This Semiannual Report to Congress summarizes the independent oversight efforts of the VA Office of Inspector General (OIG) from October 1, 2024, through March 31, 2025.

Visit the VA OIG's website to read the full report.

For this six-month period, the VA OIG identified nearly $3.3 billion in monetary impact for a return on investment of $28 for every dollar spent on oversight. These figures do not include the inestimable value of the healthcare oversight work completed to help save the lives of veterans and ensure their access to top-level medical care.

During this period, the Office of Investigations opened 256 cases and closed 213 (most opened in prior reporting periods), with efforts leading to 144 arrests. The OIG hotline staff triaged more than 17,000 contacts to help identify wrongdoing and address concerns with VA activities. The related work resulted in 598 administrative sanctions and corrective actions.

The Office of Audits and Evaluations (OAE) produced 47 work products, including one VA management advisory memoranda on VA’s progress related to reducing overdose deaths. Also included were 16 oversight reports and 30 preaward and postaward contract audits and reviews to help VA obtain fair and reasonable pricing on products and services. OAE reports for the six-month period resulted in 146 recommendations for VA improvements.

The Office of Healthcare Inspections (OHI) continued to provide the oversight necessary to assess VHA's delivery of high-quality care and leaders' efforts to build and uphold a culture that prioritizes patient safety. Of the 36 oversight products OHI published in the last six months, 10 were for-cause reports responsive to OIG hotline complaints. In addition to seven national reviews, OHI released 14 healthcare facility inspections, three care-in-the-community inspections, one mental health inspection, and one vet center inspection.

The Office of Special Reviews (OSR) conducted 21 investigative interviews and issued one report addressing VA’s lapses in oversight of a grantee providing transitional housing services to veterans at risk for homelessness. Also during this period, OSR reviewed 12 allegations of possible whistleblower retaliation involving VA contractor's employees or grantees.

The latest podcast episode of Veteran Oversight Now highlights the VA OIG’s oversight work during April 2025, including three healthcare facility inspections reports on facilities in Tennessee, New York, and Colorado.

April 2025 Monthly Highlights
Each month, the VA Office of Inspector General publishes highlights of our congressional testimony, investigative work, and oversight reports. In April 2025, the VA OIG published 12 reports that included 51 recommendations. Report topics varied from a review to determine whether claims processors are properly assigning effective dates for PACT Act-related claims to an inspection related to a patient’s delayed diagnosis and treatment for lung cancer at the VA Eastern Kansas Healthcare System in Topeka and Leavenworth.

VA OIG investigative efforts helped resolved allegations that a drug and alcohol rehabilitation facility, Seabrook House in New Jersey, submitted claims to VA’s Community Care program and the state’s Medicaid program for short-term residential treatment and partial hospitalization care for which it was not properly licensed or contracted and misled state inspectors. In a civil settlement, Seabrook agreed to pay $19.75 million to resolve False Claims Act allegations. Of this amount, VA will receive $19.15 million.

Meanwhile, 12 employees of the Louis Stokes Cleveland VA Medical Center pleaded guilty to theft after receiving more than $396,000 in Pandemic Unemployment Assistance benefits by falsifying their applications and failing to disclose their employment and wages earned at VA, and a physician at the Bedford VA Medical Center in Massachusetts was arrested and charged in the District of Massachusetts with the receipt and possession of child pornography.

Read the full monthly highlights.

Related Reports:

• The PACT Act Has Complicated Determining When Veterans’ Benefits Payments Should Take Effect
• Delayed Diagnosis and Treatment for a Patient’s Lung Cancer and Deficiencies in the Lung Cancer Screening Program at the VA Eastern Kansas Healthcare System in Topeka and Leavenworth
• Hiring of Claims Processors Generally Met Requirements and the Attrition Rate Remained Steady

Each month, the VA Office of Inspector General publishes highlights of our investigative work, congressional testimony, and oversight reports. In March 2025, the VA OIG published 17 reports that included 101 recommendations. Report topics varied from a review of VHA and VBA fiscal year 2024 supplemental funding requests and mental healthcare services at a Massachusetts’ VA medical center to a review of the veteran self-scheduling process for community care and supply and equipment management deficiencies at a Texas VA medical center.

VA OIG investigations led to the sentencing of a pharmacy operator who conspired with various doctors to charge government agencies for medically unnecessary compound prescriptions, pain creams, scar gels, and multivitamins primarily to patients covered under the Office of Workers’ Compensation Program. Elsewhere, a government subcontractor was sentenced to 12 months’ probation and ordered to pay restitution of more than $493,000 after previously pleading guilty to bank fraud. The company fraudulently obtained a Small Business Administration-backed Paycheck Protection Program loan. The company’s owner also agreed to pay more than $1.1 million as part of a civil settlement to resolve his own civil liability.

This latest podcast episode of Veteran Oversight Now highlights the VA OIG’s oversight work from March 2025, including four healthcare facility inspections reports on facilities in Massachusetts, Georgia, Virginia, and Washington, DC.

Related Reports:

• The Causes and Conditions That Led to a $12 Billion Supplemental Funding Request
• Review of VA’s $2.9 Billion Supplemental Funds Request for FY 2024 to Support Veterans’ Benefits Payments
• Inadequate Governance Structure and Identification of Chief Mental Health Officers’ Responsibilities

In this latest episode of Veteran Oversight Now, we’re bringing you highlights of our oversight work from February 2025.

Hear Acting Inspector General David Case discuss VA’s challenges with implementing its new electronic health record system before Congress as well as Dr. Julie Kroviak, acting inspector general for the Office of Healthcare Inspections, who recently testified before Congress on concerns with VA community care. Plus updates on ongoing investigations and summaries of reports published last month. Visit the VA OIG website for a full list of oversight work completed in February.

Related Report:

• Lapse in Fiduciary Program Oversight Puts Some Vulnerable Beneficiaries at Risk
• Staff Mitigated the Impact of Appointment Cancellations in a Mental Health Clinic at the VA Northern Indiana Healthcare System in Fort Wayne

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 oversight work from April 1 to September 30, 2024. This edition also includes highlights of the VA OIG’s work from October 2024.

“I’m extremely proud of all the enhancements we’ve made and the exceptional improvements we helped to bring about for VA’s programs and operations, which ultimately improve the lives of veterans and their family members.”

– VA Inspector General Michael J. Missal

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 stand-down at the facility to retrain all of the laboratory staff about the test, about the assessing of the test and processing it. And then they also passed all of that information to all of the other facilities within VISN 22. So, it wasn’t just Phoenix, you know, they made sure all of the facilities in VISN 22 had the same information and the same knowledge. So, to follow that up, they’re doing weekly audits and checking to make sure that the logging process is being done correctly. And so far, the reported compliance has been 100 percent.”

– Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director

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 edition also includes highlights of the VA OIG’s work from August 2024.

“Once the patient's heart rate completely stopped and they went into asystole, that should have triggered a code blue. Period.”

– Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director

Related Report: Care Deficiencies and Leaders’ Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee

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 and made seven recommendations related to oversight of the medical center’s Sterile Processing Service. This episode also includes highlights of the VA OIG’s work from July 2024.

“If it’s [medical device] not documented properly and it’s not documented in the system so that we can track the cleaning, the disinfecting, the sterilization, then we don’t know if it’s processed appropriately.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director

Related Report: Deficiencies in Documentation of Reusable Medical Device Reprocessing and Failures in VISN 22 Oversight of Sterile Processing Service at the Raymond G. Murphy VAMC in Albuquerque, New Mexico