Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducted a healthcare inspection to determine how surgical instruments that were not suitable for service (nonconforming instruments) were used during a patient procedure at the Carl Vinson VA Medical Center (facility) in Dublin, Georgia. The OIG identified...

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Central Western Massachusetts Healthcare System in Leeds. This evaluation focused on five key content domains: • Culture • Environment of...

Veterans Health Administration (VHA) administers healthcare services through a nationwide network of 18 regional systems referred to as Veterans Integrated Service Networks (VISNs). This Office of Inspector General (OIG) report describes the results of a VISN-level oversight evaluation of...

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Salem Healthcare System in Virginia. This evaluation focused on five key content domains: • Culture • Environment of care • Patient safety...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations related to surgical services, information security, and facility leaders’ response to patient safety concerns. The OIG substantiated the facility lacked services required to support the assigned...

The VA Office of Inspector General (OIG) reviewed a hotline complaint from January 2023 alleging that the Atlanta VA medical center’s call center was not answering calls and scheduling appointments within the expected time frame due to staffing shortages. The OIG substantiated the allegations that...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess confidential complaints alleging a veteran was going to be discharged from the Housing and Urban Development VA Supportive Housing (HUD-VASH) program and “should not have been,” and that other veterans were...

The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered throughout the Readjustment Counseling Service (RCS). This inspection evaluated four review areas within Pacific District 5 including leadership stability...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess facility leaders’ responses to a dermatologist’s deficiencies in quality of care and documentation. The OIG found supervisory staff and senior leaders failed to adequately address patient care concerns outlined by...

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Southern Oregon Healthcare System in White City. This evaluation focused on five key content domains: • Culture • Environment of care •...