Each month, the VA Office of Inspector General publishes highlights of our oversight reports, congressional testimony, and investigative work. In June 2025, the VA OIG published nine reports that included 81 recommendations. Report topics varied from an evaluation of VA’s governance of recruitment, relocation, and retention incentives awarded for VHA positions to mental health inspections of the VA Salem Healthcare System in Virginia and the VA Philadelphia Healthcare System in Pennsylvania. On ...
Jul 15, 2025•7 min•Season 4Ep. 6
Each month, the VA Office of Inspector General publishes highlights of our oversight reports, congressional testimony, and investigative work. In May 2025, the VA OIG published 11 reports that included 54 recommendations. Report topics varied from an audit of the VHA’s Pain Management, Opioid Safety, and Prescription Drug Monitoring Program to a healthcare inspection to assess allegations of deficiencies in the emergency department care provided to a patient at the Martinsburg VA Medical Center ...
Jun 17, 2025•6 min•Season 4Ep. 5
This Semiannual Report to Congress summarizes the independent oversight efforts of the VA Office of Inspector General (OIG) from October 1, 2024, through March 31, 2025. Visit the VA OIG's website to read the full report . For this six-month period, the VA OIG identified nearly $3.3 billion in monetary impact for a return on investment of $28 for every dollar spent on oversight. These figures do not include the inestimable value of the healthcare oversight work completed to help save the lives o...
May 22, 2025•6 min•Season 4Ep. 4
The latest podcast episode of Veteran Oversight Now highlights the VA OIG’s oversight work during April 2025, including three healthcare facility inspections reports on facilities in Tennessee, New York, and Colorado. April 2025 Monthly Highlights Each month, the VA Office of Inspector General publishes highlights of our congressional testimony, investigative work, and oversight reports. In April 2025, the VA OIG published 12 reports that included 51 recommendations. Report topics varied from a ...
May 15, 2025•10 min•Season 4Ep. 3
Each month, the VA Office of Inspector General publishes highlights of our investigative work, congressional testimony, and oversight reports. In March 2025, the VA OIG published 17 reports that included 101 recommendations. Report topics varied from a review of VHA and VBA fiscal year 2024 supplemental funding requests and mental healthcare services at a Massachusetts’ VA medical center to a review of the veteran self-scheduling process for community care and supply and equipment management def...
Apr 10, 2025•7 min•Season 4Ep. 2
In this latest episode of Veteran Oversight Now , we’re bringing you highlights of our oversight work from February 2025. Hear Acting Inspector General David Case discuss VA’s challenges with implementing its new electronic health record system before Congress as well as Dr. Julie Kroviak, acting inspector general for the Office of Healthcare Inspections, who recently testified before Congress on concerns with VA community care. Plus updates on ongoing investigations and summaries of reports pub...
Mar 17, 2025•10 min•Season 4Ep. 1
In the latest episode of Veteran Oversight Now , VA Inspector General Michael J. Missal discusses the VA OIG’s latest Semiannual Report to Congress that covered oversight work from April 1 to September 30, 2024. This edition also includes highlights of the VA OIG’s work from October 2024. “I’m extremely proud of all the enhancements we’ve made and the exceptional improvements we helped to bring about for VA’s programs and operations, which ultimately improve the lives of veterans and their famil...
Nov 21, 2024•16 min•Season 3Ep. 10
In this latest episode of Veteran Oversight Now , we’re revisiting a highly downloaded episode from February 2024— Unpaid Postage Bill Delays Critical Cancer Screenings . Hear from a VA OIG healthcare inspection hotline director, who discusses delays in the receipt of patients’ colorectal cancer screening tests due to an unpaid postage bill by the Phoenix VA Health Care System in Arizona. This edition also includes highlights of the VA OIG’s work from September 2024. “The VISN actually led a sta...
Nov 07, 2024•31 min•Season 3Ep. 9
In this latest episode of Veteran Oversight Now , we’re revisiting a highly downloaded episode from April 2024— Veteran Dies Following Delay in “Code Blue” Alert at Memphis VA Medical Center . Hear from a VA OIG healthcare inspection hotline director discuss how a telemetry technician’s failure to follow a series of communications within the time frame established in the facility’s cardiac telemetry monitoring policy delayed initiating a code blue alert, ending with the patient’s death. This edi...
Oct 17, 2024•27 min•Season 3Ep. 8
In the latest episode of Veteran Oversight Now , a VA OIG healthcare inspection hotline director discusses findings at the Raymond G. Murphy VA Medical Center in Albuquerque, New Mexico, where there was no documentation of required reusable medical device reprocessing, which put patients at risk for infection if the reusable medical devices used during subsequent procedures were, in fact, not cleaned per requirements. The VA OIG also found that high-level disinfection documentation was missing a...
Aug 21, 2024•23 min•Season 3Ep. 7
In the latest episode of Veteran Oversight Now , a VA OIG healthcare inspection hotline director discusses allegations that facility staff at the VA Southern Nevada Healthcare System in Las Vegas delayed ordering medications following an elderly patient’s discharge from a community hospital. The OIG substantiated that inadequate care coordination led to a delay in ordering discharge medications and found deficiencies in facility staff's response to the patient’s death by suicide. “If you go by t...
Jul 18, 2024•31 min•Season 3Ep. 6
In the latest episode of Veteran Oversight Now , a VA OIG healthcare inspection hotline director discusses allegations that some patients’ behavioral health consults were being discontinued at the Oklahoma City VA Medical Center, which resulted in some significant delays in patients receiving recommended behavioral health services. This podcast edition also includes highlights of the VA OIG’s work from May 2024. “Both in the allegation and what we found was basically that the program manager lac...
Jun 20, 2024•23 min•Season 3Ep. 5
In the latest episode of Veteran Oversight Now , VA Inspector General Michael J. Missal discusses the VA OIG’s latest Semiannual Report to Congress that covered our oversight work from October 1, 2023, to March 31, 2024. Specifically, he shares results of our most recent work related to VA’s Electronic Health Record Modernization program. To date, the VA OIG has published 19 products addressing the program’s implementation across VA facilities nationwide. In addition, IG Missal shares his though...
May 29, 2024•23 min•Season 3Ep. 4
In the latest episode of Veteran Oversight Now , a VA OIG healthcare inspection hotline director discusses a telemetry technician’s failure to follow a series of communications within the time frame established in the facility’s cardiac telemetry monitoring policy delayed initiating a code blue alert, ending with the patient’s death. This edition also includes highlights of the VA OIG’s work from March 2024. “Once the patient's heart rate completely stopped and they went into asystole, that shou...
Apr 26, 2024•27 min•Season 3Ep. 3
In the latest episode of Veteran Oversight Now , a VA OIG healthcare inspection hotline director discusses how multiple OIG reports detail chronic leadership failures at the Indianapolis, Indiana VA medical center. This edition also includes highlights of the VA OIG’s work from February 2024. “It overall affects the care that the patients receive. Some of the care just wasn’t available anymore because they didn’t have the cardiologists available.” – Trina Rollins, VA Office of Inspector General,...
Mar 28, 2024•26 min•Season 3Ep. 2
In the latest episode of Veteran Oversight Now , a VA OIG healthcare inspection hotline director discusses delays in the receipt of patients’ colorectal cancer screening tests due to an unpaid postage bill by the Phoenix VA Health Care System in Arizona. This edition also includes highlights of the VA OIG’s work from January 2024. “The VISN actually led a stand-down at the facility to retrain all of the laboratory staff about the test, about the assessing of the test and processing it. And then ...
Feb 22, 2024•31 min•Season 3Ep. 1
In the latest episode of Veteran Oversight Now , VA Inspector General Michael J. Missal shares his thoughts on changes to federal oversight since the passage of the Inspector General Act in 1978, which established 12 presidentially appointed IGs in federal departments with a mission to provide independent oversight. The VA OIG was one of the original 12. He also discusses the VA OIG’s latest Semiannual Report to Congress that covered oversight work from April 1 to September 30, 2023. This editio...
Nov 28, 2023•36 min•Season 2Ep. 9
In this latest episode of Veteran Oversight Now , a VA OIG healthcare inspection hotline director discusses the lessons learned in the care of a veteran who died after a fall in a VA outpatient clinic, part of the Southern Nevada Healthcare System in Las Vegas. This edition also includes highlights of the VA OIG’s work from August 2023. “Since [the incident] happened, the facility has made several adjustments to ensure that in an emergency situation that staff is knowledgeable of the processes t...
Sep 26, 2023•32 min•Season 2Ep. 8
In the latest episode of Veteran Oversight Now , a VA OIG healthcare inspection hotline director discusses deficiencies in the quality of emergency department care for a veteran who died by suicide at the John Cochran Division of the VA St. Louis Healthcare System in Missouri. This edition also includes highlights of the VA OIG’s work from July 2023. “Approximately 10 minutes later is when the staff person finds the patient unresponsive in the exam room with a ligature around his neck. A code wa...
Aug 24, 2023•49 min•Season 2Ep. 7
In the latest episode of Veteran Oversight Now , a VA OIG healthcare inspection hotline director discusses missteps in the care of a veteran who eventually committed suicide on the grounds of the Aiken Community Based Outpatient Clinic, part of the Charlie Norwood VA Medical Center in Augusta, Georgia. This edition also includes highlights of the VA OIG’s work from June 2023. “In VA you're assigned a primary care provider called your PCP, that, in theory, should be the main provider you see. Tha...
Jul 26, 2023•47 min•Season 2Ep. 6
In the latest episode of Veteran Oversight Now , a VA OIG healthcare inspection hotline director discusses how she and her team triage healthcare-related hotline inquiries. She shares how concerns over the management of a patient safety program led to an inspection and subsequent report at the Tuscaloosa VA Medical Center in Alabama. This edition also includes highlights of the VA OIG’s work from May 2023. “I think the takeaway for all of this is VHA needs to ensure involvement of all staff in t...
Jun 15, 2023•39 min•Season 2Ep. 5
IG Michael J. Missal discusses the VA OIG's 89th Semiannual Report to Congress covering the reporting period of October 1, 2022, to March 31, 2023. Plus oversight highlights from the VA OIG's work in March and April of 2023. For this six-month period, the VA OIG identified more than $401 million in monetary impact for a return on investment of $4 for every dollar spent on oversight. These figures do not include the inestimable value of the healthcare oversight work completed to advance patient s...
May 24, 2023•25 min•Season 2Ep. 4
In this episode, host Fred Baker talks with Dr. Julie Kroviak, the principal deputy assistant inspector general of the VA OIG’s Office of Healthcare Inspections, about changes to how cyclical healthcare reviews are conducted. Dr. Kroviak explains how her teams are reworking the Comprehensive Healthcare Inspection Program cyclical reports to provide more information on the veteran communities being served by VA medical facilities. Additionally, she shares how, for the first time, the VA OIG will ...
Mar 23, 2023•21 min•Season 2Ep. 3
In this episode of Veteran Oversight Now, host Fred Baker talks with Shawn Steele, the director of the VA OIG’s Office of Audits and Evaluations Healthcare Infrastructure Division. Taking a very unique approach, 150 OIG staff recently mobilized to evaluate the security posture of 70 VA medical facilities over three days. Persistent police staffing shortages and growing concerns about incidents that put VA staff, patients, and visitors at risk led the OIG to conduct the review, Security and Incid...
Feb 22, 2023•29 min•Season 2Ep. 2
In this episode of Veteran Oversight Now, host Fred Baker chats with Dr. Beth Winter, a psychiatrist with the VA OIG’s Office of Healthcare Inspections. They discuss her path from wanting to provide care for exotic animals to choosing to be “a people doctor instead of an animal doctor.” Dr. Winter’s distinguished career eventually led the granddaughter and daughter of veterans to the VA OIG helping provide oversight of VHA’s health care system. In this podcast, Dr. Winter discusses her work rela...
Jan 19, 2023•43 min•Season 2Ep. 1
The Semiannual Report to Congress summarizes the VA Office of Inspector General’s (OIG) oversight efforts from April 1 through September 30, 2022. For this six-month period, the VA OIG identified more than $1.4 billion in monetary impact for a return on investment of $16 for every dollar spent on oversight—which brings the fiscal year 2022 totals to nearly $4.6 billion in monetary impact for a return on investment of $24 for every dollar spent on oversight. These figures do not include the inest...
Nov 29, 2022•30 min•Season 1Ep. 11
Mentioned Investigations: Former VA Hospital Nursing Assistant Sentenced to Seven Consecutive Life Sentences for Murdering Seven Veterans and Assault with Intent to Commit Murder of an Eighth Fayetteville Doctor Sentenced To 20 Years In Federal Prison For Mail Fraud And Involuntary Manslaughter Retail Ready Owner to Forfeit $72M for VA Tuition Fraud...
Nov 01, 2022•29 min•Season 1Ep. 10
Related Reports: OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages Fiscal Year 2022 Pursuant to the VA Choice and Quality Employment Act of 2017 (VCQEA), the OIG conducted a review to identify clinical and non-clinical occupations experiencing staffing shortages within Veterans Health Administration (VHA). This is the ninth iteration of the staffing report, and the fifth evaluating facility-level data. The OIG evaluated staffing shortages by surveying VHA faci...
Sep 20, 2022•30 min•Season 1Ep. 9
Related Reports: Airborne Hazards and Open Burn Pit Registry Exam Process Needs Improvement Since 1990, some 3.5 million veterans have served in areas that potentially exposed them to airborne hazards and open burn pit toxins, which have been associated with health problems. In 2013, Congress ordered VA to establish a registry to research the potential health impacts of exposures. The VA Office of Inspector General (OIG) reviewed the management of registry exams, including whether VA medical fac...
Aug 25, 2022•34 min•Season 1Ep. 8
The Office of Investigations investigates potential crimes and civil violations of law involving VA programs and operations committed by VA employees, contractors, beneficiaries, and other individuals. These investigations focus on a wide range of matters including healthcare, procurement, benefits, construction, and other fraud; cybercrime and identity theft; bribery and embezzlement; drug offenses; and violent crimes. The office is staffed by special agents with full law enforcement authority,...
Jul 15, 2022•36 min•Season 1Ep. 7
