Department of Veterans Affairs

VA OIG attorney-advisors conducted two related internal investigations following allegations that a then special agent in charge in the Office of Investigations engaged in inappropriate conduct or sexual harassment that his superiors ignored and that contributed to a hostile work environment. OIG...

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report highlights the results of a focused evaluation of VHA facilities’ high-risk processes. The report describes findings from healthcare inspections performed at 45 medical facilities during fiscal year 2021 that...

The VA Office of Inspector General (OIG) conducted a review of Veterans Health Administration’s lethal means safety (LMS) training, firearms access and safe storage discussions within suicide risk assessments and safety plans, and clinicians’ perspectives on lethal means interventions.The OIG...

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 Mountain Home VA Healthcare System, which includes the James H. Quillen VA Medical Center and multiple outpatient...

The OIG reviewed the Veterans Health Administration’s (VHA) progress in monitoring their follow-up of canceled appointments during the COVID-19 pandemic.In 2020, the OIG reported that VHA had not followed up on about 32 percent of canceled appointments. VHA then implemented the Cancelled...

The Office of Inspector General (OIG) Care in the Community healthcare inspection program examines clinical and administrative processes associated with providing quality outpatient healthcare to veterans. This report provides a focused evaluation of Veterans Integrated Service Network (VISN) 15 and...

The VA Office of Inspector General (OIG) assessed VA’s compliance with requirements to report staffing and vacancy data on its public-facing website and the clarity of related explanations. VA is mandated to publicly release this information each quarter under the Maintaining Internal Systems and...

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report highlights the results of an evaluation of VHA facilities’ mental health programs. The report describes findings from healthcare inspections performed at 44 medical facilities during fiscal year 2021 that...

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of Veterans Health Administration (VHA) facilities’ quality, safety, and value (QSV) programs. This report describes findings from healthcare inspections performed at 45 medical...

The Office of Inspector General (OIG) conducted a review to evaluate VA’s implementation of the Referral Coordination Initiative (RCI), a program designed to improve veterans’ timely access to care, empower patients to make informed care decisions, reduce providers’ administrative burden and...