Department of Veterans Affairs

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 evaluated leadership stability, morbidity and mortality reviews, and the high risk...

In August 2022, the PACT Act significantly expanded veterans’ eligibility for benefits and services for conditions related to toxic exposure. The expansion added further complexity to VBA’s claims determination process, particularly given the voluminous guidance issued for nonpresumptive conditions...

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Lexington VA Healthcare System (system) in Kentucky to determine the validity of an allegation that patients seeking or receiving acute mental health treatment did not receive the care needed. The OIG substantiated...

The VA Office of Inspector General (OIG) issued this brief report to highlight a concern regarding the Veterans Health Administration’s (VHA’s) lack of national guidance regarding patients who use personally owned insulin pumps to manage their diabetes and present to emergency departments or...

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

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...