Inside Oversight

In this episode of Inside Oversight , Nicole Maxey, a nurse consultant with the Office of Healthcare Inspections, discusses the VA OIG’s evaluation of the transition of clinical care for service members with opioid use disorder from the Department of Defense to the Veterans Health Administration. Nicole describes deficiencies in documenting patients’ opioid use disorder, as well as the barriers fa...

In this podcast episode of Inside Oversight , Erica Taylor, a health system specialist with the Office of Healthcare Inspections, discusses a healthcare inspection at the West Palm Beach VA Healthcare System in Florida that assessed allegations related to a patient’s cancer care coordination.     “Over the years, the OIG has published many reports detailing issues related to appointment scheduling...

In this episode of Inside Oversight , Amanda Newton, an associate director with the Office of Healthcare Inspections, discusses a report on deficiencies with the Patient Safety Program at the Tuscaloosa VA Medical Center in Alabama. She shares how a lack of resources, supervisory engagement, and failure of facility leaders to act impacted the medical center’s culture of safety. Find this episode a...

In this episode, Dr. Amber Singh, an associate director with the VA OIG’s mental health team within the Office of Healthcare Inspections, discusses a published report on VHA’s Intimate Partner Violence Assistance Program. Her team conducted a national review of the program to evaluate implementation status and identify perceived barriers to compliance by surveying program coordinators and leaders....

In this episode of Inside Oversight, Dr. Wanda Hunt, a healthcare systems specialist with the VA OIG’s Office of Healthcare Inspections, discusses a recently published report on VHA’s Intensive Community Mental Health Recovery Programs. Her team examined the visit frequency for veterans enrolled in these programs between April 2019 and March 2021, as well as evaluated VHA healthcare systems’ conti...

Related Report: Failure to Mitigate Risk of and Manage a COVID-19 Outbreak at a Community Living Center at VA Illiana Health Care System in Danville, Illinois The VA OIG conducted an inspection at the VA Illiana Health Care System in Danville, Illinois, to determine the validity of allegations, specific to COVID-19 and the Community Living Center (CLC), of failure to observe infection control prac...

Related Report: Failure to Follow a Consult Process Resulting in Undocumented Patient Care at the Chillicothe VA Medical Center in Ohio The VA OIG conducted a healthcare inspection for 10 allegations related to the quality and management of patient care and the availability of resources within the Urgent Care Center at the Chillicothe VA Medical Center in Ohio. One allegation involved an urgent ca...

Related Report: Care in the Community Healthcare Inspection of VA Midwest Health Care Network (VISN 23) The OIG Care in the Community healthcare inspection program examines clinical and administrative processes associated with providing quality outpatient healthcare to veterans. This report provides a focused evaluation of Veterans Integrated Service Network (VISN) 23 and its oversight of the qual...

Vet Center Inspection Program: The VA Office of Inspector General Vet Center Inspection Program (VCIP) provides a focused evaluation of aspects of the quality of care delivered at vet centers. Vet centers are community-based clinics that provide a wide range of psychosocial services to clients, including eligible veterans, active duty service members, National Guard members, reservists, and their...

Related Report: Suicide Prevention Coordinators Need Improved Training, Guidance, and Oversight Report Summary:  As part of the Veterans Health Administration’s (VHA) suicide prevention strategy, suicide prevention coordinators at VA medical facilities are required to reach out to veterans referred from the Veterans Crisis Line. Coordinators provide access to assessment, intervention, and effectiv...

Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient’s Death by Suicide at the Harry S Truman Memorial Veterans’ Hospital in Columbia, Missouri The VA OIG conducted a healthcare inspection to determine the validity of an allegation regarding a patient’s mental health care at the Harry S. Truman Memorial Veterans’ Hospital (facility) in Columbia, Missouri, prio...

Challenges for Military Sexual Trauma Coordinators and Culture of Safety Considerations The VA OIG conducted a review of select activities and challenges of Military Sexual Trauma (MST) Coordinators and Veterans Integrated Service Network Points of Contact in response to a request from Congressman Chris Pappas, Chairman of the House Veterans’ Affairs’ Subcommittee on Oversight and Investigations,...

Review of Veterans Health Administration’s Virtual Primary Care Response to the COVID-19 Pandemic The VA Office of Inspector General (OIG) conducted a review to assess Veterans Health Administration’s (VHA) virtual primary care response to the COVID-19 pandemic, as well as the use of virtual care by primary care providers and their perceptions of VA Video Connect (VVC) between February 7 and June...

Senior Auditors Geoff Ferguson and Gris Soto discuss two related reports on improper payments for community acupuncture and chiropractic services and overall risks to evaluation and management services. In the first report, the VA OIG audited acupuncture and chiropractic care by non‑VA providers after becoming aware of patterns that suggested questionable billing practices by those providers. In t...

In this episode of Inside Oversight, Daniel Morris, a director within the Office of Audits and Evaluations, provides insight into a recent VA OIG management advisory memo that reported on concerns with consistency and transparency in the calculation and disclosure of VHA’s patient wait times. Report Summary: Concerns with Consistency and Transparency in the Calculation and Disclosure of Patient Wa...