Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducted this audit to determine if the Beneficiary Fiduciary Field System (BFFS) had the necessary controls to protect data integrity and safeguard protected information. The BFFS is the information technology system for VA’s Fiduciary Program that handles...

Spinal conditions account for two of VA’s top 10 service-connected disabilities, totaling some 1.5 million cases as of September 30, 2018. The VA Office of Inspector General (OIG) conducted this review after determining disability claims related to conditions of the spine have a higher risk of...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review the utilization of hospice and palliative care (HPC) services at the Veterans Health Administration (VHA). The OIG reviewed relevant directives, policies, handbooks and conducted interviews with VHA and non-VHA HPC...

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to an allegation that a thoracic surgeon (surgeon) provided poor quality of care to five patients. Two other allegations received were addressed in an OIG report published in 2018, Inadequate Intensivist Coverage...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate allegations that surgical pathology specimen processing delays in the pathology and laboratory medicine service (P&LMS) resulted in multiple patients’ harm and possibly death, and follow-up on the facility’s...

The VA Office of Inspector General (OIG) conducted a healthcare inspection, in response to a notification that a hospitalized patient died by suicide and a subsequent request from House Veterans Affairs Committee Chairman Mark Takano, to review the circumstances of the death. Inpatient death by...

The VA Office of Inspector General (OIG) performed this audit to determine if Veterans Health Administration (VHA) medical facilities are scanning and entering medical documentation into patients’ records accurately and in a timely manner. VHA healthcare staff rely on medical records to manage...

The VA Office of Inspector General (OIG) conducted this audit to determine whether the Office of Information and Technology and the Veterans Health Administration (VHA) effectively managed the implementation of VA’s Veterans Information Systems and Technology Architecture (VistA) Scheduling...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess the validity of allegations regarding a delay in performing an appendectomy, that the delay was caused by inadequate resident oversight, and surgeons paid by the VA were unavailable because they were working for...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations that staff at the San Diego VA Healthcare System, California, failed to provide mental health care to a patient who subsequently died by suicide. The OIG did not substantiate that the system failed to...