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Source Id
324

Deficiencies in Facility Leaders’ Summary Suspension of a Provider and Patient Safety Reporting Concerns at the VA Black Hills Health Care System in Fort Meade, South Dakota

2024
23-01502-234
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate facility leaders’ response to an alleged impairment of a general surgeon (subject provider) and assess concerns with patient safety event reporting at the VA Black Hills Health Care System (facility) in Fort Meade...

Incorrect Use of the Baker Act at the North Florida/South Georgia Veterans Health System in Gainesville, Florida

2024
23-03677-237
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the North Florida/South Georgia Veterans Health System to assess an allegation that a patient was “misled” by staff and incorrectly involuntarily admitted to the inpatient mental health unit, and that VA staff actions led...

Inspection of Select Vet Centers in Continental District 4 Zone 1

2024
22-04107-236
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered at vet centers. The OIG inspected six randomly selected vet centers throughout Continental district 4 zone 1: Fort Collins, Colorado; Kalispell, Montana...

Veterans Crisis Line Implementation of 988 Press 1 Preparation and Leaders' Response

2024
23-00925-227
Review
Department of Veterans Affairs OIG
Department of Veterans Affairs

The VA Office of Inspector General (OIG) reviewed the Veterans Crisis Line’s (VCL’s) preparation for implementation of the National Suicide Prevention Hotline three-digit dialing code “9-8-8 press 1” (988 press 1). The review focused on responder and supervisor staffing and training, including...

Inspection of Continental District 4 Vet Center Operations

2024
22-04109-238
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered throughout Readjustment Counseling Service (RCS).This inspection evaluates four review areas within Continental District 4 including leadership stability...

Incomplete Implementation of Corrective Actions to Address Pharmacy Service Concerns at the VA Central Western Massachusetts Healthcare System in Leeds

2024
23-01965-217
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess whether leaders implemented corrective actions to address pharmacy-related concerns at the VA Central Western Massachusetts Healthcare System (system) in Leeds.In early 2023, the OIG received five allegations...

Ineffective Oversight of Community Care Providers’ Special-Authorization Drug Prescribing Increased Pharmacy Workload and Veteran Wait Times

2024
23-01583-183
Audit
Department of Veterans Affairs OIG
Department of Veterans Affairs

The Veterans Health Administration (VHA) purchases community healthcare services by contracting with third-party administrators (TPAs), which in turn contract with community providers. When prescribing drugs, community providers submit prescription requests to be filled at VA pharmacies and must...

A Select Review of VHA’s Implementation of the VA Sustainability Plan

2024
23-00539-221
Review
Department of Veterans Affairs OIG
Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducted a select review of Veterans Health Administration’s (VHA's) implementation of the 2022 United States Department of Veterans Affairs Sustainability Plan, which describes priority actions for achieving federal environmental sustainability goals...

Unauthorized Community Care Dental Procedures Risked Improper Payments

2024
23-00749-171
Audit
Department of Veterans Affairs OIG
Department of Veterans Affairs

VA provides dental care to a wide range of eligible veterans. Those eligible can be referred to the community for this care if they do not live near a Veterans Health Administration (VHA) facility, are expected to experience lengthy wait times for an appointment, or community care is in their best...

VBA Did Not Always Properly Implement Compensation Cost-of-Living Adjustments

2024
24-00493-174
Other
Department of Veterans Affairs OIG
Department of Veterans Affairs

VA provides tax-free monthly compensation payments to veterans for service-connected disabilities, including special monthly compensation for certain serious disabilities or combinations of disabilities. As part of its Veterans Benefits Administration (VBA) oversight, the VA Office of Inspector...

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