Veteran Oversight Now: Recent Episodes
VA OIG
Veteran Oversight Now is an official podcast of the Department of Veteran Affairs, Office of Inspector General. Each episode features interviews with key stakeholders, discussions on high-impact reports, and highlights of recent oversight work. Listen regularly for the inside story on how the VA OIG investigates crimes and wrongdoings, audits programs that provide benefits and services to veterans, and inspects medical facilities to ensure our nation’s veterans receive safe and timely health care.
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 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 was called, meaning a code blue so that all emergency staff would present to that room, and they tried to resuscitate the patient, but that was unsuccessful, and he was pronounced dead about 10 to 15 minutes later.”
– Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director
Related Report
Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri
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. That's where all of your referrals start for specialty care, and that's how you gain continuity of care. Unfortunately, with this veteran he saw one provider, and then the next appointment saw a different provider, and then the third appointment saw a third provider.”
– Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director
Related Report:
- Deficient Care of a Patient Who Died by Suicide and Facility Leaders’ Response at the Charlie Norwood VA Medical Center in Augusta, Georgia
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 the patient safety program at the respective facilities, but also ensure oversight of those safety patient safety programs. The oversight is just as important as participation when trying to ensure that the facility has opportunities to identify system vulnerabilities and then address those concerns with the hopes of preventing future patient safety events from occurring.” Trina Rollins, Director of Hotline Coordination, Office of Healthcare Inspections
Related Publications:
- Deficiencies in the Patient Safety Program and Oversight Provided by Facility and VISN Leaders at the Tuscaloosa VA Medical Center in Alabama
- Comprehensive Healthcare Inspection of the Tuscaloosa VA Medical Center in Alabama(September 2, 2020)
- Comprehensive Healthcare Inspection of the Tuscaloosa VA Medical Center, Alabama(September 27, 2019)
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 inestimable value of the healthcare oversight work completed to advance patient safety and quality care.
During this six-month period, the Office of Investigations opened 178 cases and closed 213 (most of which were opened in prior periods), with efforts leading to 135 arrests. The OIG hotline received and triaged 18,396 contacts to help identify wrongdoing and address concerns with VA activities. Collectively, the work during this period resulted in 599 administrative sanctions and actions.
The Office of Audits and Evaluations (OAE) produced 44 publications, including five VA management advisory memorandums that highlighted concerns requiring VA’s prompt attention. Contracting review teams also conducted 47 preaward and postaward contract reviews to help VA obtain fair and reasonable pricing on products and services. OAE reports for the six-month period resulted in 198 recommendations.
The Office of Special Reviews (OSR) issued five publications, including three reports in response to allegations of senior VA officials’ misconduct, which reflect the VA OIG’s commitment to holding VA employees accountable for wrongdoing and promoting the highest standards of professional and ethical conduct. OSR also issued two joint publications: a VA management advisory memorandum with OAE regarding concerns with the calculation of patient wait time data, and a report with the Department of Defense (DoD) OIG, focusing on efforts by DoD and VA to achieve electronic health record system interoperability.
The Office of Healthcare Inspections (OHI) maintained a strong focus on leadership and organizational risks, suicide risk reduction, quality of care, and patient safety. OHI published 19 healthcare inspection reports; 17 Comprehensive Healthcare Inspection Program (CHIP) reports, including three CHIP summary reports; four national healthcare reviews; and its first Care in the Community report that examined key clinical and administrative processes associated with providing quality VA and community care.
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
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 facilities, and compared this information to the previous four years.
The OIG found that all 139 VHA facilities reported at least one severe occupational staffing shortage. The total number of reported severe shortages was 2,622. Twenty-two occupations were identified as a severe occupational staffing shortage by at least one in five facilities. Every year since 2014, the Medical Officer and Nurse occupations were reported as severe shortages. Practical Nurse was the most frequently identified clinical severe occupational staffing shortage in FY 2022, with 62 percent of facilities reporting this occupation. Custodial Worker was the most frequently reported non-clinical severe occupational shortage in FY 2022, with 69 percent of facilities reported the occupation. Medical Support Assistance was the most frequently reported Hybrid Title 38 severe occupational shortage.
In FY 2022, VHA reported twenty-two percent more severe occupational staffing shortages as compared to FY 2021. FY 2022 is the first year since implementation of VCQEA reporting requirements in which the OIG did not observe a yearly decrease in the overall number of severe occupational staffing shortages; it was also the first time that facilities identified more than 90 occupations as severe shortages. The OIG again determined the ongoing need for Custodial Worker and Medical Support Assistance, noting an increase in the number of facilities identifying these occupations as severe shortages. The OIG emphasizes the importance of VHA’s continued assessment of severe occupational staffing shortages given the increases from FY 2021 to FY 2022.
The Veterans Health Administration Needs to Do More to Promote Emotional Well-Being Supports Amid the COVID-19 Pandemic
The Veterans Health Administration (VHA) Office of Emergency Management issued the initial COVID-19 Response Plan on March 23, 2020, and then an updated version on August 7, 2020. The National Center for Organization Development created a COVID-19 rapid response consultation process for VHA leaders in a supervisory role. The Organizational Health Council developed a team that coordinated with multiple VHA program offices to create a COVID-19 Employee Support Toolkit and other resources. Additionally, several program offices independently created and disseminated employee well-being resources specific to the COVID-19 pandemic, including National Center for Organization Development, Patient Centered Care & Cultural Transformation, Chaplain Service, and the Office of Mental Health and Suicide Prevention.
The VA Office of Inspector General (OIG) identified a generally diminishing awareness of employee emotional well-being supports in relation to organizational hierarchy, low utilization of support resources by leadership and frontline employees, as well as employee perception of inadequate support and responsiveness from leadership.
The OIG conducted a review to assess how the VHA addressed the emotional well-being of employees during the COVID-19 pandemic. The OIG also conducted an overview of VHA programs, including what specialized programs were developed and deployed in response to the unique psychological challenges created by the COVID-19 pandemic for VHA’s staff. The OIG interviewed VA and VHA leaders in multiple offices. The OIG developed and deployed a survey about VHA guidance regarding employees’ emotional well-being during the pandemic, available resources, monitoring of available support programs, and employee engagement with available support programs.
The OIG made one recommendation to the Under Secretary for Health related to increasing leadership and staff awareness of COVID-19 emotional well-being resources for VHA employees and awareness of resources about potential risks and signs of burnout.
Related Reports:
Airborne Hazards and Open Burn Pit Registry Exam Process Needs ImprovementSince 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 facilities conducted them within the 90-day prescribed period. The Veterans Health Administration (VHA) began collecting and recording data in the registry in May 2014 through an online questionnaire and free in-person exams. The OIG found many veterans did not complete the 140-item questionnaire, which is not clear and veteran-centric. Veterans also did not always realize they were responsible for scheduling their own exams. Improvements in the registry exam process would help ensure more eligible and interested veterans receive them. VHA plans to establish a call center to assume some of the scheduling and coordination responsibilities by October 2022. This is well-timed given the number of veterans indicating they would like an exam has further increased since August 2021, when VA established a presumptive “service connection” for respiratory conditions due to exposure to particulate matter, such as asthma, sinusitis, and rhinitis. Whether the call center will mitigate the issues identified by the OIG cannot yet be determined, and its rollout does not negate the need for corrective actions. The OIG made seven recommendations to the under secretary for health that include revising the questionnaire to be more veteran-centric, identifying whether veterans with unscheduled exams are still interested in one, and implementing processes and metrics to ensure exams are completed. Further, the OIG recommended developing guidance to ensure responsible parties review and discuss performance data and the enhancement of registry information systems.
Veterans Prematurely Denied Compensation for Conditions That Could Be Associated with Burn Pit ExposureVA recognizes exposure to smoke from the large burn pits used by the US military to dispose of waste from its bases in Iraq, Afghanistan, and Djibouti as a potential cause of disabilities. Veterans Benefits Administration (VBA) staff processed more than 21,100 burn pit-related claims from June 2007 through September 2021. Given the potential impact on many eligible veterans, the VA Office of Inspector General (OIG) conducted this review to determine whether VBA staff followed regulations and procedures when addressing conditions that could be associated with burn pit exposure. VBA treats burn pit-related claims like most other disability compensation claims, though it also considers exposure to environmental hazards based on a veteran’s service location. VBA provides medical examiners a burn pit fact sheet to help ensure any opinion is fully informed based on all known objective facts. The review team examined three distinct samples of claimed conditions potentially related to burn pit exposure completed from May 1, 2020, to May 1, 2021, and found VBA could improve its processing and oversight. Though VBA staff nearly always made the correct decision in granting compensation for conditions identified as burn pit-related, the OIG found most denials were premature. The OIG made seven recommendations to VBA management, including correcting four errors involving improperly granted conditions, and reviewing denied cases, correcting errors they identify, and certifying that corrections were made. VBA should also update its adjudication procedures manual to provide separate and specific guidance for handling claims based on burn pit exposure and modify its examination request application to add specialty language from the burn pit fact sheet into medical opinion requests. Finally, VBA should update training materials and ensure they are consistent with the adjudication procedures manual guidance.
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, forensic auditors, and other professionals. Learn more at https://www.va.gov/oig/about/investigations.asp
Related report: Contract Medical Exam Program Limitations Put Veterans at Risk for Inaccurate Claims Decisions
Report summary:
Given the importance of medical exams to disability claims and the high cost of VA’s contracts with exam vendors, the VA Office of Inspector General (OIG) set out to determine whether the Veterans Benefits Administration (VBA) oversaw contract medical disability exams to ensure they met quality standards and contractual requirements, established procedures for correcting errors, and gave feedback to vendors to improve exam quality.
VBA’s governance of and accountability for the exam program needs to improve. The identified deficiencies appear to have persisted, at least in part, because of limitations with VBA’s management and oversight of the program at the time of the review. The OIG found VBA’s program was deficient because it hindered the ability to hold vendors accountable for correcting errors and improving exam accuracy. VBA should improve the program to help ensure vendors produce accurate exams to support correct decisions for veterans’ claims.
Contract exams are a significant investment, and VA has spent nearly $6.8 billion since fiscal year 2017. Some of the exams produced by vendors have not met contractual accuracy requirements. As a result, claims processors may have used inaccurate or insufficient medical evidence to decide veterans’ claims. Therefore, it is vital for VBA to improve the governance and accountability of the program.
The OIG made four recommendations to the acting under secretary for benefits, including ensuring vendors can be held contractually accountable for unsatisfactory performance and establishing procedures for vendors to correct errors. The OIG also recommended requiring the Medical Disability Examination Office to communicate vendor exam errors to the Office of Field Operations and the regional offices and demonstrate progress in correcting them, and analyze all available data to identify systemic errors and provide systemic exam issues and error trends to vendors.
The Semiannual Report to Congress summarizes the VA Office of Inspector General’s (OIG) oversight efforts from October 1, 2021, through March 31, 2022. For this period, the VA OIG identified nearly $4.1 billion in monetary impact for a return on investment of $41 for every dollar spent on oversight. This does not include the inestimable value of the healthcare oversight work completed to advance patient safety and quality care.
The Office of Audits and Evaluations (OAE) issued 29 publications, including one VA management advisory memoranda that highlighted concerns requiring VA’s prompt attention. Contracting review teams also conducted 49 preaward and postaward contract reviews to help VA obtain fair and reasonable pricing on products and services. OAE reports for the six-month period resulted in 128 recommendations.
The Office of Healthcare Inspections maintained a strong focus on leadership and organizational risks, COVID-19 pandemic readiness and response, suicide prevention and intervention processes, and deficiencies in care coordination. The VA OIG published 40 healthcare inspections and reviews, which included a trilogy of reports that focused on VA’s 10-year, multibillion-dollar electronic health record modernization effort.
The Office of Special Reviews (OSR) published two reports in response to allegations of senior VA officials’ misconduct, which reflect the VA OIG’s commitment to holding VA employees accountable for wrongdoing and promoting the highest standards of professional and ethical conduct. OSR also published one VA management advisory memorandum on the need to clarify guidance on SES reassignments.
The Office of Investigations opened 173 cases and closed 224 (most of which were opened in prior periods), with efforts leading to 104 arrests. The OIG hotline received and triaged 17,646 contacts in this reporting period to help identify wrongdoing and address concerns with VA activities. Collectively, the work during this six-month period resulted in 557 administrative sanctions and actions.
Click here to review the VA OIG's 87th Semiannual Report to Congress.
In this episode of Veteran Oversight Now, guest host Deputy Inspector General David Case joins Dr. Joe Etherage, director of national reporting for the Office of Healthcare Inspections, to discuss three recently released reports on VA’s Electronic Health Record Modernization program—a 10-year, multibillion-dollar modernization effort. Since the October 2020 implementation of the system at the Mann-Grandstaff VA Medical Center in Spokane, Washington, the VA OIG has received wide-ranging complaints to its hotline as well as concerns from members of Congress. The VA OIG found deficiencies that increased risks to patient safety.
Referenced reports:
Medication Management Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, Washington
Ticket Process Concerns and Underlying Factors Contributing to Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, Washington
Care Coordination Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, Washington
In this episode of Veteran Oversight Now, Dr. Julie Kroviak, deputy assistant inspector general for healthcare inspections, discusses her journey from medical student to VA doctor to leading teams conducting oversight of VHA. She introduces the new vet center inspection program, detailing how the VA OIG will inspect roughly 300 vet centers over the next few years. This month’s episode concludes with the VA OIG’s highlights for January 2022.
Dr. Kroviak on areas of focus for vet center inspections:
“Leadership will be a story that we tell in every single report we write from now on. We’re looking at leadership in local and regional levels for each vet center that we visit. Importantly, we’re looking for their internal quality reviews. You know care is being provided, and we need to know that there is appropriate oversight and intervention and when issues are found that plans are in place to remediate.”
The VA OIG has published five vet center inspection reports since the program was launched:
Pacific District 5 Zone 1 and four selected vet centers in Bellingham, WA; Tacoma, WA; Bend, OR; and Wasilla, AK, 9/30/21
Continental District 4 Zone 2 and four selected vet centers in Alexandria, LA; Houston Southwest, TX; Laredo, TX; and Mesquite, TX, 9/30/21
Southeast District 2 Zone 2 and four selected vet centers in Clearwater, FL; Ocala, FL; Sarasota, FL; and Ponce, Puerto Rico, 9/30/21
Continental District 4 Zone 1 and four selected vet centers in Casper, WY; Denver, CO; El Paso, TX; and Midland, TX, 12/2/21
Pacific District 5 Zone 2 and four selected vet centers in Fresno, CA; High Desert, CA; Santa Cruz County, CA; and Honolulu, HI, 12/20/21
Visit our website to learn more about the work of the VA OIG's Office of Investigations.
Report potentially unlawful activity or potential violations of rules or regulations; fraud, waste, and abuse; and gross mismanagement of VA programs and operations to the VA OIG Hotline:
Online: https://www.va.gov/oig/hotline/default.asp
Phone: 800-488-8244
Monday–Wednesday and Friday between 9:00 a.m. to 4:00 p.m. (Eastern Time) or Thursday between 9:00 a.m. to 1:00 p.m. (Eastern Time)
Fax: 202-495-5861
Mail:
VA Inspector General Hotline (53H)
810 Vermont Avenue, NW
Washington, DC 20420
The Semiannual Report to Congress summarizes the VA Office of Inspector General (OIG) oversight from April 1 through September 30, 2021.
For this period, the VA OIG identified over $2.9 billion in monetary impact for a return on investment of $29 for every dollar spent on oversight. This does not include the inestimable value of the healthcare oversight work completed to advance patient safety and quality care. The OIG hotline received and triaged 15,104 contacts in this reporting period, bringing the total to 29,233 for the fiscal year.
The Office of Audits and Evaluations (OAE) published 42 reports, including three VA management advisory memoranda highlighting issues for prompt VA response. Contract review teams also conducted 58 preaward and postaward contract reviews and six claims reviews to help VA obtain fair and reasonable pricing on products and services. OAE reports for the six-month period resulted in 184 recommendations.
The Office of Healthcare Inspections focused on veterans’ access to high-quality care and the continuity of that care even as the pandemic persisted. The VA OIG published 74 healthcare inspections and reviews during the reporting period with 559 recommendations. The reports included examinations of the criminal actions of a serial murderer and an intoxicated pathologist, including the devastating impact of these actions and how they went unaddressed for so long.
The Office of Special Reviews published a report that received significant national attention, detailing a case in which a veteran, who was missing for weeks, was found dead in a stairwell of a building on a VA medical facility campus. The report delves into the widespread confusion among VA personnel and weaknesses in policies and procedures related to searches for missing patients and residents, routine police patrols, and building-cleaning practices.
The Office of Investigations opened 169 cases and closed 207 (most of which were opened in prior periods), with efforts leading to 113 arrests. Collectively, the work during this period resulted in 729 administrative sanctions and actions involving VA personnel.
Review this report and previous semiannual reports to congress at the VA OIG website.