Deficiencies in Case Management and Access to Care for HUD-VASH Veterans at the VA Greater Los Angeles Healthcare System in California

Date Issued: 1/30/2025

Report Number: 24-01598-43

Topics:  Care Coordination ● Clinical Care Services Operations ● Patient Care Services Operations

Leaders Failed to Ensure a Dermatologist Provided Quality Care at the Carl T. Hayden VA Medical Center in Phoenix, Arizona

Date Issued: 1/23/2025

Report Number: 24-00194-42

Topics:  Care Coordination ● Medical Staff Privileging Credentialing ● Patient Safety

Healthcare Facility Inspection of the VA Western New York Healthcare System in Buffalo

Date Issued: 1/8/2025

Report Number: 24-00597-22

Topics:  Patient Care Services Operations ● Patient Safety

Deficiencies in Inpatient Mental Health Suicide Risk Assessment, Mental Health Treatment Coordinator Processes, and Discharge Care Coordination

Date Issued: 12/18/2024

Report Number: 21-02389-23

Topics:  Care Coordination ● Mental Health ● Suicide Prevention

Staff Incorrectly Processed Claims When Denying Veterans’ Benefits for Presumptive Disabilities Under the PACT Act

Date Issued: 12/3/2024

Report Number: 24-00118-01

Topics:  PACT Act

Healthcare Facility Inspection of the VA Hudson Valley Healthcare System in Montrose, New York

Date Issued: 9/24/2024

Report Number: 24-00601-254

Topics:  Patient Safety



Additional Controls Are Needed to Improve the Reliability of Grant and Per Diem Program Data

Date Issued: 9/18/2024

Report Number: 23-02610-226

Topics:  Clinical Care Services Operations