Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review the high usage of community care services for primary care by the VA Loma Linda Healthcare System (system), the impact of that use, and system leaders’ oversight of VA outpatient clinics (clinics).The OIG found that...

The VA Office of Inspector General (OIG) Vet Center Inspection Program evaluated aspects of the quality of care delivered at six randomly selected vet centers throughout Southeast district 2 zone 1: Augusta, Marietta, and Savannah in Georgia; Johnson City, Tennessee; Charleston, South Carolina; and...

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 Tuscaloosa VA Medical Center in Alabama. This evaluation focused on five key...

During a recent audit of VHA’s personnel suitability program, the VA OIG received a whistleblower complaint alleging that untrained human resources officials from Veterans Integrated Service Network 20 (VISN 20) were overturning pre screening determinations. The complaint included an example in...

The VA Office of Inspector General (OIG) conducted an inspection to assess allegations that senior leaders failed to practice high reliability organization (HRO) principles and created a culture of fear at the VA Eastern Colorado Health Care System (facility) in Aurora.The OIG substantiated the...

The OIG conducted this review to determine to what extent VBA identified veterans potentially eligible for prior disability claim readjudication and retroactive benefits under the National Defense Authorization Act (NDAA) and identified two missed populations. Of the approximately 86,894 veterans in...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review how facility leaders’ actions may have impacted intensive care unit (ICU) coverage, patient care, and resident education at the VA Eastern Colorado Health Care System in Aurora (facility).The OIG was unable to...

To better understand the coordination of Veterans Health Administration (VHA) maternity care services for women veterans, the VA Office of Inspector General (OIG) conducted a national survey of VHA Maternity Care Coordinators’ (MCCs) reported staffing, duties, and challenges. While the OIG found...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review VISN and facility leaders’ response to allegations that an optometrist was not practicing to the standard of care at the Cheyenne VA Medical Center (facility) in Wyoming. In a response to an OIG request for review...