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Source Id
324

Care in the Community Inspection of VA MidSouth Healthcare Network (VISN 9) and Selected VA Medical Centers

2024
23-01737-205
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

The Office of Inspector General (OIG) Care in the Community program evaluates selected performance elements of the Veterans Health Administration (VHA) Veterans Community Care Program. The resulting report describes selected care coordination activities required to initiate and process referrals for...

Veterans Health Administration Initiated Toxic Exposure Screening as Required by the Promise to Address Comprehensive Toxics (PACT) Act but Improvements Needed in the Training Process

2025
23-02682-09
Review
Department of Veterans Affairs OIG
Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducted a national review to evaluate Veterans Health Administration’s (VHA’s) implementation of the PACT Act of 2022, which mandated veteran toxic exposure screenings, and required clinical staff training. Section 603 of the PACT Act mandated that, within...

VBA Did Not Ensure Employees Sent Some Letters Using Its Package Manager Application

2025
23-00547-187
Review
Department of Veterans Affairs OIG
Department of Veterans Affairs

Package Manager is part of the Centralized Benefits Communication Management Program introduced in 2018 to modernize VBA mailing. The application bundles documents from veterans’ electronic claims folders and standard enclosures into virtual packages for printing and mailing. Employees then must...

Healthcare Facility Inspection of the VA Northeast Ohio Healthcare System in Cleveland

2025
24-00590-268
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 VA Northeast Ohio Healthcare System in Cleveland. This evaluation focused on five key content domains:• Culture• Environment of care• Patient...

Inspection of Select Vet Centers in Pacific District 5 Zone 1

2024
24-00386-265
Inspection / Evaluation
Department of Veterans Affairs OIG
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 at vet centers. The OIG inspected four randomly selected vet centers throughout Pacific district 5 zone 1: Anchorage, Alaska; Eugene, Oregon; and Everett...

Leaders Failed to Address Community Care Consult Delays Despite Staff’s Advocacy Efforts at VA Western New York Healthcare System in Buffalo

2024
23-03679-262
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations regarding community care consult appointment scheduling practices and delays for patients with serious health conditions who received community care at the VA Western New York Healthcare System (system)...

VHA Needs to Establish Internal Controls for Developing Its Ambulatory Care Budget Estimate

2024
23-01624-243
Audit
Department of Veterans Affairs OIG
Department of Veterans Affairs

Ambulatory care, which refers to medical services performed in outpatient settings, is the basis by which most care is delivered within the Veterans Health Administration (VHA) healthcare system. Because over half of VHA’s medical care budget is for ambulatory care (about $65.1 billion for FY 2023)...

VBA’s and NCA’s Personnel Suitability Programs Need Improved Governance

2024
23-02890-209
Audit
Department of Veterans Affairs OIG
Department of Veterans Affairs

In March 2018, the VA Office of Inspector General (OIG) reported on deficiencies within the Veterans Health Administration (VHA) personnel suitability program, concluding that neither VA nor VHA effectively governed the background investigation process to ensure requirements were met at medical...

Inspection of Select Vet Centers in Pacific District 5 Zone 2

2024
24-00388-266
Inspection / Evaluation
Department of Veterans Affairs OIG
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 at vet centers. The OIG inspected four randomly selected vet centers throughout Pacific district 5 zone 2: Corona and Temecula, California; and Kauai and...

Inspection of Select Vet Centers in Pacific District 5 Zone 3

2024
24-00389-267
Inspection / Evaluation
Department of Veterans Affairs OIG
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 at vet centers. The OIG inspected four randomly selected vet centers throughout Pacific district 5 zone 3: Phoenix and West Valley, Arizona; Antelope...

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