Each month, the VA Office of Inspector General publishes highlights of our oversight reports, congressional testimony, and investigative work. In August 2025, the VA OIG published 17 reports that included 72 recommendations to VA.

Report topics included a review of medical facilities in VISN 12 (VA Great Lakes Health Care System) and whether they correctly identified veterans eligible for community care, informed them of their care options, and delivered timely care. Another report recommended VA medical facilities improve the monitoring of pharmacy automated dispensing cabinets for accountability over high-risk medications.

VA OIG investigative efforts resulted in the conviction of a former nurse at a Texas VA medical center who falsely claimed she had checked on a patient who ultimately died. In addition, a former VA-appointed fiduciary was indicted for allegedly stealing more than $133,000 from an elderly veteran who resided at the Cincinnati VA Medical Center.

Related Reports:

· VISN 12 Needs to Improve How It Administers the Veterans Community Care Program

· Pharmacy Automated Dispensing Cabinets Need Improved Monitoring for Accountability over High-Risk Medications

· Inconsistent Implementation of VHA Oncology Program Requirements Due to Insufficient Oversight

The Honorable Cheryl L. Mason was confirmed by the Senate as the inspector general of the VA on July 31, 2025, and shortly after being sworn in, took up her leadership of the VA OIG on August 4. IG Mason previously served as the chairman of the Board of Veterans’ Appeals at VA. For more information on IG Mason, see her bio.

In July 2025, the VA OIG published 18 reports that included 101 recommendations. Report topics included a review of VBA’s planning and implementation of the Military Sexual Trauma Operations Center and its governance structure for processing these types of claims. Another healthcare inspection examined deficiencies in care at the Batavia Community Living Center that contributed to a resident’s death at the VA Western New York Healthcare System in Buffalo.

On Capitol Hill, Shawn Steele, director of the human capital and operations division for the Office of Audits and Evaluations, testified on July 22 at a hearing before the Subcommittee on Oversight and Investigations of the House Veterans’ Affairs Committee (HVAC). His testimony focused on the OIG’s findings in a recent report on deficiencies in VA’s oversight of recruitment, retention, and relocation incentive payments.

VA OIG investigative efforts contributed to the indictment of 11 members of a transnational criminal organization who submitted billions in fraudulent claims to federal and private health insurance programs for durable medical equipment that was never prescribed or issued to the beneficiaries. In addition, a veteran pleaded guilty in Florida to VA disability compensation benefits fraud as the result of a proactive investigation. The loss to VA is about $1.1 million.

Related Reports:

• Implementation of a Military Sexual Trauma Operations Center Resulted in Minimal Change Despite Planned Intent to Improve Claims-Processing Accuracy

• Deficiencies in Care at the Batavia Community Living Center Contributed to a Resident’s Death at the VA Western New York Healthcare System in Buffalo

• Failures Related to the Care and Discharge of a Patient and Leaders’ Response at the VA New Mexico Healthcare System in Albuquerque

Each month, the VA Office of Inspector General publishes highlights of our oversight reports, congressional testimony, and investigative work. In June 2025, the VA OIG published nine reports that included 81 recommendations. Report topics varied from an evaluation of VA’s governance of recruitment, relocation, and retention incentives awarded for VHA positions to mental health inspections of the VA Salem Healthcare System in Virginia and the VA Philadelphia Healthcare System in Pennsylvania.

On Capitol Hill, Jennifer McDonald, PhD, director of the Community Care Division for the Office of Audits and Evaluations, testified on June 11 before the House Veterans’ Affairs’ Subcommittee on Oversight and Investigations. Her testimony focused on the impact of VHA’s pause in using its Program Integrity Tool—a system that consolidates community care payment data that is used, in part, to determine if veterans or their private insurance companies should be billed for care that is not connected to injuries or conditions related to their military service. She also highlighted the OIG’s work that identified deficiencies in how VA plans, implements, and remediates identified weaknesses in information technology modernization efforts.

VA OIG investigative efforts resulted in the conviction of a chief executive officer of a healthcare software company for a billion-dollar fraud conspiracy. Meanwhile, VA OIG investigative efforts in Louisiana led to the sentencing of two individuals for fraudulently obtaining federal pandemic relief loans.

Related Reports:

• Recruitment, Relocation, and Retention Incentives for VHA Positions Need Improved Oversight

• Mental Health Inspection of the VA Salem Healthcare System in Virginia

• Mental Health Inspection of the VA Philadelphia Healthcare System in Pennsylvania