Veteran Oversight Now

Louis Calderon:
This is Veteran Oversight Now, the Veterans Affairs Office of Inspector General official podcast. I’m your host, Louis Calderon.

Here are some updates from our Office of Investigations.

A VA OIG investigation revealed a former nurse at the Michael E. DeBakey VA Medical Center in Houston made false entries in the VA’s computerized patient record system. She claimed to have observed a patient on several occasions during her shift on July 26 and 27, 2024. Contrary to these entries, evidence revealed she did not have any contact with the patient at those times. Early on July 27, medical personnel found the patient unresponsive and pronounced him dead. The former nurse pleaded guilty in the Southern District of Texas to making or using false writings or documents.

Another investigation by the VA OIG and Social Security Administration OIG resulted in charges alleging that from about April 2005 through March 2022, a son withdrew VA and Social Security benefits payments totaling about $350,000 from his deceased mother’s bank account—who was a surviving spouse of a World War II veteran. Of this amount, the total loss to VA is more than $305,000. He was charged in the Middle District of Pennsylvania with wire fraud.

Elsewhere, a multiagency investigation revealed that a veteran threatened a mass casualty event during calls to the Veterans Crisis Line and the Crisis Center of Comal County, Texas. During a subsequent search of the veteran’s home, investigators seized a cache of weapons and ammunition. The veteran was sentenced in the Western District of Texas to 25 months’ imprisonment and 36 months’ supervised release after previously pleading guilty to the illegal possession of a machine gun, possession of an unregistered firearm, and attempted tampering with records or objects.

The OIG also published 17 reports in August, resulting in 72 recommendations to VA.
An administrative investigation found that the former chancellor of the VA Acquisition Academy accepted gifts from a conference center hotel in Aurora, Colorado, and failed to disclose them on her 2023 public financial disclosure. She also directed VA staff to solicit and accept sponsorships for social events held during a training symposium at the conference center. In addition, she discouraged her executive assistant from asking questions or seeking guidance regarding possible ethics violations. The OIG recommended that VA consider whether more training is necessary regarding sponsorships for VA events and acceptance of free meals, and also whether VA ethics officials should take additional steps regarding the then chancellor’s 2023 public financial disclosure. VA concurred and provided acceptable responses to the OIG’s recommendations.

An OIG review found VISN 12 medical facilities, covering parts of Illinois, Indiana, Michigan, and Wisconsin, did not consistently:
• identify veterans eligible for community care,
• inform them of their care options, and
• deliver timely care.

Schedulers lacked the means to identify all available appointments and VHA guidance was uneven. VISN 12 took 44 days on average from scheduling to appointment for community care and 35 days for VA care. This exceeded VA’s timeliness goals. The network also had about 250 consults incomplete for longer than one year. The VISN 12 director concurred with the OIG’s four recommendations to improve scheduler performance. The OIG has two planned follow-up national reviews regarding eligibility and care option notifications, as well as timeliness of care.

An OIG national review found inconsistent implementation of VHA requirements for oncology programs. For example, not all VISNs had an established multidisciplinary cancer committee. Also, no VISNs had submitted an inventory of oncology services or facility points of contact within the last year to the VA National Oncology Program Office. The OIG found a lack of oversight contributed to the inconsistent implementation of oncology program requirements. The under secretary for health concurred with the five recommendations and provided an action plan to address them.

The OIG also published multiple cyclical reports in August. Four healthcare facility inspection reports focused on healthcare systems in Ohio, Washington, and Texas, resulting in 16 recommendations to VA. Two Vet Center Inspection Program reports evaluated vet centers in Fort Wayne, Indiana; Detroit and Escanaba, Michigan; Cincinnati, Ohio; Des Moines and Sioux City, Iowa; Kansas City, Missouri; and Rapid City, South Dakota. These two reports had a total of 15 recommendations.

Read more about the VA OIG’s oversight work in August 2025 on our website at vaoig.gov.

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Thank you for listening.