An audit has found that ineffective oversight by the VA Loma Linda Healthcare System and staffing shortages at five of its outpatient clinics operating under contract contributed to the cancellation of more than two-thirds of patient appointments over a two‑year period.

The audit by the U.S. Department of Veterans Affairs Office of Inspector General was prompted by numerous hotline complaints about the problems at outpatient clinics in Rancho Cucamonga, Corona, Murrieta, Palm Desert and Victorville. It covered the 2022 and 2023 fiscal years.

“This lack of effective oversight delayed solutions that could have mitigated contracted staffing shortages and excessive appointment cancellations. Ultimately, a lack of effective oversight can reduce veterans’ access to care,” states the audit, published in September.

VA Loma Linda Healthcare System is a regional VA network serving 78,000 veterans that includes the Jerry L. Pettis Memorial VA Medical Center in Loma Linda and seven outpatient clinics across San Bernardino and Riverside counties. Five of the clinics are managed by STG International, a private company that provides health care delivery and other services to federal agencies, but clinics in Blythe and Hemet are not managed by STGi and were not part of the audit.

Staffing shortages cited

Of the 64,000 appointment cancellations over the two-year audit period, 44,000 of them were initiated by clinic staff due to staffing shortages. The Rancho Cucamonga and Palm Desert clinics failed to hit mandated staffing levels for the entire period, while the other three were out of compliance 90% of the time. Taken together, the clinics repeatedly exceeded the allowable number of appointment cancellations for more than 79% of the audit period.

In May 2023, for example, most Palm Desert clinic care teams — each of which are supposed to include a registered nurse, care manager, clinical associate and an administrative associate — were severely understaffed. Only one patient care team had all required staff, while others had partial or no staff, with some employees stretched across multiple teams and failing VA staffing standards, the audit states.

During the 2022 and 2023 fiscal years, the outpatient clinics repeatedly canceled more patient appointments than allowed under their VA contract. Monthly cancellations, the audit states, should have stayed below 11%, but the clinics averaged 14% to 27%.

The audit also noted that VA Loma Linda’s assistant director, who is responsible for monitoring operations of the outpatient clinics, did not effectively coordinate staffing levels with staff members, did not consistently enforce contract requirements and did not effectively monitor performance measures at the clinics.

“As a result, healthcare system leaders missed opportunities during the contract start-up to mitigate the noncompliance with contract requirements and ensure a more successful transition to the current contract,” according to the audit.

The audit did not name who was serving as assistant director at the time of the audit. According to VA Loma Linda’s website, its current assistant director is Evan Young, who was appointed to the position in March 2023.

Private contractor

The five Inland Empire clinics operate under a $123.7 million contract with Virginia‑based STG International, awarded by the VA in October 2020. STGi began managing the five clinics on Oct. 1, 2021, on behalf of VA Loma Linda. Following the 2021-22 fiscal year, the contract called for four option years through Sept. 30, 2026.

Although the audit did not name STG International as the contractor, federal public records and previous reporting by the Southern California News Group show the company began managing the clinics in 2021.

The audit noted that the contract amount changed over the years — from $123.7 million in 2020 to $141 million in April 2023 due to several modifications, such as increasing cost-per-patient rates and additional costs for facility equipment. But the amount decreased to $117 million in April 2024, when the VA removed the Murrieta and Palm Desert clinics from the contract and they reverted back to VA control due to issues with the contract.

Officials at STG International could not be reached for comment. Officials at VA Loma Linda did not respond to requests for comment.

Under fire

VA Loma Linda has faced years of scrutiny over its lack of oversight at the five outpatient clinics and delays in implementing recommended fixes. Persistent staffing shortages and inadequate monitoring have contributed to ongoing problems.

In February 2025, VA Acting Inspector General David Case told a House subcommittee that the VA Loma Linda’s unresolved community care deficiencies reflect a nationwide VA problem. A 40-page OIG report released in April 2024 highlighted its leadership’s failure to address obvious issues.

The report found that in 2022, VA Loma Linda made 992 referrals from its five STGi-managed clinics — the highest among all VA community-based outpatient clinics. Two weeks after STGi began managing the clinics, VA officials received a media inquiry about a patient who faced “access issues” at the Palm Desert facility.

Staffing shortages and full caseloads, according to the report, forced VA Loma Linda to pause new patient enrollment in May 2022, referring patients to outside physicians. Appointment wait times then ranged from 28 to more than 53 days — well above the VA’s seven-day target.

Unable to absorb the extra patients, the system increased use of community care providers, which the VA community care office struggled to schedule in a timely manner.

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OIG recommendations

The OIG recommended, among other things, that VA Loma Linda strengthen its process of monitoring staffing levels at its outpatient clinics, ensure accuracy of data relating to clinic performance standards, and review and enforce staffing contingency plans, including maximizing the contractor’s use of temporary replacements to minimize staffing shortages.

VA Loma Linda generally concurred with the OIG findings and provided corrective action plans, including improving how it oversees outpatient clinic contracts, speeding up provider credentialing, and requiring proper training before staff can schedule veteran appointments, according to the audit.