Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducted a healthcare inspection related to community care coordination delays for a patient with oral cancer at the Veterans Health Care System of the Ozarks (facility) in Fayetteville, Arkansas.The OIG determined that the facility’s Office of Community...

During a prior review, the VA Office of Inspector General (OIG) discovered three scenarios in which the VA improperly collected debts from veterans without first providing them with legally required notice and due process and notified VA. This management advisory memorandum gives VA the information...

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report highlights the results of a focused evaluation of Veterans Health Administration (VHA) facilities’ medication management related to remdesivir use. The report describes medication management-related...

The VA Office of Inspector General (OIG) assessed the oversight and stewardship of funds by the VA Cincinnati Healthcare System. The review team looked at four areas to determine if appropriate controls and oversight were in place for open obligations oversight, purchase card use, Medical/Surgical...

From August 1953 through December 1987, the Agency for Toxic Substances and Disease Registry estimated one million individuals could have been exposed to contaminated drinking water at Camp Lejeune, a US military training facility. In March 2017, VA established a presumption of military service...

The VA Office of Inspector General (OIG) assessed allegations at the VA Greater Los Angeles Health Care System in California (facility) that community living center (CLC) nursing staff failed to (i) assess a resident who was complaining of pain; (ii) properly document assessments, reassessments...

Given the importance of accurately and consistently deciding veterans’ claims for disability benefits, the Veterans Benefits Administration (VBA) includes in its quality assurance efforts special-focused reviews that target specific topic areas, such as military sexual trauma. The Office of...

The VA Office of Inspector General (OIG) assessed an allegation at the Michael E. DeBakey VA Medical Center (facility) that community living center (CLC) staff delayed life-sustaining treatment for a patient (Patient A) who experienced cardiac arrest and died. The OIG also reviewed an allegation...

In August 2020, the Veterans Health Administration’s (VHA) Office of Connected Care introduced a “digital divide” consult process where patients can receive a video-capable device (iPad) after obtaining a referral and a socioeconomic assessment. The VA Office of Inspector General (OIG) reviewed the...

The VA Office of Inspector General (OIG) conducted this review to determine whether the Veterans Benefits Administration (VBA) accurately adjusted compensation and pension benefit payments for fugitive felons as mandated by law. If VBA does not adjust payments, veterans who are fugitive felons will...