Department of Veterans Affairs OIG

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess the impact of additional staffing on patient access to care in the community through the VA Maryland Health Care System (system) in Baltimore. The OIG found that high consult volume contributed to system staff’s...

The OIG evaluated allegations related to (1) the crisis management of a client at the Everett Vet Center; (2) documentation added to the client’s clinical record by district 5, zone 1 (district) and Everett Vet Center leaders to justify lack of action; and (3) altered notes. The OIG reviewed...

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 Coatesville Healthcare System in Pennsylvania. This evaluation focused on five key content domains: • Culture • Environment of care •...

VBA’s Pension and Fiduciary Service, which administers the death benefits program, assists eligible claimants with burial expenses, plot costs, and transportation costs for a veteran’s remains. To streamline claims processing for death benefits, VBA launched a system called pension automation. This...

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 Boston Healthcare System in Massachusetts. 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 Connecticut Healthcare System in West Haven. This evaluation focused on five key content domains: • Culture • Environment of care •...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate facility leaders’ response to surgical care concerns related to two facility surgeons at the St. Cloud VA Medical Center (facility) in Minnesota. The OIG found facility leaders generally met the Veterans Health...

In July 2022, the VA Office of Inspector General (OIG) published a report finding that Veterans Benefits Administration (VBA) staff prematurely denied service connected compensation to veterans with conditions that could be associated with burn pit exposure. The OIG made seven recommendations, and...