Department of Veterans Affairs

This Office of Inspector General Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the outpatient settings at the West Texas VA Health Care System and associated outpatient clinics in Texas and New Mexico. This evaluation focused on four key...

The VA Office of Inspector General (OIG) conducted an inspection to review allegations that providers at the Charlie Norwood VA Medical Center in Augusta, Georgia, delayed care and failed to “provide services,” for a patient who died by suicide on the grounds of the Aiken Community Based Outpatient...

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA Black Hills Health Care System (facility) in Fort Meade and Hot Springs, South Dakota, to evaluate how facility leaders addressed an administrative investigation board’s (AIB) findings and recommendations.The OIG...

The VA OIG issued a management advisory memorandum to highlight concerns regarding outdated policies governing the Veterans Health Administration’s (VHA’s) mental health services and requested follow-up action. Two policies cited in the memorandum, VHA Handbook 1160.01(1), Uniform Mental Health...

The VA Office of Inspector General (OIG) assessed allegations that San Diego VA Medical Center (facility) staff provided an inadequate evaluation of cognitive functioning, suicide risk, grave disability, and care coordination for a patient who died approximately six hours after leaving the facility...

This Office of Inspector General Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the VA Long Beach Healthcare System, which includes the Tibor Rubin VA Medical Center and multiple outpatient clinics in...

The VA Office of Inspector General (OIG) conducted a review to assess implementation and use of VA Video Connect (VVC) prior to and during the COVID-19 pandemic. The OIG explored why providers used telephone communication more frequently than VVC at the onset of the pandemic and how the Veterans...

The VA Office of Inspector General (OIG) reviewed how the Medical Disability Examination Office (MDEO) is monitoring mileage requirements in the contract exam process because veterans reported on satisfaction surveys that they had to travel excessive distances to attend exams.Contracts with...

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 9: VA MidSouth Healthcare Network in Nashville, Tennessee. This evaluation...

The COVID-19 pandemic caused a surge in demand for ventilators and provoked concerns about potential supply shortages across VA medical facilities. During the course of a previous broader review, the VA Office of Inspector General (OIG) uncovered a potential issue with the number of ventilators...