Department of Veterans Affairs

In response to a congressional request, the VA Office of Inspector General (OIG) conducted this audit to determine whether processors of non-VA emergency care claims inappropriately denied or rejected the claims, and, if so, whether the cause was pressure to meet production standards. The OIG...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate care of a patient who died in a behavioral health unit at the Gulf Coast Veterans Health Care System, Biloxi, Mississippi. The specific concern was the unit staff’s failure to initiate full resuscitation efforts...

The VA Office of Inspector General (OIG) conducted an inspection in response to episodes of non-adherence to Veterans Health Administration (VHA) and VA policies on patient information privacy and security at the Tibor Rubin VA Medical Center, Long Beach, California. After a VA computer update, a...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess sustained performance of actions taken to close previous OIG recommendations at the Veterans Crisis Line (VCL) located in Canandaigua, New York; Atlanta, Georgia; and Topeka, Kansas. VCL is a crisis hotline...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate factors that may have impacted or contributed to the unexpected death of a ventilator-dependent patient on the Spinal Cord Injury (SCI) unit at the VA San Diego Healthcare System and to follow-up on the facility’s...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate concerns related to a patient’s response to oxycodone, an opioid pain mediation, including initial post-surgery care and during an acute change in condition (event) at the facility. The OIG also assessed...

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

The VA Office of Inspector General (OIG) audited the Program of Comprehensive Assistance for Family Caregivers to determine whether the Veterans Health Administration (VHA) took timely and consistent action to discharge veterans and their caregivers from the Family Caregiver Program, and...

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

The VA Office of Inspector General (OIG) conducted a healthcare inspection to address concerns with patients’ access to care and delays in outpatient mental health care. The OIG identified patients’ limited access to outpatient mental health care as evidenced by the staff’s insufficient use of the...