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
· Inconsistent Implementation of VHA Oncology Program Requirements Due to Insufficient Oversight
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.
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:
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:
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:
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 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.
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 review to determine whether claims processors are properly assigning effective dates for PACT Act-related claims to an inspection related to a patient’s delayed diagnosis and treatment for lung cancer at the VA Eastern Kansas Healthcare System in Topeka and Leavenworth.
VA OIG investigative efforts helped resolved allegations that a drug and alcohol rehabilitation facility, Seabrook House in New Jersey, submitted claims to VA’s Community Care program and the state’s Medicaid program for short-term residential treatment and partial hospitalization care for which it was not properly licensed or contracted and misled state inspectors. In a civil settlement, Seabrook agreed to pay $19.75 million to resolve False Claims Act allegations. Of this amount, VA will receive $19.15 million.
Meanwhile, 12 employees of the Louis Stokes Cleveland VA Medical Center pleaded guilty to theft after receiving more than $396,000 in Pandemic Unemployment Assistance benefits by falsifying their applications and failing to disclose their employment and wages earned at VA, and a physician at the Bedford VA Medical Center in Massachusetts was arrested and charged in the District of Massachusetts with the receipt and possession of child pornography.
Read the full monthly highlights.
Related Reports:
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 deficiencies at a Texas VA medical center.
VA OIG investigations led to the sentencing of a pharmacy operator who conspired with various doctors to charge government agencies for medically unnecessary compound prescriptions, pain creams, scar gels, and multivitamins primarily to patients covered under the Office of Workers’ Compensation Program. Elsewhere, a government subcontractor was sentenced to 12 months’ probation and ordered to pay restitution of more than $493,000 after previously pleading guilty to bank fraud. The company fraudulently obtained a Small Business Administration-backed Paycheck Protection Program loan. The company’s owner also agreed to pay more than $1.1 million as part of a civil settlement to resolve his own civil liability.
This latest podcast episode of Veteran Oversight Now highlights the VA OIG’s oversight work from March 2025, including four healthcare facility inspections reports on facilities in Massachusetts, Georgia, Virginia, and Washington, DC.
Related Reports:
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 published last month. Visit the VA OIG website for a full list of oversight work completed in February.
Related Report:
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 family members.”
– VA Inspector General Michael J. Missal
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 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 they also passed all of that information to all of the other facilities within VISN 22. So, it wasn’t just Phoenix, you know, they made sure all of the facilities in VISN 22 had the same information and the same knowledge. So, to follow that up, they’re doing weekly audits and checking to make sure that the logging process is being done correctly. And so far, the reported compliance has been 100 percent.”
– Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director
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 edition also includes highlights of the VA OIG’s work from August 2024.
“Once the patient's heart rate completely stopped and they went into asystole, that should have triggered a code blue. Period.”
– Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director
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 and made seven recommendations related to oversight of the medical center’s Sterile Processing Service. This episode also includes highlights of the VA OIG’s work from July 2024.
“If it’s [medical device] not documented properly and it’s not documented in the system so that we can track the cleaning, the disinfecting, the sterilization, then we don’t know if it’s processed appropriately.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director
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 the timeline, this is 17 days after the patient’s first visit to the emergency room with the shortness of breath problems. . . . Unfortunately, the patient completed suicide that same day without receiving the medication.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director
This podcast edition also includes highlights of the VA OIG’s work from June 2024.
Related Report: Care Concerns and Failure to Coordinate Community Care for a Patient at the VA Southern Nevada Healthcare System in Las Vegas
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 lacked a working knowledge of the consult management and scheduling processes.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director
Related Report: Discontinued Consults Led to Patient Care Delays at the Oklahoma City VA Medical Center in Oklahoma
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 thoughts on the VA OIG’s work related to VA’s personnel suitability program as well as recent crime and fraud alerts. A recent fraud alert encourages VBA staff to report when veterans share that they are being charged high fees from unaccredited individuals for assistance with completing disability benefits questionnaires (DBQs) or an initial claim filing. This podcast edition also includes highlights of the VA OIG’s work from April 2024.
“It's wonderful to be able to talk about all the incredible work that our staff performs in the service of our nation's veterans. I could not be more proud of the progress our staff has made in achieving our mission to serve veterans and the public by conducting meaningful, fair, and evidence-driven oversight of VA.” – Inspector General Michael J. Missal.
Related Report: 91st Semiannual Report to Congress
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 should have triggered a code blue. Period.”
– Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director
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, Office of Healthcare Inspections, Hotline Director
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 they also passed all of that information to all of the other facilities within VISN 22. So, it wasn’t just Phoenix, you know, they made sure all of the facilities in VISN 22 had the same information and the same knowledge. So, to follow that up, they’re doing weekly audits and checking to make sure that the logging process is being done correctly. And so far, the reported compliance has been 100 percent.”
– Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director
Related Report: Delayed Receipt of Patients’ Colorectal Cancer Screening Tests at the Phoenix VA Health Care System in Arizona
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 edition also includes highlights of the VA OIG’s work from October 2023.
“As only the sixth Senate-confirmed VA Inspector General over the past 45 years, it is truly an honor and privilege to work on behalf of veterans and taxpayers. It is also a real honor and privilege to work with all of our staff to meet our mission of meaningful independent oversight. We had a great fiscal year 2023 and we look forward to an even more impactful fiscal year 2024.” – VA Inspector General Michael J. Missal
Related Reports:
Read the VA OIG's 90th Semiannual Report to Congress.
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 that they need to implement and carry out that will hopefully result in a better outcome.”
– Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director
Related Report:
Published: 6/28/2023
Report #22-02725-132