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 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 2024, from October 1, 2023 to March 31, 2024.

IG Missal, welcome.

IG Michael J. Missal:
Thank you, Fred. As you know, I love talking about our semiannual report.

Fred Baker:
Well, as this report is being released, our office is completing its 45th year as an independent oversight office. This is the VA OIG's 91st semiannual report to Congress, and according to the report, the OIG identified more than $1.45 billion in monetary impact during the six-month reporting period. This comes very close, however, to matching the OIG's monetary impact for the entire fiscal year of 2023.

IG Michael J. Missal:
Yeah, that's correct, Fred. We have a really challenging and complex mission, and our primary focus is on the impact that we have for veterans and their families. As a result, that sometimes leads to fluctuations in monetary impact.

While we're always proud to report such a high number—since we are also focused on VA being a good steward of taxpayer funds— our monetary impact number, however, does not include the impact that our health care inspection staff make every day. They are focused on ensuring that veterans get the high quality and timely care they deserve. You can't measure that impact in dollars.

Fred Baker:
I noticed that the Office of Health Care Inspections published 59 oversight reports this period. Many of their publications highlighted in this report focus on patient safety. In fact, one report found that a scheduling error in the new electronic health record system contributed to the death of a patient.

IG Michael J. Missal:
Yes, that's correct and obviously very tragic.

Many of the reports highlighted in the health care section illustrate how a failure in leadership can lead to deficiencies in patient safety and quality of care. In that particular case, it was a combination of the electronic health records system error and inadequate mental health care that contributed to this veteran’s death. Both of these issues could have been prevented with more effective and engaged leadership.

Regarding the system error, VHA has a required protocol in the event that a mental health patient misses an appointment. At minimum, staff should make three phone calls to the patient on three separate days. The EHR system is supposed to route the missed appointment to a queue that prompts the schedulers to make those subsequent attempts to contact the patient. The system failed to do that in this case, so no one tried calling the patient beyond the day of the missed appointment. The team concluded that this lack of contact efforts may have, and I underscore “may have,” contributed to the patient's disengagement from mental health treatment and ultimately the patient's substance use relapse and death.

The team also looked at the history of the patient’s care and found deficiencies at multiple levels. This included a nurse practitioner failing to evaluate a request from the patient to restart medication, a supervisory psychologist not thoroughly evaluating the patient's depression and failing to reconcile critical clinical information, and staff failing to send the patient monthly caring communications after the patient's high risk for suicide flag was inactivated, which is required by policy. On top of all that, following the patient's death, facility leaders conducted a root cause analysis but didn't communicate the resulting lessons learned to staff as expected and needed.

Fred Baker:
Certainly, a tragic story that I feel emphasizes the criticalness of our oversight work. VA's electronic health record modernization efforts seem to have had many obstacles. I noticed that this isn't the only highlighted report that's related to these modernization efforts.

IG Michael J. Missal:
That's correct. Overall, the OIG has published 19 products addressing the Electronic Health Record System Modernization program in the last four years with more than 70 recommendations for corrective action. We published three in this reporting period, including a management advisory memorandum issued by the Office of Audits and Evaluations, which we highlight in the semiannual report.

Fred Baker:
And that memo is also related to scheduling issues, correct?

IG Michael J. Missal:
That's correct. We released the memo out of concern that the many scheduling system challenges that VA staff were experiencing at the five electronic health record system deployment sites, all of which are smaller VA medical facilities, would be magnified at larger, more complex facilities such as the Captain James A. Lovell Federal Health Care Center in Chicago, where the new electronic health record system was recently deployed. The memorandum focuses on deficiencies with another queue, the displacement appointment queue, which is used by staff to identify appointments that need to be rescheduled due to changes in the schedule of the health care provider. The new electronic health record system was not always routing appointments to this queue, and appointments that were properly routed to the queue sometimes disappeared.

The memo also points out that following implementation of the electronic health record system, medical facilities may need to increase their staffing levels, as well as the use of overtime, if VHA expects appointments to meet or exceed pre-deployment levels. Significantly, VA decided to delay the electronic health record system deployment at all facilities in order to resolve these and many other problems.

Fred Baker:
So, sticking with the Office of Audits and Evaluations but switching gears a bit, they've also identified significant deficiencies in VA's personnel suitability program. Explain that a bit and talk about those findings.

IG Michael J. Missal:
These are really impactful reports. For a bit of context, VA positions must undergo background investigations as a condition of their employment to help ensure the safety of veterans, their family members, other VA employees and visitors, that they may encounter when going to medical centers and other facilities. In addition to checking that an individual is suited for the position, this vetting also helps secure sensitive information and VA resources. During this period, we testified before Congress on VA's lack of oversight, effective data, and information technology systems to ensure that required background investigations were conducted and adjudicated within required timelines for staff at medical facilities nationwide. Delays increase the risk of putting individuals whose vetting is still ongoing in positions where they can serve veterans and, depending on the job, have access to drugs, expensive equipment and supplies, and sensitive information or systems.

Fred Baker:
Well, it certainly sounds like a very important topic for our oversight. This has been a particularly busy time right now for our work, correct?

IG Michael J. Missal:
Absolutely. We are all passionate about what we do and the impact that we have. Other massive VA initiatives such as PACT Act implementation, which expands care and benefits for toxic exposure during military service—perhaps the greatest increase in VA health care and benefits—as well as community health care expansion, modernization of VA's financial systems, and replacing its supply chain management system makes our oversight work that much more consequential.

Fred Baker:
So, with all of this going on, what's the VA OIG doing to keep up, keep pace?

IG Michael J. Missal:
We're an organization that keeps trying to improve. To that end, we've expanded and enhanced virtually all of our oversight areas. The Office of Health Care Inspections launched a new cyclical inspection program that focuses on inpatient mental health services, which is VA's number one clinical priority. Also, one of our most recognized programs, the cyclical inspection of VA hospitals and clinics called the Comprehensive Health Care Inspection Program, or CHIP, is being re-imagined as the Healthcare Facility Inspection Program or HFI. This enhancement will be of even greater value to medical facility staff and leaders, as well as other stakeholders. These inspections are designed to better assess the culture of a facility and its influence on the delivery of health care.

We've also expanded our reach in criminal investigations and have been deploying proactive data analytics in an effort to identify and catch fraudsters as quickly as possible. During this reporting period, our special agents opened 178 investigations, with efforts leading to 112 arrests. Collectively, the OIG's work over this reporting period also resulted in 459 administrative sanctions and corrective actions. OIG investigations routinely uncover large amounts of benefit payments made to ineligible individuals. Also significant, education investigations target fraudsters that do not deliver promised education services to eligible veterans, service members and their qualified family members.

Fred Baker:
Speaking of fraudsters, our office recently began releasing fraud and crime alerts to the public and to VA staff, identifying trends and red flags to look for. Can you speak to those for a bit?

IG Michael J. Missal:
Yeah, that's correct, and that's a really great development we've had. Two important alerts were issued by our office during this reporting period. The first notified VBA employees of the need to identify and report possible public disability benefits questionnaires, or DBQ, fraud schemes. Public DBQs are benefit forms that veterans must complete and submit to help VA evaluate their disability benefit claims. The fraud alert encourages VBA staff to report when veterans share that they are being charged high fees from unaccredited individuals for assistance with completing DBQs or an initial claim filing, or when public DBQs raise questions of authenticity or other red flags.

The second alert pertained to the theft of funds by fiduciaries who have been appointed to manage the financial affairs of veterans and other beneficiaries unable to do so for themselves. It identified several red flags for this type of theft, including fiduciary lacking documentation to support expenses, being unresponsive to VA requests, and restricting VA's access to beneficiaries during field exams. These and other investigative efforts enhance the detection of high-dollar fraud in a number of risk areas and help prevent harm to veterans, their families, and caregivers.

Fred Baker:
You mentioned the use of data analytics, and that's been a huge growth area for OIG across the community and us as well.

IG Michael J. Missal:
That's been a true game changer for us. As highlighted in the semiannual report, our data analytics group gives us an incredible advantage in the work that we do. They work closely with all OIG directorates to advance oversight work in a broad range of subjects, including financial management, staffing levels, community care referrals and usage, contracts and procurements, as well as VA suicide prevention efforts, homelessness programs, vet center services, the fiduciary program, and so many other programs.

Fred Baker:
Well, it certainly is evident that the VA OIG is working hard to fulfill its mission to serve veterans and the public by conducting meaningful independent oversight. IG Missal, thank you for your time today. Is there anything else you'd like to add before we sign off?

IG Michael J. Missal:
I greatly appreciate having this opportunity, Fred. It's really wonderful to be able to talk about all of the incredible work that our staff performs in the service of our nation's veterans. I could not be more proud of the progress our staff have made in achieving our mission to serve veterans and the public by conducting meaningful, fair, and evidence-driven oversight of VA. OIG personnel, many of whom are veterans themselves, or whose family have served, are deeply committed to improving the efficiency, effectiveness, and integrity of VA to significantly improve the lives of veterans, their families, caregivers, and survivors.

I also encourage everyone to visit our new website, vaoig.gov, where you can read the full semiannual report as well as every oversight report published by the OIG, summaries of our criminal investigations, podcast interviews with OIG subject matter experts, and many other important resources.

Fred Baker:
Thank you, IG Missal. And now we will go to Lauren, our cohost, and she'll have a recap of our monthly highlights.

Lauren O’Connor:
Thanks, Fred.

The reporting period for the next Semiannual Report to Congress is already off to a busy start. It began April 1 and runs through September 30.

On April 10, Dr. Jennifer Baptiste, Deputy Assistant Inspector General for Healthcare Inspections, testified before the Senate Veterans’ Affairs Committee. Her testimony focused on the challenges VA faces in its efforts to increase and enhance its services for women veterans. This includes addressing the OIG-identified healthcare program deficiencies in supporting the needs of this growing population. She emphasized the importance of VA improving access to gender-specific care within their facilities as well as the coordination of care that women veterans receive in the community because some services—such as maternity care—are not generally provided by VA. Find Dr. Baptiste’s written statement as well as a recording of her opening statement on the OIG website under the Congressional Relations tab.

Meanwhile, in April, nine investigations had significant developments. I’ll highlight a couple. A VA OIG and VA Police Service investigation found that a registered nurse at the VA Palo Alto Health Care System engaged in inappropriate sexual contact with a mentally incapacitated veteran who was receiving inpatient treatment. After pleading guilty to abuse of a dependent person, the nurse was sentenced in Santa Clara County Superior Court to one year of probation and ordered to complete a sex offender treatment program. She also may not renew her nursing license nor have contact with the victim.

In another case, a multiagency investigation revealed that a veteran submitted false documents to VA to obtain a loan for a property valued at $2.1 million. The veteran also used his position as an Army financial counselor to target gold star families to invest their survivor benefits in investment accounts that were managed by his private employer. The defendant pleaded guilty in the District of New Jersey to charges of wire fraud, securities fraud, making false statements in a loan application, committing acts furthering a personal financial interest, and making false statements to a federal agency. The investigation was completed by the VA OIG, Homeland Security Investigations, the Defense Criminal Investigative Service, and the FBI.

The VA OIG published 31 reports in April. Several of these reports concerned veterans receiving care from community providers.

The Office of Audits and Evaluations issued the report Improved Oversight Needed to Evaluate Network Adequacy and Contractor Performance. VHA, through the Veterans Community Care Program, purchases care for veterans through Community Care Network contracts. The Office of Integrated Veteran Care oversees execution of these contracts with third-party administrators that manage community care providers in the network. The OIG found that the office did not hold third-party administrators accountable for some contract requirements. Specifically, it did not oversee that third-party administrators ensured facilities had enough community providers to administer care within the timeliness and drive-time standards required. The office also did not conduct analyses of facilities’ network adequacy needs, confirm that third-party administrators maintained provider networks accepting VA patients, or position itself to defend facilities’ needs for additional providers. The under secretary for health concurred with the OIG’s eight recommendations regarding oversight of future third-party administrators.

As required by the MISSION Act, VHA identifies healthcare providers who have been removed from VA employment due to violations of policy “relating to the delivery of safe and appropriate care” and excludes them from the VA Community Care Program. An Office of Healthcare Inspections review found that VHA’s process failed to identify all healthcare providers removed from VA employment. The process also did not accurately identify personnel actions indicating healthcare providers were removed for violating policies relating to the delivery of safe and appropriate care. These process failures resulted in ineligible healthcare providers being included in, as well as eligible providers being excluded from, the community care program. VHA concurred with the OIG’s two recommendations to improve the criteria and processes used to identify ineligible healthcare providers and the reason for their removal from VA employment.

Another report by OHI found increased use of primary care in the community by the VA Loma Linda Healthcare System in California. This inspection assessed the high usage of community care services for primary care, the impact of that use, and healthcare system leaders’ oversight of VA outpatient clinics. The OIG found that the new company responsible for managing clinics not operated by VHA experienced challenges staffing those clinics. This increased the number of patients assigned to panels of patient-aligned care team providers. As a result, the healthcare system leaders paused enrollment of new patients at all five non-VHA-operated clinics. While there were delays in processing and scheduling community care consults after the increase in primary care in the community, the OIG did not identify patients who experienced poor outcomes. A lack of oversight of non-VHA-operated clinics, as well as frequent changes of leadership at the healthcare system and the new company, highlighted a vulnerability in the overall management of primary care services. The OIG made three recommendations regarding primary care staffing and panel sizes, timeliness of community care consult processing, and clinic oversight.

The OIG also published 21 Comprehensive Healthcare Inspection Program reports in April. These reports featured VA medical facilities in 17 states.

We also published three Vet Center Inspection Program reports in April. The first two focused on zones 1 and 2 in Southeast District 2, specifically vet centers in the following areas: Augusta, Marietta, and Savannah in Georgia; Johnson City, Tennessee; Charleston, South Carolina; Fort Lauderdale, Fort Myers, Gainesville, Lakeland, Naples, and Bay County, in Florida; and San Juan in Puerto Rico.

The third Vet Center Inspection Program report reviewed leadership stability, morbidity and mortality reviews, the high-risk suicide flag SharePoint site, and consultation and safety plans in the Southeast District. You can read all of April’s reports on the VA OIG website.

Thank you for listening to April’s highlights. Visit our website for all VA OIG podcast episodes.

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. 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 1-800-488-8244. If you are a veteran in crisis or concerned about one, call the Veterans Crisis Line at one 800-273-8255. Press one and speak with a qualified responder now.