Department of Veterans Affairs

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)...

The VA Office of Inspector General (OIG) conducted an inspection to evaluate novel coronavirus disease (COVID-19) screening processes at 237 VA facilities (medical centers, community-based outpatient clinics, and community living centers) and to collect data on pandemic preparations. Screening...

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 used to develop a report to Congress on...

The OIG performed a risk assessment of VA’s grant closeout process to determine if an audit or review of VA’s process was warranted, as required by the Grants Oversight and New Efficiency Act of 2016. The act also required agencies to report on grants that were expired for more than two years that...

The VA Office of Inspector General (OIG) conducted an inspection related to a patient’s emergent mental health services, medication management, and emergency procedures at the facility. The inspection team identified an additional concern related to the Recovery and Engagement and Coordination for...