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 VA Bronx Healthcare System in New York. This evaluation focused on five key content domains: • Culture • Environment of care • Patient safety...

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

In 2023, the VA OIG received several allegations that raised concerns about the management of supplies and equipment and workplace culture at the Michael E. DeBakey VA Medical Center in Houston, Texas. The OIG initiated this review to evaluate whether the Houston facility supply chain management...

The VA Office of Inspector General (OIG) assessed aspects of community care and VA direct care programs at the Montana VA Healthcare System (system) for fiscal year 2022. Among patients who received VA primary care and VA mental health care, 98.8 and 77.5 percent, respectively, did so exclusively...

The OIG’s Mental Health Inspection Program (MHIP) evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on the inpatient care delivered at the Edward P. Boland VA Medical Center, part of the VA Central Western Massachusetts Healthcare...

The VA Office of Inspector General (OIG) conducted a national review to evaluate the governance structure and responsibilities related to the Veterans Integrated Service Network (VISN) Chief Mental Health Officer (CMHO) role. The OIG found that VHA communicated inconsistent mandatory and...

The OIG conducted a legislatively mandated review of the circumstances and the underlying conditions that led to VBA announcing a potential shortfall and the need for FY 2024 supplemental funding. In July 2024, the VA Secretary announced to Congress that VBA needed about $2.9 billion, in addition to...

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

In July 2024, VA informed Congress that the Veterans Health Administration (VHA) might need an additional $12 billion in funding in fiscal year (FY) 2025 to support medical care for the last three months of FY 2024 and all of FY 2025—primarily for community care, staffing, prosthetics, and pharmacy...

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to a congressional referral regarding the care of a patient who was admitted for alcohol withdrawal and later died at the Hampton VA Medical Center (facility) in Virginia. The OIG identified failures in the...