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Source Id
324

Unauthorized Community Care Dental Procedures Risked Improper Payments

2024
23-00749-171
Audit
Department of Veterans Affairs OIG
Department of Veterans Affairs

VA provides dental care to a wide range of eligible veterans. Those eligible can be referred to the community for this care if they do not live near a Veterans Health Administration (VHA) facility, are expected to experience lengthy wait times for an appointment, or community care is in their best...

VBA Did Not Always Properly Implement Compensation Cost-of-Living Adjustments

2024
24-00493-174
Other
Department of Veterans Affairs OIG
Department of Veterans Affairs

VA provides tax-free monthly compensation payments to veterans for service-connected disabilities, including special monthly compensation for certain serious disabilities or combinations of disabilities. As part of its Veterans Benefits Administration (VBA) oversight, the VA Office of Inspector...

Deficiencies in Informed Consent for Admission and Against Medical Advice Discharge Processes for a Patient at the VA Southern Nevada Healthcare System in Las Vegas

2024
24-00160-212
Inspection / Evaluation
Department of Veterans Affairs OIG
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...

Delays and Deficiencies in the Mental Health Care of a Patient at the Michael E. DeBakey VA Medical Center in Houston, Texas

2024
23-00776-207
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

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...

Inadequate Care of a Patient Who Died by Suicide on a Medical Unit at the Sheridan VA Medical Center in Wyoming

2024
23-03159-204
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

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...

Mismanaged Surgical Privileging Actions and Deficient Surgical Service Quality Management Processes at the Hampton VA Medical Center in Virginia

2024
23-00995-211
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

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...

VBA Needs to Improve the Accuracy of Decisions for Total Disability Based on Individual Unemployability

2024
23-01772-162
Review
Department of Veterans Affairs OIG
Department of Veterans Affairs

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...

Better Collection of Family Preference Data May Minimize Risk of Burial Scheduling Delays

2024
23-01773-166
Audit
Department of Veterans Affairs OIG
Department of Veterans Affairs

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...

Noncompliance with Suicide Prevention Policies at the Overton Brooks VA Medical Center in Shreveport, Louisiana

2024
23-02898-195
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

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...

Lessons Learned for Improving the Integrated Financial and Acquisition Management System’s Acquisition Module Deployment

2024
23-00151-117
Review
Department of Veterans Affairs OIG
Department of Veterans Affairs

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...

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