Department of Veterans Affairs

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...

Identity, credential, and access management (ICAM) is a set of tools, policies, and systems used to ensure the right individual has access to the right resource, at the right time, for the right reason in support of federal business objectives. In February 2021, the VA Office of Inspector General...

The OIG investigated an allegation that an attorney at the Board of Veterans’ Appeals (BVA) may have accessed a BVA senior executive’s government email account without permission, including email concerning a personnel matter involving the attorney. The complaint further alleged that the attorney...

In a March 2021 review, the VA OIG identified several cases in which Veterans Benefits Administration (VBA) employees in Chicago, Illinois, improperly created debts in veterans’ accounts when reducing disability levels. The OIG conducted this review to determine the magnitude of the problem...

The VA Office of Inspector General (OIG) conducted an inspection to examine oversight of a provider who engaged in sexual misconduct toward patients and practiced acupuncture without credentials or privileges. The OIG also reviewed leaders’ awareness and response to these issues. Current and former...