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...

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...

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...

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...

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...

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...

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,...

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...

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....

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...

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...

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...

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...

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...

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 do not include the inestimable value of the healthcare oversight work completed to advance...

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 served by VA medical facilities. Additionally, she shares how, for the first time, the VA OIG...

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 shortages and growing concerns about incidents that put VA staff, patients, and visitors at risk led the OIG to conduct the review, Security and...

In this episode, a psychiatrist discusses the narrow window of time for interventions that can help prevent suicide by lethal means related to a recent VA OIG report. Plus highlights of the VA OIG's work from December 2022.

Inspector General Michael J. Missal discusses the VA OIG's 88th Semiannual Report to Congress. Plus highlights of the OIG activities over the past month.

In this episode, host Fred Baker chats with James Ross, DAIG for the Office of Investigations, about his path from Orlando police officer to VA OIG special agent to senior executive leading the organization’s field operations and proactive investigation divisions. Plus Sept. 2022 highlights.

In this episode, Dr. Julie Kroviak and Dr. Beth Winter with our Office of Healthcare Inspections discuss VHA staffing shortages and stress on its workforce based on findings from two published reports. Plus highlights of the OIG's recent oversight work.

In this episode, host Fred Baker talks with Leigh Ann Searight and Brent Arronte, deputy IGs with the Office of Audits and Evaluations, about two burn pit reports published in July. Plus highlights of the OIG's recent oversight work.

In this episode, Jane Muir, the director of the Office of Investigation's Audit and Analysis Division, shares her experiences working as an forensic auditor at the VA OIG with host Fred Baker. Plus highlights of the OIG's recent oversight work.

Steve Bracci, director of the claims and medical exams inspection division, discusses the report, Contract Medical Exam Program Limitations Put Veterans at Risk for Inaccurate Claims Decisions, with host Fred Baker. Plus highlights of the OIG's recent oversight work.