Veteran Oversight Now

Fred Baker:
Welcome back to another episode of Veteran Oversight Now, an official podcast of the VA Office of Inspector General. I’m your host, Fred Baker.
Each month on this podcast, we’ll bring you highlights of the OIG’s recent oversight activities and interview key stakeholders in the office’s critical work for veterans.
Joining us today is the VA’s Inspector General Michael J. Missal. He’ll discuss the OIG’s latest Semiannual Report to Congress, which covers the first half of fiscal year 2023 from October 1, 2022, to March 31, 2023.
Mr. Missal, welcome.
IG Missal:
Thank you, Fred. I’m excited to be here to share information about our semiannual report.
Fred Baker:
This is the VA OIG’s 89th Semiannual Report to Congress. The first thing that jumps out about this edition is the front cover. It is a collage of veterans and letters spanning multiple generations. What’s the story behind the cover?
IG Missal:
Yes, that’s a great question, Fred. We are proud not only of the veterans who work in our office, but of family members who have served as well. Many of us have generations who have served, and this cover is really a tribute and recognition of their outstanding service to our country.
Fred Baker:
Your father’s picture is featured on the cover, correct?
IG Missal:
Yes. He’s in the picture with the downed German plane. He served in the Army’s 286th Combat Engineer Battalion, and he was 32 years old at the time, which was seen as old back then. His nickname was “Pops.” And he just loved his service, and it meant so much to him.
Fred Baker:
I remember those old days. The old man was the lieutenant colonel, who was 35 years old.
IG Missal:
Yes.
Very impressive design, and no wonder our staff have such a passion for our mission. Before we dive into the report content, I also noticed that this report is lighter than those in the past. In fact, it’s roughly half the page count of the previous report. Why is that?
IG Missal:
I can assure you this doesn’t mean we only did half the work of the previous time period! What happened is the Inspector General Act was recently amended by Congress to change our reporting requirements. Including summaries of every published report is no longer required, so long as the summaries are readily available online, which they have been. In fact, our online version of the semiannual report hyperlinks to all of our reports. I think this is a positive change for semiannual reports as a document, as the content is much more focused now, and the reports that we choose to highlight can all focus on a single theme. In this semiannual report, the theme is accountability.
Fred Baker:
Yes, your cover letter discusses accountability within VA. You lay out five key components of accountability—strong governance, adequate and qualified staffing, updated systems and processes, effective quality assurance and monitoring, and stable leadership. Why was it important to focus on accountability?
IG Missal:
Accountability is critical for any organization to have continuous improvement. These five categories impact all of VA. Accountability is how VA can improve as an organization, a goal we all share. The OIG’s work this reporting period found that VA has struggled with these five foundational concepts of accountability, and the semiannual report illustrates how deficiencies in any one of these areas can have far-reaching, negative impacts on veterans and their families and can cause the delivery of inadequate benefits and services and the waste or misuse of taxpayer dollars.
Fred Baker:
According to the semiannual report, in this past six-month period, the OIG identified nearly $402 million in monetary impact for a return on investment of $4 for every dollar spent on oversight. While we publish the return on investment as part of the semiannual report, that number is not your primary measurement of value, correct?
IG Missal:
Correct. I’ve always said that numbers tell only a part of the story, and we manage to impact. The OIG’s real value is the impact our work has on VA and the lives of veterans and their family members. Many of the reports highlighted in this semiannual report demonstrate how the OIG makes an impact in other, non-monetary ways. For example, our Audits and Evaluations team, alongside some of our investigators, visited seventy different VA medical facilities to review security and incident preparedness conditions at these sites. We found multiple security vulnerabilities and deficiencies, most notably staffing shortages that contributed to the lack of a visible and active police presence.
Fred Baker:
Let’s talk about what prompted that review.
IG Missal:
In fiscal year 2022, there were thirty-six separate serious incident reports across thirty-two medical facilities, including a bomb threat that resulted in a full evacuation. VA campuses are open by design. They need to be easily accessible for patients, which makes them more difficult to secure. But we found that VA wasn’t meeting the minimum security requirements set out in their policy. Besides the lack of a visible police presence, additional security measures were not being taken, such as securing doors that should not be publicly accessible and ensuring surveillance cameras were operating correctly and being monitored. These are simple measures that can make a real difference. Again, even though these findings do not have a monetary impact, this report has big impact on the safety of VA patients, as well as VA staff and visitors. This, to me, is a really important report.
Fred Baker:
I should mention here that we released a podcast episode where we talk at length with the director in charge of this security review. I’d encourage all listeners to go back and give that episode a listen. Also, prior to that podcast, we interviewed an OIG psychiatrist from the Office of Healthcare Inspections on another report that’s also highlighted in this semiannual report to Congress—Deficiencies in Lethal Means Safety Training, Firearms Access Assessment, and Safety Planning for Patients with Suicidal Behaviors by Firearms. Can you tell us a little about that report?
IG Missal:
Sure. This is another critical report. First, let me just point out that, for individuals who have suicidal ideations, the time between deciding to act on these ideations and actually attempting the suicide could be as little as five to ten minutes. Therefore, every minute counts, and simple interventions can make a big difference. Safe storage practices, such as using a gun safe or lock box or storing unloaded firearms separate from ammunition, may lengthen this crucial time period enough to prevent the suicide. We found that VHA staff who interact with patients who have suicidal ideations, as well as access to firearms, are not always talking to them about safe storage, as required by VA policy.
Fred Baker:
Do we know how often these discussions were not being held?
IG Missal:
Yes. We looked at the records of 480 patients who have experienced firearm-related suicide behavior events, including fifteen patients for whom the event was fatal. Safe storage discussions were not documented in about 30 percent of the required comprehensive suicide risk evaluations for these patients. Of the fifteen patients who actually died by suicide by firearm, safe storage discussions were not documented for three.
Fred Baker:
Why weren’t they having these discussions?
IG Missal:
Like so many of our reports, it comes down to governance and leadership. VHA needs to ensure that its personnel are equipped and prepared to do their jobs. We found that a third of all VISNs, which are the regional leadership of medical centers, fell below a 90 percent completion rate regarding mandatory lethal means safety training, and the monitoring of this training completion was not as stringent as one might expect—especially given that suicide prevention is VA’s top clinical priority. During this national review, we conducted a survey of mental health, primary care, and emergency department clinicians. About 75 percent of the respondents who completed lethal means safety training reported discussing firearms storage with patients during risk assessment and safety planning. This number falls to 50 percent among those who did not complete the training. Two of our recommendations focused on training compliance among staff and the oversight structure for monitoring the completion of this training.
Fred Baker:
Switching gears slightly to the concept of adequate and qualified staffing, another of your five components of accountability. In one of our recently released reports, the Office of Special Reviews found that some individuals employed by VHA were supposed to be barred from federal healthcare jobs. How did that happen?
IG Missal:
Well, the Department of Health and Human Services OIG maintains the List of Excluded Individuals and Entities, which is meant to prevent those who have been found unsuited for working in federally funded healthcare programs from having access to medical facilities. This protects their assets, information systems, and—most importantly—their patients. We found four former nursing professionals were employed by VHA despite being on this list. One of them was on the list because of a healthcare fraud conviction. The other three had their nursing licenses either revoked or suspended, and this can happen for a variety of reasons, including criminal convictions, lack of knowledge or skill, or unsafe practices. Thankfully, all four individuals were in housekeeping, clerical, and support positions and none were engaged in patients’ health care. One of these individuals is now deceased; the other three have been terminated.
Fred Baker:
Do we know how they slipped through VHA’s hiring process?
IG Missal:
Yes, one was because of human error. The other three slipped through because they changed their surnames after being added to the list, and the OIG found that there was no national VHA policy or guidance requiring human resources staff to search candidates’ prior names. There was also a coding error in the computer program that VHA uses to check employee social security numbers against the excluded list. This coding error has since been corrected, and VHA concurred with our recommendations related to revising and implementing policies to include prior names in the screening of candidates.
Fred Baker:
Aside from our report-generating directorates, our Office of Investigations has had a busy six months. Can you talk about some of their recent work?
IG Missal:
Sure. Our Office of Investigations, as you pointed out, has been incredibly busy. They’ve opened 222 cases during this six-month period, which is staggering. We usually open around 170 cases every six months. In addition, we have been issuing many more fraud alerts. In January, we released an alert that focused on education benefits fraud, informing veterans and the public on how to identify schools engaged in this type of crime.
A couple key investigations highlighted in the semiannual report included one where our investigators caught two employees at the Dallas VA Medical Center who embezzled $2.9 million. They used their government-issued purchase cards to make phony purchases through two fictitious shell companies. They would create fake invoices and use existing items in the medical center’s inventory to conceal that the fictitious companies never delivered any materials. As a result of the great work of our investigators, we were able to secure a guilty plea from both defendants.
Another case highlighted in the semiannual report involves a registered nurse who worked in the VA Palo Alto Healthcare System. The nurse was arrested for allegedly engaging in inappropriate sexual contact with a veteran who was mentally incapacitated.
Fred Baker:
Wow. Our nationwide network of auditors, inspectors, and investigators certainly are working hard every day to fulfill our mission of serving veterans and the public by conducting meaningful independent oversight. IG Missal, thank you for your time today. Is there anything else you would like to add before you sign off?
IG Missal:
Thank you, Fred. I greatly appreciate the opportunity to talk about our work. None of this would be possible without the great work of our staff. I’d really like to thank them for their incredible dedication and commitment to our mission. Their efforts make a real difference in the lives of veterans and their families every single day. I encourage everyone to read the Semiannual Report to Congress, which is available on our website, as it summarizes the scope and breadth of our oversight work. I look forward to speaking with you again soon.
Fred Baker:
Thank you, IG Missal. If you’d like to read this semiannual report or any publication from the Office of Inspector General, visit our website at va.gov/oig.
Next up, we have a recap of our monthly highlights.
Mary Estacion:
You’ve just heard the IG discuss the highlights from the latest VA OIG Semiannual Report to Congress, which covered the reporting period of October 1, 2022 through March 31, 2023. Here are highlights of the work the VA OIG accomplished in March to close out the reporting period. I’ll start with investigations.
A VA OIG investigation resulted in charges alleging that a former supervisor at the VA Medical Center in Philadelphia, Pennsylvania, used his government-issued purchase card to place orders with a particular company that totaled $1.6 million. The former supervisor allegedly received cash payments of more than $28,000 from the owner of this company. The defendant was charged in the Eastern District of Pennsylvania with the acceptance of gratuities by a public official.
Another VA OIG investigation resulted in charges alleging that a former VA-appointed fiduciary misappropriated approximately $90,000 in VA benefits meant for her brother through numerous wire transfers to her own bank account. The defendant was indicted in the Western District of New York on charges of wire fraud.
Another investigation the VA OIG conducted involved employees at the VA medical center in Bay Pines, Florida. Between November 2020 and May 2021, a veteran sent more than 100 text messages to medical center employees, threatening assault and murder using explosives and drones. The veteran pleaded guilty in the Middle District of Florida to the interstate transmission of threats. The VA OIG and FBI Joint Terrorism Task Force conducted this investigation.
As for reports, the OIG published 12 in March. This includes Comprehensive Healthcare Inspection Program reports on the Amarillo VA Health Care System in Texas and the VA Texas Valley Coastal Bend Health Care System in Harlingen.
The OIG’s Office of Audits and Evaluations published five reports in March.
One of them involves the Veterans Business Administration, or VBA. When there is a need to verify the continued existence or the current severity of a disability, veterans are reexamined. While required reexaminations are important to ensure taxpayer dollars are spent appropriately, unwarranted reexaminations are a waste of appropriated funds, could cause undue hardships for veterans, and reduce the efficiency and timeliness of claims processing. The OIG found VBA did not require staff to cite objective evidence for why reexaminations were needed. It also did not define criteria for claims processors responsible for reviewing reexamination controls, establishing training requirements, or monitoring completion of relevant training. VBA concurred with the OIG’s three recommendations to update guidance, training, and information systems.
Another report published in March concerns an inspection the OIG conducted to evaluate allegations that the West Palm Beach VA Healthcare System staff failed to coordinate care for a patient who was diagnosed with cancer and ultimately died from the disease. The pulmonologist failed to notify the patient of chest CT scan results and did not use required scheduling processes to ensure follow-up appointments occurred. This may have resulted in delays in critical care for the patient. The OIG made three recommendations to the facility director to ensure that pulmonology providers communicate test results to patients, those providers follow the required appointment scheduling processes, and community care notes are reviewed and actions taken as needed.
The VA OIG started the next congressionally mandated reporting period busy as ever. Here are a few highlights from April.
Dr. Julie Kroviak, the principal deputy assistant inspector general for the Office of Healthcare Inspections, testified on April 18 before the House Committee on Veterans’ Affairs’ Subcommittee on Health. Her testimony focused on the findings and recommendations of the report Noncompliance with Community Care Referrals for Substance Abuse Residential Treatment at the VA North Texas Health Care System. This inspection was prompted by allegations that staff at the facility’s substance use disorder treatment program placed patients on waitlists for several months and failed to offer them non-VA community residential care referrals.
Dr. Kroviak emphasized the need for staff to adhere to community care policies, as well as for the VA to improve its collaboration with third-party administrators and community care providers for high-risk veterans with complex mental health conditions. In response to questions, Dr. Kroviak discussed the hallmarks of a high-quality community care residential rehabilitation program and the challenges in coordinating care for high-risk veterans with substance use disorders.
April updates to VA OIG investigations include a case in which a psychiatrist at the Marion VA Medical Center in Illinois used her position to intentionally sell prescription opioids to her patients for financial gain. She pleaded guilty in the Southern District of Illinois to conspiracy to distribute controlled substances. The VA OIG and FBI investigated the case.
An investigation VA OIG conducted with the Massachusetts State Police alleges that a housekeeping aide at the West Roxbury VA Medical Center stole a $5,000 winning scratch ticket from a terminally ill veteran who was receiving end-of-life treatment at the facility. To conceal the theft, the aide allegedly directed a codefendant with no connection to VA to redeem the winning ticket. Both were charged in West Roxbury District Court in Massachusetts with larceny and fraud-related offenses.
The OIG issued seven reports in April.
In one report, the OIG’s Office of Audits and Evaluations reviewed the acquisition and handling of ventilators during the pandemic by the Audie L. Murphy Memorial Veterans’ Hospital in San Antonio, Texas. The OIG found that the hospital acquired more ventilators than were needed for veteran care. Duplicate purchases were made due to hospital officials’ concerns about delays and supply chain disruptions. More than 50 ventilators, worth about $2.5 million, were never used and were stored for more than 19 months while other VA facilities reported shortages. The OIG recommended VA document a methodology for determining the number of ventilators required during routine and emergency operations and whether the remaining ventilators are needed or can be turned in. VA concurred with the OIG’s recommendations. VA submitted documentation of corrective actions, and the OIG closed the recommendations.
Another report concerns the veterans’ right to undergo disability exams within a reasonable distance from their homes. Because some veterans have expressed concerns regarding the excessive distances they’ve traveled for exams, the OIG reviewed how VBA’s Medical Disability Examination Office monitors mileage requirements in the contract exam process. The team found that VBA is not monitoring whether vendors that perform disability exams document veterans’ consent to travel beyond contractual mileage limits. If vendors are not obtaining this consent, veterans may not be aware of their right to undergo exams within reasonable distances, potentially burdening elderly veterans or those with disabilities. The OIG recommended the under secretary for benefits monitor compliance with contractual mileage limits and ensure vendors document the consent of veterans who agree to travel beyond these limits.
Also in April, the OIG’s Office of Healthcare Inspections issued two Comprehensive Healthcare Inspection Program reports. These reports focused on the VA Long Beach Healthcare System in California and the VA MidSouth Healthcare Network in Nashville, Tennessee.
For more information about these and the other reports the VA OIG have recently published, go to our website at va.gov/oig and select “reports” under the Publications tab.
That’s it for this episode of Veteran Oversight Now.
Check out other episodes wherever you listen to podcasts.
Thanks for listening.
This has been an official podcast of the VA Office of Inspector General. Veteran Oversight Now is produced by the Office of Communications and Public Affairs and is available at va.gov/oig. Tune in monthly to hear how the VA OIG serves veterans, their families, and caregivers through meaningful independent oversight. Check out the website for more on the VA OIG oversight mission, read current reports, and keep up to date on the latest criminal investigations. Report potential crimes related to VA; waste or mismanagement; potential violations of laws, rules, or regulations; or risks to patients, employees, or property to the OIG online or call the hotline at 1-800- -8244. If you are a veteran in crisis or concerned about one, call the Veterans Crisis Line at 1-800-273-8255, press 1, and speak with a qualified responder now.