Department of Veterans Affairs

The VA Office of Inspector General reviewed the Community Based Outpatient Clinics (CBOCs) and primary care clinics (PCCs) of the Wilmington VA Medical Center. The purpose of the review was to determine whether the CBOCs and PCCs provide safe, consistent, and high-quality health care for our...

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Beckley VA Medical Center and two outpatient clinics in West Virginia. The inspection covered key...

The OIG examines individual nonpharmaceutical proposals submitted by commercial contractors for Federal Supply Schedule contracts with an anticipated annual value of $3 million or more, with an anticipated annual value of $500,000 or more for dealers or resellers without significant sales to the...

The OIG examines individual pharmaceutical proposals submitted by commercial contractors for Federal Supply Schedule contracts that have an anticipated annual value of $5 million or more or that VA has asked the OIG to review. The OIG’s oversight work helps VA contracting officers negotiate fair and...

The VA Office of Inspector General (OIG) conducted a review of Veterans Health Administration (VHA) inpatient mental health unit (mental health unit) suicide risk identification processes, suicide prevention safety plans, mental health treatment coordinator (MHTC) role requirements, and discharge...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess the impact of additional staffing on patient access to care in the community through the VA Maryland Health Care System (system) in Baltimore. The OIG found that high consult volume contributed to system staff’s...

The OIG evaluated allegations related to (1) the crisis management of a client at the Everett Vet Center; (2) documentation added to the client’s clinical record by district 5, zone 1 (district) and Everett Vet Center leaders to justify lack of action; and (3) altered notes. The OIG reviewed...

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 Coatesville Healthcare System in Pennsylvania. This evaluation focused on five key content domains: • Culture • Environment of care •...

VBA’s Pension and Fiduciary Service, which administers the death benefits program, assists eligible claimants with burial expenses, plot costs, and transportation costs for a veteran’s remains. To streamline claims processing for death benefits, VBA launched a system called pension automation. This...

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 Boston Healthcare System in Massachusetts. This evaluation focused on five key content domains: • Culture • Environment of care • Patient...