Department of Veterans Affairs

The VA Office of the Inspector General (OIG) reviewed VA’s Fiduciary Program to determine whether Veterans Benefits Administration (VBA) staff finalized proposed incompetency determinations timely. The OIG found VBA delays in completing final competency determinations completed from March 1 through...

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 VA Oklahoma City Health Care System (Facility). The review covered key clinical and administrative processes associated with promoting quality care...

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 Captain James A. Lovell Federal Health Care Center (Facility). The review covered key clinical and administrative processes associated with...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate allegations regarding two patients’ care in the Hemodialysis Unit at the Wilmington VA Medical Center in Delaware. Although the OIG was unable to substantiate that the care received in a dialysis unit contributed...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations concerning the care of a patient who underwent cardiac surgery in 2015 at the VA Ann Arbor Healthcare System in Michigan. The OIG was unable to substantiate that the patient received inappropriate care...

The VA Office of Inspector General (OIG) investigated an allegation that the Executive Director of the Florida National Cemetery improperly stored his personal vehicle in a garage on Long Island National Cemetery property after he transferred to Florida and asked subordinates to drive him in...

In response to a request from Representative Tim Walz, the VA Office of Inspector General (OIG) reviewed the care of a patient who died from a self-inflicted gunshot wound less than 24 hours after discharge from the inpatient mental health unit of the Minneapolis VA Health Care System. The OIG...

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

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 Veterans Health Care System of the Ozarks (Facility). The review covered key clinical and administrative processes associated with promoting...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations regarding a patient’s abuse and neglect in a community living center (CLC) at the Northport VA Medical Center, New York. The OIG substantiated that a patient who died at the facility fell while living in...