Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducted a national review to assess elements of the Veterans Health Administration’s (VHA’s) Intensive Community Mental Health Recovery programs (ICMHR). ICMHR provides highly intensive community-based care to veterans with serious mental illness. Visit...

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 Memphis VA Medical Center in Tennessee. This evaluation focused on five key operational areas:• Leadership and...

The VA Office of Inspector General (OIG) conducted this inspection to assess the stewardship and oversight of funds by the VA Palo Alto Health Care System in California. This inspection assessed financial activities and administrative processes to determine whether appropriate controls and oversight...

The VA Office of Inspector General (OIG) evaluated allegations that VA North Texas Health Care System (VA North Texas) domiciliary substance use disorder treatment program (DOM SUD) staff placed patients on waitlists and failed to offer non-VA community residential care (community residential care)...

The VA Office of Inspector General (OIG) evaluated allegations that a patient presented unscheduled to the Chico Community-Based Outpatient Clinic in California (Chico CBOC) and later was involved in a violent incident with family members, and facility leaders did not address employee concerns...

The VA Office of Inspector General (OIG) evaluated allegations that a primary care provider did not timely identify a liver abnormality nor inform a patient about a terminal cancer diagnosis at Overton Brooks VA Medical Center (facility) in Shreveport, Louisiana. The OIG identified additional...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess an allegation that a patient received poor care in the Emergency Department at the Baltimore VA Medical Center (facility) in Maryland, which resulted in an amputation at the patient’s left forearm at a non-VA...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations related to the mental health care of a female patient at the VA Greater Los Angeles Healthcare System (facility) in California, which included that a psychiatry physician resident (psychiatry trainee)...

The VA Office of Inspector General (OIG) conducts information security inspections to assess whether VA facilities are meeting federal security requirements. They are typically conducted at selected facilities that have not been assessed in the sample for the annual audit required by the Federal...

The Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered at vet centers. This report focuses on Midwest district 3 zone 1 and four selected vet centers: Cleveland, Columbus, and Toledo in Ohio; and South Bend in...