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Source Id
324

Noncompliance with Community Care Referrals for Substance Abuse Residential Treatment at the VA North Texas Health Care System

2023
21-03864-34
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

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)...

Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California

2023
22-01363-52
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

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...

Delayed Cancer Diagnosis and Deficiencies in Care Coordination for a Patient at the Overton Brooks VA Medical Center in Shreveport, Louisiana

2023
21-02612-53
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

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...

Poor Emergency Department Care of a Patient at the Baltimore VA Medical Center in Maryland

2023
22-01668-45
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

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...

Inadequate Supervision of a Mental Health Provider and Improper Records Management for a Female Patient at the VA Greater Los Angeles Health Care System in California

2023
21-03734-32
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 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)...

Inspection of Information Security at the Tuscaloosa VA Medical Center in Alabama

2023
22-01854-13
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

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...

Vet Center Inspection of Midwest District 3 Zone 1 and Selected Vet Centers

2023
21-03231-38
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

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...

Inspection of Information Security at the Southern Oregon Rehabilitation Center and Clinics

2023
22-01836-12
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducts information security inspections to assess whether VA facilities are meeting federal security requirements. These inspections focus on four security control areas that apply to local facilities and have been selected based on their levels of risk...

Deficiencies in Credentialing, Privileging, and Evaluating a Cardiologist at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana

2023
22-00029-40
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

The VA Office of Inspector General (OIG) assessed allegations at the Richard L. Roudebush VA Medical Center (facility) that a newly trained interventional cardiologist was hired despite poor training and references. Further allegations claimed that the interventional cardiologist provided poor...

Comprehensive Healthcare Inspection of the El Paso VA Health Care System in Texas

2023
22-00043-39
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

This Office of Inspector General Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the outpatient care provided at the El Paso VA Health Care System in Texas. This evaluation focused on four key operational areas:• Leadership and organizational risks...

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