Department of Veterans Affairs

The VA Office of Inspector General (OIG) reviewed the Veterans Crisis Line’s (VCL’s) preparation for implementation of the National Suicide Prevention Hotline three-digit dialing code “9-8-8 press 1” (988 press 1). The review focused on responder and supervisor staffing and training, including...

The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered throughout Readjustment Counseling Service (RCS).This inspection evaluates four review areas within Continental District 4 including leadership stability...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess whether leaders implemented corrective actions to address pharmacy-related concerns at the VA Central Western Massachusetts Healthcare System (system) in Leeds.In early 2023, the OIG received five allegations...

The Veterans Health Administration (VHA) purchases community healthcare services by contracting with third-party administrators (TPAs), which in turn contract with community providers. When prescribing drugs, community providers submit prescription requests to be filled at VA pharmacies and must...

The VA Office of Inspector General (OIG) conducted a select review of Veterans Health Administration’s (VHA's) implementation of the 2022 United States Department of Veterans Affairs Sustainability Plan, which describes priority actions for achieving federal environmental sustainability goals...

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...

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...

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...