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 ...
…
continue reading
Inside Oversight is an official podcast of the Department of Veteran Affairs, Office of Inspector General. Each episode examines in detail some of our more nuanced oversight reporting. To understand the complexities of the topics, we talk with the report authors to gain insight into how the team conducted its work, what it found, and the impact on veterans and the public. Visit the VA OIG website for recently published reports.
…
continue reading
![Artwork](/static/images/128pixel.png)
1
Poor Paperwork Potentially Puts Patients at Risk: New Mexico VAMC Reuses Medical Devices without Documenting Proper Cleaning
22:36
22:36
Play later
Play later
Lists
Like
Liked
22:36
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 dur…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
Inadequate Care Coordination at the VA Southern Nevada Healthcare System in Las Vegas
31:06
31:06
Play later
Play later
Lists
Like
Liked
31:06
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 le…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
Patients Delayed Care Due to Failure to Follow Behavior Health Consult and Scheduling Process
23:15
23:15
Play later
Play later
Lists
Like
Liked
23:15
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 edit…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
IG Missal Highlights 91st Semiannual Report to Congress
22:45
22:45
Play later
Play later
Lists
Like
Liked
22:45
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, t…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
Veteran Dies Following Delay in “Code Blue” Alert at Memphis VA Medical Center
27:16
27:16
Play later
Play later
Lists
Like
Liked
27:16
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 al…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
Chronic Leadership Failures Plague Cardiology Department at Indiana VAMC
26:02
26:02
Play later
Play later
Lists
Like
Liked
26:02
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. S…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
Unpaid Postage Bill Delays Critical Cancer Screenings
30:43
30:43
Play later
Play later
Lists
Like
Liked
30:43
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…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
IG Missal Reflects on Inspector General 45th Anniversary and Latest Semiannual Report to Congress
36:21
36:21
Play later
Play later
Lists
Like
Liked
36:21
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 origina…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
Lessons Learned after Patient Death following a Fall in a Las Vegas VA Outpatient Clinic
31:39
31:39
Play later
Play later
Lists
Like
Liked
31:39
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 …
…
continue reading
![Artwork](/static/images/128pixel.png)
1
Nurse Consultant Shares Challenges for Veterans with Opioid Use Disorder Transitioning from DoD to VHA
20:58
20:58
Play later
Play later
Lists
Like
Liked
20:58
In this episode of Inside Oversight, Nicole Maxey, a nurse consultant with the Office of Healthcare Inspections, discusses the VA OIG’s evaluation of the transition of clinical care for service members with opioid use disorder from the Department of Defense to the Veterans Health Administration. Nicole describes deficiencies in documenting patients…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
“I don’t want to die.” Veteran Left Alone in VA Emergency Department Dies from Suicide
48:30
48:30
Play later
Play later
Lists
Like
Liked
48:30
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…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
Health System Specialist Discusses Inadequate Care at the West Palm Beach VA Facility
9:27
9:27
Play later
Play later
Lists
Like
Liked
9:27
In this podcast episode of Inside Oversight, Erica Taylor, a health system specialist with the Office of Healthcare Inspections, discusses a healthcare inspection at the West Palm Beach VA Healthcare System in Florida that assessed allegations related to a patient’s cancer care coordination. “Over the years, the OIG has published many reports detai…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
Veteran Suicide at Outpatient Clinic in South Carolina Highlights Tragic Missteps in Patient Care
47:21
47:21
Play later
Play later
Lists
Like
Liked
47:21
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…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
VA OIG Safety Expert Discusses Deficiencies with Patient Safety at the Tuscaloosa VAMC
32:17
32:17
Play later
Play later
Lists
Like
Liked
32:17
In this episode of Inside Oversight, Amanda Newton, an associate director with the Office of Healthcare Inspections, discusses a report on deficiencies with the Patient Safety Program at the Tuscaloosa VA Medical Center in Alabama. She shares how a lack of resources, supervisory engagement, and failure of facility leaders to act impacted the medica…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
Oversight, Employee Participation Critical to Patient Safety Programs Says Healthcare Hotline Director
38:50
38:50
Play later
Play later
Lists
Like
Liked
38:50
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 al…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
IG Michael J. Missal Discusses VA OIG's 89th Semiannual Report to Congress
25:14
25:14
Play later
Play later
Lists
Like
Liked
25:14
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 f…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
Proactive Oversight: Senior Leader Shares How the VA OIG is Changing Some Healthcare Inspections
21:07
21:07
Play later
Play later
Lists
Like
Liked
21:07
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…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
Intimate Partner Violence Assistance Program Implementation Status and Barriers to Compliance
21:25
21:25
Play later
Play later
Lists
Like
Liked
21:25
In this episode, Dr. Amber Singh, an associate director with the VA OIG’s mental health team within the Office of Healthcare Inspections, discusses a published report on VHA’s Intimate Partner Violence Assistance Program. Her team conducted a national review of the program to evaluate implementation status and identify perceived barriers to complia…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
VA OIG Teams Tackle Security Posture Problems at VA Medical Facilities Nationwide
29:28
29:28
Play later
Play later
Lists
Like
Liked
29:28
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 …
…
continue reading
![Artwork](/static/images/128pixel.png)
1
VA OIG Healthcare Systems Specialist Discusses New Report on Intensive Community Mental Health Recovery Programs
33:05
33:05
Play later
Play later
Lists
Like
Liked
33:05
In this episode of Inside Oversight, Dr. Wanda Hunt, a healthcare systems specialist with the VA OIG’s Office of Healthcare Inspections, discusses a recently published report on VHA’s Intensive Community Mental Health Recovery Programs. Her team examined the visit frequency for veterans enrolled in these programs between April 2019 and March 2021, …
…
continue reading
![Artwork](/static/images/128pixel.png)
1
VA OIG Psychiatrist Discusses VHA's Lethal Means Safety Training, Firearms Access Assessment, and Safety Planning
42:53
42:53
Play later
Play later
Lists
Like
Liked
42:53
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 granddaug…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
Inspector General Interview: 88th Semiannual Report to Congress
29:53
29:53
Play later
Play later
Lists
Like
Liked
29:53
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 t…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
VA OIG Senior Investigator Highlights Noble Mission of Protecting Veterans
28:40
28:40
Play later
Play later
Lists
Like
Liked
28:40
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 Frau…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
OIG Healthcare Leaders Talk VHA Staffing Shortages, Stress on the Workforce
29:44
29:44
Play later
Play later
Lists
Like
Liked
29:44
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 i…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
Healthcare Inspector Discusses COVID-19 Outbreak at a Community Living Center in Illinois
28:51
28:51
Play later
Play later
Lists
Like
Liked
28:51
Related Report: Failure to Mitigate Risk of and Manage a COVID-19 Outbreak at a Community Living Center at VA Illiana Health Care System in Danville, Illinois The VA OIG conducted an inspection at the VA Illiana Health Care System in Danville, Illinois, to determine the validity of allegations, specific to COVID-19 and the Community Living Center (…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
Healthcare Inspectors Discuss Issues Related to a Patient's Quality of Care in Ohio's Chillicothe VAMC
11:01
11:01
Play later
Play later
Lists
Like
Liked
11:01
Related Report: Failure to Follow a Consult Process Resulting in Undocumented Patient Care at the Chillicothe VA Medical Center in Ohio The VA OIG conducted a healthcare inspection for 10 allegations related to the quality and management of patient care and the availability of resources within the Urgent Care Center at the Chillicothe VA Medical Ce…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
Director of Community Care Discusses VISN 23's Healthcare Inspection
15:30
15:30
Play later
Play later
Lists
Like
Liked
15:30
Related Report: Care in the Community Healthcare Inspection of VA Midwest Health Care Network (VISN 23) The OIG Care in the Community healthcare inspection program examines clinical and administrative processes associated with providing quality outpatient healthcare to veterans. This report provides a focused evaluation of Veterans Integrated Servi…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
Deputy Assistant IGs Discuss Two Burn Pit Reports
34:03
34:03
Play later
Play later
Lists
Like
Liked
34:03
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 poten…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
VA OIG Healthcare Inspectors Discuss the Vet Center Inspection Program
57:02
57:02
Play later
Play later
Lists
Like
Liked
57:02
Vet Center Inspection Program: The VA Office of Inspector General Vet Center Inspection Program (VCIP) provides a focused evaluation of aspects of the quality of care delivered at vet centers. Vet centers are community-based clinics that provide a wide range of psychosocial services to clients, including eligible veterans, active duty service membe…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
VA OIG Director Discusses Forensic Auditing
36:24
36:24
Play later
Play later
Lists
Like
Liked
36:24
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 ide…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
Audit Manager Discusses OIG Report on VHA's Suicide Prevention Coordinators
24:38
24:38
Play later
Play later
Lists
Like
Liked
24:38
Related Report: Suicide Prevention Coordinators Need Improved Training, Guidance, and Oversight Report Summary: As part of the Veterans Health Administration’s (VHA) suicide prevention strategy, suicide prevention coordinators at VA medical facilities are required to reach out to veterans referred from the Veterans Crisis Line. Coordinators provide…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
Senior Benefits Inspector Discusses Risks with VA's Contract Medical Exam Program
29:14
29:14
Play later
Play later
Lists
Like
Liked
29:14
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 (V…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient’s Death by Suicide
12:49
12:49
Play later
Play later
Lists
Like
Liked
12:49
Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient’s Death by Suicide at the Harry S Truman Memorial Veterans’ Hospital in Columbia, Missouri The VA OIG conducted a healthcare inspection to determine the validity of an allegation regarding a patient’s mental health care at the Harry S. Truman Memorial Veteran…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
Challenges for Military Sexual Trauma Coordinators and Culture of Safety Considerations
12:43
12:43
Play later
Play later
Lists
Like
Liked
12:43
Challenges for Military Sexual Trauma Coordinators and Culture of Safety Considerations The VA OIG conducted a review of select activities and challenges of Military Sexual Trauma (MST) Coordinators and Veterans Integrated Service Network Points of Contact in response to a request from Congressman Chris Pappas, Chairman of the House Veterans’ Affai…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
VHA’s Virtual Primary Care Response to the COVID-19 Pandemic
11:55
11:55
Play later
Play later
Lists
Like
Liked
11:55
Review of Veterans Health Administration’s Virtual Primary Care Response to the COVID-19 Pandemic The VA Office of Inspector General (OIG) conducted a review to assess Veterans Health Administration’s (VHA) virtual primary care response to the COVID-19 pandemic, as well as the use of virtual care by primary care providers and their perceptions of V…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
VA OIG Auditors Discuss Improper Payments for Community Acupuncture and Chiropractic Services and Risks to Evaluation and Management Services
32:50
32:50
Play later
Play later
Lists
Like
Liked
32:50
Senior Auditors Geoff Ferguson and Gris Soto discuss two related reports on improper payments for community acupuncture and chiropractic services and overall risks to evaluation and management services. In the first report, the VA OIG audited acupuncture and chiropractic care by non‑VA providers after becoming aware of patterns that suggested quest…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
VA OIG Director Discusses VHA’s Methodologies for Calculating and Presenting Wait Times
29:52
29:52
Play later
Play later
Lists
Like
Liked
29:52
In this episode of Inside Oversight, Daniel Morris, a director within the Office of Audits and Evaluations, provides insight into a recent VA OIG management advisory memo that reported on concerns with consistency and transparency in the calculation and disclosure of VHA’s patient wait times. Report Summary: Concerns with Consistency and Transparen…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
Deputy Inspector General Highlights Newest VA Electronic Health Record Reports
34:38
34:38
Play later
Play later
Lists
Like
Liked
34:38
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 Oct…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
Senior Healthcare Inspection Leader Discusses New Vet Center Inspection Program
31:55
31:55
Play later
Play later
Lists
Like
Liked
31:55
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…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
VA OIG Special Agent in Charge Discusses New Healthcare Fraud Division
38:06
38:06
Play later
Play later
Lists
Like
Liked
38:06
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 Mo…
…
continue reading
![Artwork](/static/images/128pixel.png)
1
VA Inspector General Interview: 86th Semiannual Report to Congress
22:26
22:26
Play later
Play later
Lists
Like
Liked
22:26
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 over…
…
continue reading