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Source Id
324

The Accuracy of Veteran Readiness and Employment Claims Cannot Be Assessed Because of Insufficient Documentation

2025
23-03328-197
Audit
Department of Veterans Affairs OIG
Department of Veterans Affairs

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...

Inadequate Oversight Allowed a Senior Benefits Representative to Inaccurately Authorize Thousands of Decisions

2025
24-03608-203
Review
Department of Veterans Affairs OIG
Department of Veterans Affairs

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...

Review of Response to Changes in a Patient’s Condition and Quality Reviews at the VA Greater Los Angeles Healthcare System in California

2026
24-03531-09
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

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...

Healthcare Facility Inspection of the Eastern Oklahoma VA Health Care System in Muskogee

2026
25-00194-239
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

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 •...

VHA Did Not Effectively Oversee the Use of Manual Journal Vouchers

2025
25-00451-200
Audit
Department of Veterans Affairs OIG
Department of Veterans Affairs

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...

Loma Linda Healthcare System’s Oversight of Community-Based Outpatient Clinic Contracts Needs Strengthening

2025
23-00324-170
Review
Department of Veterans Affairs OIG
Department of Veterans Affairs

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...

Better Guidance and Measures Would Help Optimize the Productivity of Clinical Resource Hub Physicians

2025
24-03319-213
Audit
Department of Veterans Affairs OIG
Department of Veterans Affairs

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...

Healthcare Facility Inspection of the West Palm Beach VA Healthcare System in Florida

2025
25-00190-226
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

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

Weak Governance Threatens the Viability of a Major Construction Project at the Palo Alto VA Medical Center in California

2025
23-03189-148
Review
Department of Veterans Affairs OIG
Department of Veterans Affairs

In its fiscal year (FY) 2009 budget request, VA identified the need for the Palo Alto major construction project to improve seismic safety at the Palo Alto Health Care System. The planned construction project would also provide ambulatory and polytrauma care. Over the next 15 years, the project’s...

Deficiencies in Consult Management in the Endocrinology Service at the VA Fayetteville Coastal Healthcare System in North Carolina

2025
24-02634-229
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review allegations regarding internal endocrine consult management, endocrine clinic utilization, and patient access to gender-affirming hormone therapy (GAHT) at the VA Fayetteville Coastal Healthcare System (system) in...

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