Department of Veterans Affairs

The VA Office of Inspector General (OIG) assessed the reliability of wait time data and evaluated whether Veterans Integrated Service Network (VISN) 15 provided timely access to health care within its medical facilities and through Choice, and whether they appropriately managed consults. The OIG...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate the circumstances of a patient’s death involving alleged mismanagement of the patient’s resuscitation (Event) at the Buffalo VA Medical Center (Facility), Buffalo, New York, and actions taken by Facility leaders...

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to an anonymous complaint alleging patients experienced extended wait times for primary care appointments and that funds intended to maintain or improve primary care services at the Monterey Community Based...

This report is the result of an Office of Inspector General (OIG) inspection of the VA Medical Center in Washington, D.C., (DC VAMC) that began in March 2017 after receiving a confidential complaint. The OIG released an interim report on April 12, 2017, identifying risks to patients and VA assets...

An audit as a result of a September 2015 allegation regarding the Network Contracting Office (NCO) 21’s award of a $3.3 million contract to the Contract Office Group, Inc. (COG) to provide interior design services and furnishings to renovate a Sacramento VA Medical Center campus building in Mather...

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 Jonathan M. Wainwright Memorial VA Medical Center (facility). The review covered key clinical and administrative processes associated with...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations regarding patient safety and poor quality of care in the Haley’s Cove Community Living Center (CLC) at the James A. Haley Veterans Hospital (facility) in Tampa, FL. The OIG substantiated that with...

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered by the Hampton VA Medical Center (Facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality...

The VA Office of Inspector General (OIG) conducted an inspection in response to allegations about a failure in notifying a patient of test results at the VA Connecticut Healthcare System, West Haven Campus. The complainant alleged (a) a urologist failed to advise a patient of prostate-specific...

The VA Office of Inspector General (OIG) assessed all identified 2015 initial Traumatic Brain Injury (TBI) Compensation and Pension (C&P) Examinations to determine if the examiners met certain VA stipulations. The OIG conducted the review in response to a legislative mandate and it was expanded at...