Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to allegations of an inadequate response to a Code Orange and patient safety concerns for a missing patient at the facility. The OIG substantiated that the patient went missing from the facility in spring 2018...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to determine the validity of confidential allegations that system leaders interfered with primary care providers’ opioid prescribing practices; requirements specified in Veterans Health Administration’s (VHA) Pain Management...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess anonymous allegations involving multiple quality of care and leaders’ failures at the facility. Many of the allegations were largely unfounded; however, the OIG identified concerns including clinical staff members...

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

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to allegations related to the discharge of a patient from an inpatient mental health unit at a Veterans Integrated Service Network 4 Medical Facility. The patient was arrested by VA Police, discharged to a federal...

The VA Office of the Inspector General (OIG) conducted this audit to follow up on previous reviews of its capital asset programs, which have identified areas of improvement for both major and minor construction projects, and to determine whether VA effectively managed the procurement and awarding of...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess Veterans Health Administration (VHA) facilities’ utilization of clinical pharmacists who work under a scope of practice in a mental health outpatient care setting. After reviewing relevant policies and conducting...

The VA Office of Inspector General (OIG) performed this review as required by the VA MISSION Act of 2018. VA has experienced chronic healthcare professional shortages since at least 2015, and the law requires annual reporting on steps taken to achieve full staffing and the additional funds needed to...

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...