Department of Veterans Affairs OIG

The VA Office of Inspector General (OIG) conducted an inspection to evaluate the Veterans Integrated Service Network (VISN) 7 leaders’ effectiveness in identifying and resolving concerns regarding the VA Dublin Healthcare System’s (system’s) leadership and operational challenges. The OIG determined...

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Battle Creek Healthcare System in Michigan. This evaluation focused on five key content domains: • Culture • Environment of care • Patient...

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Southern Nevada Healthcare System in North Las Vegas. This evaluation focused on five key content domains: • Culture • Environment of care...

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Central Alabama Health Care System in Montgomery. This evaluation focused on five key content domains: • Culture • Environment of care •...

The VA Office of Inspector General (OIG) conducted an inspection to evaluate allegations concerning patients’ data security and related oversight practices within the national cancer prevention, treatment, and research program and Office of Research & Development (ORD). The OIG identified additional...

The VA Office of Inspector General (OIG) conducted a healthcare inspection of the VA Nebraska-Western Iowa Health Care System (facility) in Omaha from November 2024 through May 2025, following a congressional request to evaluate allegations related to the inpatient mental health unit’s environment...

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Syracuse VA Medical Center (facility) to assess allegations of reduced clinical services, poor leadership communication, and staff resignations. The OIG also identified concerns about patient transfer delays and...

This report presents the results of the VA OIG’s supplemental review of service obligations for VHA’s recruitment, relocation, and retention incentives, which follows on a report published in June 2025. While completing that audit, the OIG team became aware of an issue occurring when some VA...

The VA Office of Inspector General (OIG) identified a potential patient safety risk related to the Veterans Health Administration’s (VHA’s) use of generative artificial intelligence (AI) chat tools for clinical care and documentation. Generative AI creates new, original content by learning patterns...

The VA Office of Inspector General (OIG) evaluated allegations about the care of a patient at the Marion VA Health Care System (facility) who died by suicide. The OIG reviewed concerns that the patient’s traumatic brain injury (TBI), pain, and mental health needs were not addressed. The OIG...