Department of Veterans Affairs OIG

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate allegations that surgical pathology specimen processing delays in the pathology and laboratory medicine service (P&LMS) resulted in multiple patients’ harm and possibly death, and follow-up on the facility’s...

The VA Office of Inspector General (OIG) conducted a healthcare inspection, in response to a notification that a hospitalized patient died by suicide and a subsequent request from House Veterans Affairs Committee Chairman Mark Takano, to review the circumstances of the death. Inpatient death by...

The VA Office of Inspector General (OIG) performed this audit to determine if Veterans Health Administration (VHA) medical facilities are scanning and entering medical documentation into patients’ records accurately and in a timely manner. VHA healthcare staff rely on medical records to manage...

The VA Office of Inspector General (OIG) conducted this audit to determine whether the Office of Information and Technology and the Veterans Health Administration (VHA) effectively managed the implementation of VA’s Veterans Information Systems and Technology Architecture (VistA) Scheduling...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess the validity of allegations regarding a delay in performing an appendectomy, that the delay was caused by inadequate resident oversight, and surgeons paid by the VA were unavailable because they were working for...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations that staff at the San Diego VA Healthcare System, California, failed to provide mental health care to a patient who subsequently died by suicide. The OIG did not substantiate that the system failed to...

In response to a congressional request, the VA Office of Inspector General (OIG) conducted this audit to determine whether processors of non-VA emergency care claims inappropriately denied or rejected the claims, and, if so, whether the cause was pressure to meet production standards. The OIG...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate care of a patient who died in a behavioral health unit at the Gulf Coast Veterans Health Care System, Biloxi, Mississippi. The specific concern was the unit staff’s failure to initiate full resuscitation efforts...

The VA Office of Inspector General (OIG) conducted an inspection in response to episodes of non-adherence to Veterans Health Administration (VHA) and VA policies on patient information privacy and security at the Tibor Rubin VA Medical Center, Long Beach, California. After a VA computer update, a...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess sustained performance of actions taken to close previous OIG recommendations at the Veterans Crisis Line (VCL) located in Canandaigua, New York; Atlanta, Georgia; and Topeka, Kansas. VCL is a crisis hotline...