Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA Eastern Colorado Health Care System (facility) in Aurora to review telemetry medical instrument technician (MIT) actions and leaders’ response to allegations that an MIT (MIT A) changed patient alarm settings and...

The Office of Inspector General (OIG) evaluated concerns related to Veterans Integrated Service Network (VISN) 10 staff’s care and treatment coordination for a patient who died. The OIG reviewed the sufficiency of Veterans Health Administration (VHA) leaders’ actions prior to and following...

The VA Office of Inspector General (OIG) reviewed an allegation that a patient experienced a delay in receiving basic life support (BLS) during a medical emergency on the grounds of the Carl T. Hayden VA Medical Center (facility) in Phoenix, Arizona, and later died at a community hospital.The OIG...

In January 2023, the VA Office of Inspector General (OIG) received a hotline allegation that Network Contracting Office (NCO) 12 participated in unethical sole-source contracting practices while procuring cardiothoracic services contracts at the Captain James A. Lovell Federal Health Care Center in...

The VA Office of Inspector General’s (OIG’s) Mental Health Inspection Program (MHIP) evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on the inpatient care delivered at the VA Augusta Health Care System (HCS) in Georgia. Augusta HCS...

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

This Office of Inspector General (OIG) Healthcare Facility Inspections program report describes the results of a focused evaluation of the care provided at VA Hudson Valley Healthcare System, which includes the Franklin Delano Roosevelt Hospital in Montrose, New York. This evaluation focused on five...

The VA Office of Inspector General (OIG) conducted this audit to determine whether VA complied with the law governing geospatial data and to follow up on recommendations from its previous report. VA’s administrations rely on geospatial data when supporting budgets, performing strategic planning, and...

To comply with the VA Transparency & Trust Act of 2021 (Transparency Act), VA must provide a detailed plan to Congress outlining its intent and justification for obligating and expending COVID-19 relief funds covered by the act. Additionally, the Transparency Act requires VA to submit biweekly...

The VA Office of Inspector General (OIG) issued a management advisory memorandum to inform the Veterans Health Administration (VHA) Under Secretary for Health of concerns facility leaders and staff expressed to OIG staff regarding VA’s new electronic health record (EHR) during Healthcare Facility...