Department of Veterans Affairs OIG

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate the 2016 overdose death of a patient in a residential treatment program (Program) at a Veterans Integrated Service Network 10 medical facility (Facility). The purpose of the inspection was to review the...

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA San Diego Healthcare System (Facility). The review covered key clinical and administrative processes associated with promoting quality care...

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Beckley VA Medical Center (Beckley), West Virginia, regarding a complainant’s allegations that delays in urological care, including kidney surgery, and an increase in a kidney lesion’s size occurred that resulted in an...

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to a complainant’s allegations regarding an anesthesiologist who provided outpatient sedation services at the James E. Van Zandt VA Medical Center (Facility), Altoona, Pennsylvania. The OIG did not substantiate an...

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to a complaint that a primary care provider (PCP1) at a Veteran Integrated Service Network (VISN) 20 Facility (Facility) continued to prescribe controlled substances to a patient at high-risk for overdose. The OIG...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review circumstances surrounding a Residential Rehabilitation Treatment Program patient’s death from heroin overdose at a Veterans Integrated Service Network (VISN) 1 medical facility (facility). The OIG determined that...

The VA Office of Inspector General (OIG) substantiated an allegation that the VA Southern Nevada Healthcare System’s (System) prosthetics laboratory did not provide timely and cost-effective services to veterans for frequently prescribed compression garments and orthotic shoes. The laboratory showed...

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Hudson Valley Health Care System (Facility). The review covered key clinical and administrative processes associated with promoting quality care...

The VA Office of Inspector General (OIG) conducted a risk assessment of the three types of charge cards used by VA—purchase cards (including convenience checks), travel cards, and fleet cards. Office of Management and Budget Memorandum M-13-21, Implementation of the Government Charge Card Abuse...

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Memphis VA Medical Center (Facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality...