Department of Veterans Affairs

The VA Office of Inspector General (OIG) issued this preliminary result advisory memorandum to communicate a serious patient safety risk related to acute ischemic stroke (AIS) management at the Wm. Jennings Bryan Dorn VA Medical Center (facility) in Columbia, South Carolina. During a healthcare...

The VA Office of Inspector General (OIG) reviewed aspects of community care utilization at the VA Boston Healthcare System for fiscal year 2024. The system, part of Veterans Integrated Service Network 1, includes three VA medical centers and several outpatient clinics. VA direct care (provided at VA...

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 Louisville Healthcare System in Kentucky. This evaluation focused on five key content domains: • Culture • Environment of care • Patient...

Veteran Readiness and Employment (VR&E) is a VBA program that provides job training and other services to rehabilitate veterans who have an employment handicap, which federal law defines as a service connected disability limiting the veteran’s “ability to prepare for, obtain, or retain employment...

The OIG received a hotline allegation that the Veterans Service Center manager at the Philadelphia VA Regional Benefit Office permitted a senior veterans service representative (VSR) to “blindly” approve hundreds of rating decisions for disability benefits claims each day without conducting the...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess care concerns and inadequate quality reviews related to a patient’s death at the VA Greater Los Angeles Healthcare System (facility). The OIG determined that clinical staff did not timely recognize, address, and...

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the Eastern Oklahoma VA Health Care System in Muskogee. This evaluation focused on five key content domains: • Culture • Environment of care •...

From October 2023 through September 2024, VHA processed almost 114,000 manual journal vouchers, representing about $71.2 billion in healthcare-related accounting transactions. Manual journal vouchers are used to record salary accruals, expenditure transfers, and other adjustments where processing...

VHA provides outpatient services to veterans at community-based outpatient clinics (CBOCs) nationwide. The VA OIG conducted this review to assess contract oversight of staffing and appointment cancellation performance measures at five Loma Linda Healthcare System CBOCs in California. The OIG found...

As directed under the MISSION Act, VA created clinical resource hubs to improve healthcare access for veterans in underserved areas. The hubs backstop medical facilities in each regional Veterans Integrated Service Network (VISN) that do not have enough clinical staff due to attrition, recruiting...