Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducted a healthcare inspection to address care and process issues for an Emergency Department patient and out of operating room airway management processes (OOORAM). The OIG substantiated that an advanced practice registered nurse caused airway trauma...

The VA Office of Inspector General (OIG) conducted this review in response to a November 2017 anonymous complaint that the W.G. Hefner VA Medical Center located in Salisbury, North Carolina, purchased a robotic surgical system for about $2.3 million without adequate planning and approval. The...

The OIG conducted an inspection at the request of Congressmen Pete Aguilar and Mark Takano to review concerns related to environment of care (EOC), infection control practices including Legionella testing, provider availability, leadership responsiveness, and allegations in the dental clinic at the...

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the Edward Hines Jr. VA Hospital. The inspection covers leadership and organizational risks and key processes associated with promoting quality care. For this inspection, the areas of...

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Jesse Brown VA Medical Center. The inspection covers leadership and organizational risks and key clinical and administrative processes associated with promoting quality care...

Between March and August 2016, VA’s Technology Acquisition Center (TAC) awarded the Transformation Twenty-One Total Technology Next Generation multiple award contract to 28 contractors for information technology services. The contract has a total maximum value of $22.3 billion. The VA Office of...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate concerns related to the care provided to a patient who was mistakenly treated with phototherapy for bed bugs and developed complications. Two days after receiving the phototherapy treatment, the patient was...

Acting on a hotline complaint, the VA Office of Inspector General (OIG) reviewed whether a VA-contracted disability medical exam provider—Medical Support Los Angeles—had the capacity to complete scheduled exams, and whether Veterans Benefits Administration (VBA) staff were canceling and rescheduling...

The VA Office of Inspector General (OIG) conducted this review to determine whether the Veterans Benefits Administration (VBA) had adequate controls in place to ensure exempt veterans did not pay VA home loan guaranty funding fees and to refund fees previously charged to exempt veterans. Veterans...

The VA Office of Inspector General (OIG) conducted this review to determine whether VA complied with the Improper Payments Elimination and Recovery Act of 2010 (IPERA) for fiscal year (FY) 2018. IPERA requires federal agencies to review and identify programs and activities that may be susceptible to...