Veteran Oversight Now

Highlights of VA OIG's Oversight Work from August

Each month, the VA Office of Inspector General publishes highlights of our oversight reports, congressional testimony, and investigative work. In August 2025, the VA OIG published 17 reports that included 72 recommendations to VA.    Report topics included a review of medical facilities in VISN 12 (VA Great Lakes Health Care System) and whether they correctly identified veterans eligible for community care, informed them of their care options, and delivered timely care. Another report recommended VA medical facilities improve the monitoring of pharmacy automated dispensing cabinets for accountability over high-risk medications.   VA OIG investigative efforts resulted in the conviction of a former nurse at a Texas VA medical center who falsely claimed she had checked on a patient who ultimately died. In addition, a former VA-appointed fiduciary was indicted for allegedly stealing more than $133,000 from an elderly veteran who resided at the Cincinnati VA Medical Center.    Related Reports:   ·        VISN 12 Needs to Improve How It Administers the Veterans Community Care Program [https://www.vaoig.gov/reports/review/visn-12-needs-improve-how-it-administers-veterans-community-care-program]   ·        Pharmacy Automated Dispensing Cabinets Need Improved Monitoring for Accountability over High-Risk Medications [https://www.vaoig.gov/reports/review/pharmacy-automated-dispensing-cabinets-need-improved-monitoring-accountability-over]   ·        Inconsistent Implementation of VHA Oncology Program Requirements Due to Insufficient Oversight [https://www.vaoig.gov/reports/national-healthcare-review/inconsistent-implementation-vha-oncology-program-requirements]

Highlights of VA OIG’s Oversight Work from July

The Honorable Cheryl L. Mason was confirmed by the Senate as the inspector general of the VA on July 31, 2025, and shortly after being sworn in, took up her leadership of the VA OIG on August 4. IG Mason previously served as the chairman of the Board of Veterans’ Appeals at VA. For more information on IG Mason, see her bio [https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.vaoig.gov%2Fabout-us%2FInspector-General&data=05%7C02%7C%7C8e052008f80740e279ff08dddb3e3d9b%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638907782540896560%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=Jmx0D9M804cMi1NdtAKXIYB3%2Fw3KNhGqwlgH85jUqgM%3D&reserved=0].   In July 2025, the VA OIG published 18 reports that included 101 recommendations. Report topics included a review of VBA’s planning and implementation of the Military Sexual Trauma Operations Center and its governance structure for processing these types of claims. Another healthcare inspection examined deficiencies in care at the Batavia Community Living Center that contributed to a resident’s death at the VA Western New York Healthcare System in Buffalo.    On Capitol Hill, Shawn Steele, director of the human capital and operations division for the Office of Audits and Evaluations, testified on July 22 at a hearing before the Subcommittee on Oversight and Investigations of the House Veterans’ Affairs Committee (HVAC). His testimony focused on the OIG’s findings in a recent report on deficiencies in VA’s oversight of recruitment, retention, and relocation incentive payments.   VA OIG investigative efforts contributed to the indictment of 11 members of a transnational criminal organization who submitted billions in fraudulent claims to federal and private health insurance programs for durable medical equipment that was never prescribed or issued to the beneficiaries. In addition, a veteran pleaded guilty in Florida to VA disability compensation benefits fraud as the result of a proactive investigation. The loss to VA is about $1.1 million. Related Reports:   * Implementation of a Military Sexual Trauma Operations Center Resulted in Minimal Change Despite Planned Intent to Improve Claims-Processing Accuracy [https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.vaoig.gov%2Freports%2Freview%2Fimplementation-military-sexual-trauma-operations-center-resulted-minimal-change&data=05%7C02%7C%7C8e052008f80740e279ff08dddb3e3d9b%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638907782540922135%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=q%2BCuWb65RG9v8HpoKRVhneW3uvtKhGwOfjeVv7ZN2wo%3D&reserved=0]   * Deficiencies in Care at the Batavia Community Living Center Contributed to a Resident’s Death at the VA Western New York Healthcare System in Buffalo [https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.vaoig.gov%2Freports%2Fhotline-healthcare-inspection%2Fdeficiencies-care-batavia-community-living-center-contributed&data=05%7C02%7C%7C8e052008f80740e279ff08dddb3e3d9b%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638907782540938048%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=HIHgACUnuPJAQ57SChBl18UTwSsZmaPVpnwM1HueYOU%3D&reserved=0]   * Failures Related to the Care and Discharge of a Patient and Leaders’ Response at the VA New Mexico Healthcare System in Albuquerque [https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.vaoig.gov%2Freports%2Fhotline-healthcare-inspection%2Ffailures-related-care-and-discharge-patient-and-leaders&data=05%7C02%7C%7C8e052008f80740e279ff08dddb3e3d9b%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638907782540952270%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=5cXSfXVaQJKscgTRUO9%2BZ463HW4ikEjKVKkV8CMS7VM%3D&reserved=0]

Highlights of VA OIG’s Oversight Work from June

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 Capitol Hill, Jennifer McDonald, PhD, director of the Community Care Division for the Office of Audits and Evaluations, testified on June 11 before the House Veterans’ Affairs’ Subcommittee on Oversight and Investigations. Her testimony focused on the impact of VHA’s pause in using its Program Integrity Tool—a system that consolidates community care payment data that is used, in part, to determine if veterans or their private insurance companies should be billed for care that is not connected to injuries or conditions related to their military service. She also highlighted the OIG’s work that identified deficiencies in how VA plans, implements, and remediates identified weaknesses in information technology modernization efforts.    VA OIG investigative efforts resulted in the conviction of a chief executive officer of a healthcare software company for a billion-dollar fraud conspiracy. Meanwhile, VA OIG investigative efforts in Louisiana led to the sentencing of two individuals for fraudulently obtaining federal pandemic relief loans.    Related Reports:   * Recruitment, Relocation, and Retention Incentives for VHA Positions Need Improved Oversight [https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.vaoig.gov%2Freports%2Faudit%2Frecruitment-relocation-and-retention-incentives-vha-positions-need-improved-oversight&data=05%7C02%7C%7C45db8f0c961b48dfc09808ddc07b148c%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638878357033144162%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=KnqIaE3xGW1cNy5cLAPGY%2BndjiYnhEAQMFjiBKLecEI%3D&reserved=0]   * Mental Health Inspection of the VA Salem Healthcare System in Virginia [https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.vaoig.gov%2Freports%2Fmental-health-inspection-program%2Fmental-health-inspection-va-salem-healthcare-system&data=05%7C02%7C%7C45db8f0c961b48dfc09808ddc07b148c%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638878357033161520%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=R5AyzOeN8vC2AhNZlbdjve8vJpyfUexOsMkg2xX8RFE%3D&reserved=0]   * Mental Health Inspection of the VA Philadelphia Healthcare System in Pennsylvania [https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.vaoig.gov%2Freports%2Fmental-health-inspection-program%2Fmental-health-inspection-va-philadelphia-healthcare-system&data=05%7C02%7C%7C45db8f0c961b48dfc09808ddc07b148c%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638878357033181804%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=wypeSBtzQhLbmt%2Fzub8zfKnu%2BMCsmNPSVA7uH1Q33oU%3D&reserved=0]

Highlights of VA OIG’s Oversight Work from May

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 in West Virginia.    On Capitol Hill, Deputy Assistant IG Brent Arronte, in the Office of Audits and Evaluations, testified on May 14 before the House Veterans’ Affairs’ Subcommittee on Disability Assistance and Memorial Affairs. His testimony focused on the OIG’s independent oversight of VA’s compensation and benefits programs, specifically how inadequate staff training combined with often unclear and inadequate guidance contribute to incorrect payments being made to veterans.    VA OIG investigative efforts resulted in the sentencing of four defendants for their roles in an $110 million healthcare kickback scheme. Meanwhile, a former nurse at the Michael E. DeBakey VA Medical Center in Houston was indicted for falsely claiming she had checked on a patient who ultimately died.  Read the full monthly highlights at: https://www.vaoig.gov/report/monthly-highlights    Related Reports:   * Better Communication and Oversight Could Improve How the Pain Management, Opioid Safety, and Prescription Drug Monitoring Program Manages Funds [https://www.vaoig.gov/reports/audit/better-communication-and-oversight-could-improve-how-pain-management-opioid-safety]   * Failure to Flag Fiduciaries Who Were Removed Results in Risk to Vulnerable Beneficiaries [https://www.vaoig.gov/reports/review/failure-flag-fiduciaries-who-were-removed-results-risk-vulnerable-beneficiaries]   * Deficiencies in Emergency Care for a Female Veteran at Martinsburg VA Medical Center in West Virginia [https://www.vaoig.gov/reports/hotline-healthcare-inspection/deficiencies-emergency-care-female-veteran-martinsburg-va]

Highlights from VA OIG's 93rd Semiannual Report to Congress

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 [https://www.vaoig.gov/semiannual-reports-to-congress].   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 of veterans and ensure their access to top-level medical care. During this period, the Office of Investigations opened 256 cases and closed 213 (most opened in prior reporting periods), with efforts leading to 144 arrests. The OIG hotline staff triaged more than 17,000 contacts to help identify wrongdoing and address concerns with VA activities. The related work resulted in 598 administrative sanctions and corrective actions. The Office of Audits and Evaluations (OAE) produced 47 work products, including one VA management advisory memoranda on VA’s progress related to reducing overdose deaths. Also included were 16 oversight reports and 30 preaward and postaward contract audits and reviews to help VA obtain fair and reasonable pricing on products and services. OAE reports for the six-month period resulted in 146 recommendations for VA improvements. The Office of Healthcare Inspections (OHI) continued to provide the oversight necessary to assess VHA's delivery of high-quality care and leaders' efforts to build and uphold a culture that prioritizes patient safety. Of the 36 oversight products OHI published in the last six months, 10 were for-cause reports responsive to OIG hotline complaints. In addition to seven national reviews, OHI released 14 healthcare facility inspections, three care-in-the-community inspections, one mental health inspection, and one vet center inspection. The Office of Special Reviews (OSR) conducted 21 investigative interviews and issued one report addressing VA’s lapses in oversight of a grantee providing transitional housing services to veterans at risk for homelessness. Also during this period, OSR reviewed 12 allegations of possible whistleblower retaliation involving VA contractor's employees or grantees.