Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess an allegation that facility leaders failed to complete clinical and institutional disclosures for three identified patients. The OIG substantiated that one of the three patients received a delayed institutional...

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the leadership performance and oversight by Veterans Integrated Service Network 21: VA Sierra Pacific Network in Pleasant Hill, California. This evaluation...

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the Comprehensive Healthcare Inspection of the James E. Van Zandt VA Medical Center in Altoona, Pennsylvania. This evaluation focused on...

In July 1973, a fire damaged or destroyed up to 18 million Army and Air Force official military personnel files at the National Archives and Records Administration’s (NARA) National Personnel Records Center (NPRC) in St. Louis, Missouri. This disaster makes it difficult for affected veterans—those...

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the Royal C. Johnson Veterans’ Memorial Hospital in Sioux Falls and multiple outpatient clinics in Iowa and South Dakota. This evaluation...

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Michael E. DeBakey VA Medical Center (facility) in Houston, Texas, to evaluate Veterans Integrated Service Network (VISN) and facility leaders’ response to critical surgical events from 2018 through 2021 and assess...

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the Alexandria VA Health Care System, which includes the Alexandria VA Medical Center and associated outpatient...

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the Central Arkansas Veterans Healthcare System, which includes the John L. McClellan Memorial Veterans’ Hospital...

The VA Office of Inspector General (OIG) conducted national surveys of Veterans Integrated Service Network (VISN) patient safety officers (PSO) and facility patient safety managers (PSM). Both surveys focused on patient safety topics, including oversight, culture, staffing, and training. The OIG...

Anticipating a surge in disability benefits claims resulting from the passage of the PACT Act, the Veterans Benefits Administration (VBA) launched a project to automate the processing of hypertension (high blood pressure) claims—specifically, claims that request an increased evaluation or rating for...