Mann-Grandstaff VA Medical Center in Spokane, Washington. The facility was scheduled to be the first facility to implement the new EHR system on March 28, 2020, which VA postponed on February 10...

The OIG conducted an independent review of the VA reports on special disabilities capacity for fiscal years 2017 and 2018. The reports focus on VA’s capacity to meet the specialized treatment and rehabilitative needs of disabled veterans in five areas: (1) spinal cord injury and disorder, (2)...