Veteran Oversight Now

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 commu...

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 recomme...

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 V...

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 defic...

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...

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 Apr...

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 revi...

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...

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...

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 e...

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 tele...

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 clea...

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 an...

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...

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 th...

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...

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 anym...

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 retr...

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 Semia...

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...

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 sta...

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...

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...

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...

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...