Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducted an inspection to assess allegations regarding staff's failure to follow informed consent and against medical advice (AMA) discharge processes and that staff held a patient on the locked mental health unit involuntarily for 48 hours at the VA...

The OIG evaluated concerns at the Michael E. DeBakey VA Medical Center (facility) regarding staff’s failure to arrange an evidence-based psychotherapy (EBP) referral for a patient assigned a high risk for suicide patient record flag (high-risk flag). The OIG reviewed concerns that staff did not...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess an allegation of inadequate clinical care of a patient who died by suicide on the inpatient medical unit.In summer 2023, a physician admitted the patient to the facility’s medical unit, placed an order for one-to...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review surgical service and quality management concerns at the Hampton VA Medical Center (facility) in Virginia.The OIG found facility leaders conducted three focused clinical care reviews (FCCRs) in response to concerns...

When a veteran is unable to secure and maintain a substantially gainful occupation because of service-connected disabilities, VA policy states that the veteran should be rated totally disabled—also referred to as total disability based on individual unemployability (TDIU)—for monthly compensation...

The OIG received a hotline allegation in June 2022 concerning delays of over 30 days to complete burials at the Santa Fe National Cemetery. In August 2022, the executive director of the National Cemetery Administration (NCA) Pacific District substantiated the delays and attributed them to limited...

The VA Office of Inspector General (OIG) evaluated facility compliance with Veterans Health Administration (VHA) suicide prevention policy at the Overton Brooks VA Medical Center in Shreveport, Louisiana, in the care of two patients, one who died by suicide and one who attempted suicide.The OIG...

VA has one of the largest acquisition functions in the federal government. In fiscal year 2023, VA obligated over $60.8 billion to provide health care and other benefits to veterans. To modernize its financial and acquisition processes, VA is implementing the Integrated Financial and Acquisition...

The OIG conducts information security inspections to assess whether VA facilities are meeting federal security requirements. They are typically conducted at selected facilities that have not been assessed in the sample for the annual audit required by the Federal Information Security Modernization...

In September 2023, VA announced it had erroneously awarded millions of dollars in critical skill incentive (CSI) payments to senior executives at its central office. VA cancelled the payments, notified Congress, and requested the Office of Inspector General (OIG) review the matter.CSIs are a new...