VA Inspector General Interview: 86th Semiannual Report to Congress

Veteran Oversight Now

The Semiannual Report to Congress summarizes the VA Office of Inspector General (OIG) oversight from April 1 through September 30, 2021.

For this period, the VA OIG identified over $2.9 billion in monetary impact for a return on investment of $29 for every dollar spent on oversight. This does not include the inestimable value of the healthcare oversight work completed to advance patient safety and quality care. The OIG hotline received and triaged 15,104 contacts in this reporting period, bringing the total to 29,233 for the fiscal year.

The Office of Audits and Evaluations (OAE) published 42 reports, including three VA management advisory memoranda highlighting issues for prompt VA response. Contract review teams also conducted 58 preaward and postaward contract reviews and six claims reviews to help VA obtain fair and reasonable pricing on products and services. OAE reports for the six-month period resulted in 184 recommendations.

The Office of Healthcare Inspections focused on veterans’ access to high-quality care and the continuity of that care even as the pandemic persisted. The VA OIG published 74 healthcare inspections and reviews during the reporting period with 559 recommendations. The reports included examinations of the criminal actions of a serial murderer and an intoxicated pathologist, including the devastating impact of these actions and how they went unaddressed for so long.

The Office of Special Reviews published a report that received significant national attention, detailing a case in which a veteran, who was missing for weeks, was found dead in a stairwell of a building on a VA medical facility campus. The report delves into the widespread confusion among VA personnel and weaknesses in policies and procedures related to searches for missing patients and residents, routine police patrols, and building-cleaning practices.

The Office of Investigations opened 169 cases and closed 207 (most of which were opened in prior periods), with efforts leading to 113 arrests. Collectively, the work during this period resulted in 729 administrative sanctions and actions involving VA personnel.

Review this report and previous semiannual reports to congress at the VA OIG website.