Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review the delay in a patient’s diagnosis and care and determine the extent and contributory causes of delays in communicating abnormal test results at the Dwight D. Eisenhower VA Medical Center, Leavenworth, Kansas. After...

At Congressman Bill Posey’s request, the VA Office of Inspector General (OIG) conducted a healthcare inspection at the Orlando VA Medical Center, Florida, following allegations that a patient died while experiencing a delay in obtaining approval for surgery outside VA. It was additionally alleged...

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to a request from the OIG Office of Investigations to review the care of a patient at the Perry Point VA Medical Center, Maryland. The patient died in the hospice unit after receiving a potential overdose of a...

The VA Office of Inspector General (OIG) conducted this audit to determine whether VA met the data center requirements of the Federal Information Technology Acquisition Reform Act. The OIG found that VA did not maintain complete and updated data center inventories or include sufficient plans for...

The VA Office of Inspector General (OIG) identified a primary care provider who appeared to have falsely documented patients’ blood pressure readings at the Danville Community Based Outpatient Clinic (CBOC) of the Salem VA Medical Center (facility), Virginia. The CBOC is a contracted clinic staffed...

The VA Office of Inspector General (OIG) conducted a focused evaluation of the Washington DC VA Medical Center. The review covered key processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value (QSV); Credentialing and Privileging; Environment of...

The VA Office of Inspector General (OIG) conducted a healthcare inspection at a Veterans Integrated Service Network 21 medical facility in response to a complaint alleging that a provider’s deficient practices placed patients at risk for poor outcomes, the provider mismanaged clinic time and...

In May and October 2017, the VA Office of Inspector General (OIG) received several complaints alleging mismanagement and misuse of the VA Executive Protection Division. The complainants alleged ineffective procedures, scheduling and overtime abuses, pay administration issues, time card fraud, and...

This healthcare inspection assessed allegations that over a multi-year period, providers at three facilities ordered or continued to order a high dose of an antidepressant medication amitriptyline for a patient who was not told about the risks of the high dose, and was experiencing some side effects...

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Marion VA Medical Center. The review covered key clinical and administrative processes associated with promoting quality care—Leadership and...