Bureaucracy Times

All the news fit to be declassified.

Tag: Veterans Affairs

  • The Furnace Broke. The Recommendations Didn’t.

    The VA Office of Inspector General visited the Thomas E. Creek VA Medical Center in Amarillo for four days in February 2026 and found a hospital that had spent the previous three months heating itself with the equipment version of a séance. The resulting Healthcare Facility Inspection report reads like most of its siblings in this OIG series, calm, procedural, and quietly damning. Two recommendations. Zero questioned costs. A director who concurred with everything and asked, politely, for one of them to be closed before the ink dried. It is the kind of report that could put you to sleep if you didn’t notice that the sleeping happened in a hospital where nobody was checking whether the medication was still good.

    A Building That Kept Its Own Time

    In late November 2025, the heating system at Amarillo’s main hospital stopped working. Not a fuse, not a thermostat, an aged air handling unit whose replacement parts, executive leaders told inspectors, “were not readily available to order.” The outage ran for approximately three months. Engineering staff got by reviving old steam furnaces that had presumably been left in place for exactly this occasion, and when that wasn’t enough, they deployed space heaters and moved veterans out of a medical surgical unit that never did get adequate heat back. The Associate Director said the facility’s infrastructure plan includes replacing other aging systems “to prevent similar disruptions in the future,” which is the sentence every institution says right after the thing it was supposed to prevent has already happened.

    This is presented in the report’s Culture section, under the heading “System Shocks,” as a story about resilience. The staff adapted. The mission continued. Nobody froze. All of that is true, and none of it changes the fact that a facility with a $597 million medical care budget kept a wing of veterans warm with the hospital equivalent of camping gear for a full winter because a part could not be sourced. The OIG made no recommendation on this. It did not need to. The next section of the report supplies its own commentary.

    The Room Where Nobody Checked the Weather

    The Environment of Care section is where the actual grading happens, and Amarillo did not do well. Inspectors touring the medical surgical units, the ICU, the emergency department, and the community living center (VA’s term for its nursing homes) found wall damage in the emergency department and CLC hallways, damaged floors in the CLC, stained ceiling tiles over the emergency waiting area and the CLC dining room, and, in the CLC’s clean utility room, dirty equipment and items simply left on the floor next to whatever was supposed to stay clean. VHA Directive 1608(1) requires facilities to keep those two categories physically separated for the obvious reason that “clean” and “next to a mop bucket” are not the same condition.

    Then there’s the medication rooms. Staff in the ICU and the CLC were not monitoring temperature and humidity, a basic requirement under VHA Directive 1108.07(2) that exists because medications stored outside 68 to 77 degrees Fahrenheit and 30 to 60 percent relative humidity can degrade without anyone noticing. The Associate Director told inspectors he had no idea staff weren’t doing this. The facility’s own written policy, in place since 2023, said they were supposed to be. Nobody had checked whether the policy was being followed until the OIG did.

    The facility’s fix for this one is worth sitting with. In its written response, Amarillo reported that nursing staff, when interviewed, “were unable to speak to the established process,” which is a generous way of saying the people responsible for the room didn’t know there was a room to be responsible for. The corrective action was staff education and new signage identifying a point of contact. The facility then reviewed a year of monitoring data, found humidity excursions had in fact occurred, decided none of the affected medications needed to be thrown out, and asked the OIG to close the recommendation. The OIG agreed, on September 28, 2026, the same day this report was published. Recommendation open, evaluated, and closed inside the same document. That is not oversight moving quickly. That is oversight arriving exactly in time to watch the facility grade its own test.

    A Finding With Its Own Frequent Flyer Program

    None of this would be especially newsworthy if it were unique to Amarillo. It isn’t. The VA Indiana Healthcare System’s inspection, completed earlier in this same cycle, cited supplies and debris left on a clean supply room floor and chipped, damaged walls with visible residue in a patient room, language close enough to Amarillo’s that it could be a find and replace job. The VA Western Colorado Healthcare System’s inspection went further, issuing eight recommendations that included the identical clean and dirty item separation failure, plus ceiling vent dust, wall repair, and a call for the regional VISN office itself to start actually overseeing the environment of care program it was supposed to be overseeing all along.

    Three different facilities, three different states, three different inspection windows, and the same finding under the same directive with the same prescribed remedy: develop a plan, educate staff, monitor compliance until it holds for six consecutive months. VHA Directive 1608(1) has been in place since 2021. It has been amended once, in 2023, seemingly without anyone updating the muscle memory of the maintenance staff tasked with following it. This is not three unlucky facilities. This is what a compliance program looks like when the response to a finding is standardized but the underlying behavior isn’t.

    Closed, In the Sense That the Paperwork Says So

    The Amarillo report closes on an uneasy note of institutional self-awareness. In its conclusion, the OIG mentions, almost in passing, that it is tracking VHA’s ongoing restructuring, the collapse of 18 regional networks down to five, completed just months before this inspection was published, and that the agency plans to “monitor VHA’s change management” going forward. It is a tidy sentence to end on, and it says nothing about who, in a newly consolidated five-network structure, will be responsible for making sure the next facility’s clean utility room stays clean.

    The honest reading of this report is not that Amarillo is a badly run hospital. Employee survey responses describe leaders who communicate often, veterans who travel from three states away specifically to be treated there, and a 94 percent trust rating that beats the VA average. The honest reading is that a facility can do nearly everything right and still leave a heating system to fail for three months because a part wasn’t in stock, and still let a medication room go unmonitored for however long it takes an inspector with a clipboard to notice. The OIG will be back in roughly three years to check again. Given the pattern at Indiana and Western Colorado, there is no particular reason to expect the sequel to look different, only that it will, once again, be resolved with an action plan, a monitoring period, and a director who concurs.

    Fediverse Reactions

  • The VA Hospital That Kept Failing the Same Inspection

    The VA Office of Inspector General spent four days in August 2025 walking the halls of the VA New Jersey Healthcare System, and what it found reads less like a discovery than a rerun. Untested fire doors. Exposed wiring. Expired hand sanitizer. Missing sprinkler head plates. Every one of these had already been flagged, by two other auditors, in two prior years. The OIG simply confirmed that nobody had done anything about it (VA OIG, Report 25-00242-195, Sept. 25, 2026).

    A Facility With Three Report Cards and One Grade

    The Joint Commission inspected East Orange and Lyons in the spring of 2024 and found damaged ceiling tiles, emergency pull cords wrapped uselessly around handrails, and a hand sanitizer dispenser bolted directly above an electrical outlet, an arrangement that National Fire Protection Association code exists specifically to prevent. Weeks later, the Veterans Integrated Service Network’s own annual safety evaluation found the same wiring problems, the same missing sprinkler plates, the same neglected eye wash stations. Then in August 2025, sixteen months and one more VISN evaluation later, OIG inspectors arrived and cataloged the identical list. Bugs in light fixtures. An eye wash station blocked by trash cans. Another behind a locked door. A blanket warmer with a broken thermometer, so nobody could confirm it wasn’t running hot enough to injure a patient.

    The most damning line in the entire report is not a violation; it’s an explanation. Facility leaders told the OIG that when a Joint Commission finding came in, they assigned a “champion” to fix that specific item, track it for a few months, and close it out. Nobody then checked whether the same defect existed two floors up, or in the other building, or in the room next door. The system was built to close tickets, not to fix conditions. That is not an oversight. That is a workflow, and it is the reason three separate inspections over two years kept finding the same broken country.

    The Clock That Stopped in 2018

    Buried in the fire safety section is a detail that deserves more alarm than it got. Components of East Orange’s sprinkler system were last fully tested in 2018. Federal fire code requires that testing every three years. Nobody inside the facility caught the seven year lapse. It took an outside inspector, flipping through maintenance logs during a routine three year cycle visit, to notice that the system meant to put out fires in a building full of bedridden patients hadn’t been checked since the first Trump administration.

    The facility’s written response is a masterclass in bureaucratic redemption arc, promising a “comprehensive action plan,” an assessment of all six hundred fire doors, “interim life safety measures,” and monthly reporting up a new committee chain. All of this is true and all of it is also what gets written every time an inspector shows up with a clipboard. The test is not the pledge; it’s whether the OIG’s next visit, on its own three year cycle, finds anything different.

    Nobody Told the Family

    The report’s second major thread involves adverse events, VHA’s term for incidents that harm or nearly harm a patient. In the twelve months before the inspection, the facility recorded a delayed diagnosis, a serious injury, and a death, each the kind of event that VHA policy requires be formally disclosed to the patient or their family. The facility disclosed none of them. Risk managers told OIG inspectors they had “varying interpretations” of which adverse events actually triggered the disclosure requirement, an admission that a policy meant to protect patients had quietly become optional at the point of use.

    Separately, patient safety staff had let twenty nine corrective actions from prior root cause analyses go overdue, and executive leadership said they had no idea. The chief of quality had been on the job for fourteen days when the OIG walked in and told her about a backlog that had been accumulating on someone else’s watch for months.

    The Corrective Action Plan Is Also a Genre

    None of this is new to VA, and none of it is unique to New Jersey. The pattern here, an inspection generates a promise, the promise generates a committee, the committee generates a monthly report, and the underlying condition waits patiently to be rediscovered by the next auditor, is close to the operating system of federal accountability itself. VA New Jersey’s leadership turned over almost entirely in the year before the inspection, a new director, a new chief of engineering, a new quality chief, each inheriting a facility mid collapse and each producing, on cue, a fresh action plan with a fresh target date of March or December 2027.

    Reading eleven recommendations and eleven corresponding concurrences, each attached to a specific committee that will “monitor” compliance until some threshold of ninety percent is reached for six consecutive months, one starts to suspect that the compliance theater has become more sophisticated than the compliance itself. The VISN director concurred in one paragraph. The facility director concurred in one paragraph. Both thanked the OIG for the opportunity.

    The veterans using that emergency department, the ones navigating a locked interior route or an outdoor ramp to reach it, are unlikely to be reassured by a committee’s monitoring cadence. They would probably just like the doors to close.

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  • How the VA Turned a $34.5 Million Construction Plan Into a $100 Million Disaster in Arkansas

    The Veterans Health Administration’s capacity for self-inflicted institutional failure remains as reliably catastrophic as ever. A new Office of Inspector General report, released in September 2026, documents how five construction and maintenance projects at the Fayetteville VA Medical Center in Arkansas went from a collectively budgeted $34.5 million to approximately $100 million in actual or projected costs, with delays ranging from one year to more than seven years beyond their scheduled completion dates. As of January 2026, only one of the five projects had been finished. The others languished in various states of partial construction, abandonment, or perpetual redesign.

    The core allegation that prompted the OIG investigation, submitted via hotline complaint in March 2024, was straightforward: the facility was chronically unable to execute basic construction management tasks. Three of the four allegations were substantiated. The fourth, regarding contract terminations, wasn’t needed; the more damning finding was that the facility didn’t even fail to terminate contracts properly, because it managed not to terminate any construction-related contracts at all between 2019 and 2024, suggesting a different species of dysfunction entirely.

    The OIG report identifies the underlying cause with surgical precision: the engineers delegated as Contracting Officers’ Representatives (CORs) at Fayetteville didn’t do their jobs. They failed to provide architectural and engineering firms with complete VA design and physical security requirements. They handed construction contractors statements of work so vague that bidders peppered the facility with clarifying questions that went unanswered or received replies that prompted yet more questions. None of the three CORs interviewed for the investigation had taken formal training on developing statements of work, despite this being identified in VHA guidance as a primary responsibility. No formal design review process existed, despite the Federal Acquisition Regulation requiring CORs to maintain records of their design approvals. In lieu of institutional process, the facility’s engineering team conducted design reviews via email and spreadsheet, often without signatures, frequently without documentation of which engineer actually did the reviewing.

    This is not complexity masquerading as bureaucracy. This is bureaucracy pretending to be competence.

    The Geometry of Delay

    The mathematics of Fayetteville’s construction failures follows a peculiar pattern: small initial omissions compound into massive downstream costs and schedule disruptions. Consider the inpatient mental health building, the facility’s flagship project. Originally budgeted at $9.5 million with a planned October 2018 completion date, it remained under construction as of January 2026, more than seven years late, at an estimated final cost around $19 million. As the OIG investigation traced the project’s trajectory, the story of how a straightforward 21,056-square-foot psychiatric facility became a near-decade-long institutional migraine emerged from the contract record.

    The architectural and engineering design did not comply with VA physical security standards because the CORs writing the initial design contract omitted VA-specific requirements from the statement of work. This wasn’t a disagreement about standards or a calculated decision to incorporate standards later. The VA design requirements simply weren’t communicated. When construction bidders reviewed the design documents and began asking contractors’ reasonable questions about security specifications, lighting minimums, electrical connections, piping, stairwells, and elevator shafts, the facility’s response was essentially: we’ll figure it out. The COR’s responses were vague enough that contractors asked follow-up questions, some of which went unanswered. After the contract was awarded at $12.4 million, well above the $9.5 million budget, construction began. Then the contractors discovered the design didn’t meet VA standards. Automatic door operators required for patient accessibility throughout the building were absent. An over-the-door alarm system for suicide prevention in patient rooms was missing. The design lacked proper gaps between exterior masonry and walls, a deficiency that led to a legal dispute and cost the facility $1.8 million in contractor time spent resolving the noncompliance.

    In total, the mental health building accumulated 34 contract modifications, of which 16 related directly to design errors and omissions. Another project, the logistics area and sterile processing service renovation, began with a $2.7 million budget and 6,300 square feet of intended space. Architects eventually informed the facility that the selected location lacked sufficient square footage to meet the project’s design requirements. Rather than catching this during the planning phase, the discovery triggered a two-month work stoppage while the facility and its architectural firm argued about scope. When they agreed to expand the space, the project’s footprint ballooned to 13,500 square feet. By January 2024, the facility decided to split the project in two. The original $2.7 million project is now projected to cost $28.9 million total, with completion dates pushed five years into the future. The sterile processing component alone now carries a $24.8 million price tag.

    The laundry facility renovation followed a similar arc, though with more dramatic physical consequences. The original $1.9 million project eventually cost over $8 million. During construction, water damage was discovered in the building’s concrete floor; damaged concrete and rebar had to be removed and replaced before any other work could proceed. This discovery suggests contractors were bidding on a site assessment that had no apparent connection to what was actually in the ground. The statement of work didn’t adequately describe existing site conditions, so contractors bid on a phantom project, then discovered the real one halfway through construction.

    The Accounting of Incompetence

    The financial impact extends beyond the direct project costs. The facility spent over $1.1 million from its general operations funds on indirect expenses related to construction delays. When the inpatient mental health building delayed its opening, furniture purchased for the facility in 2020 needed warehousing. The facility paid a contractor $52,000 in December 2022 to store furniture for a building that still wasn’t ready for occupancy. Eventually, the facility moved the furniture to on-site storage to reduce costs further. Storage, surveillance, and laundry operations were temporarily outsourced or relocated due to construction delays, creating a cascading series of workarounds, each carrying its own budget impact.

    The three projects affected by cost-estimate variances all exceeded independent government cost estimates by more than 20 percent. The mental health building’s estimated construction cost was $8.2 million; the awarded contract was $12.4 million. The inpatient medical surgery unit’s estimated cost was $7.8 million; the awarded contract was $11.7 million. The logistics renovation estimate was $1.8 million; the awarded contract was $4.1 million. The OIG notes that while VA has no established criteria for acceptable variance between estimates and contract awards, significant deviations result in schedule delays while additional budget approvals are sought.

    There’s a damning detail embedded in the OIG’s analysis of independent government cost estimates. These estimates are supposed to be developed by CORs and based on prior project information, market research, anticipated direct and indirect costs, and design review. They’re meant to serve as a baseline against which to evaluate whether a contractor’s proposed price is reasonable. But the Fayetteville CORs were developing these estimates without having received training on how statements of work affect cost estimates, because training on developing statements of work simply wasn’t part of their onboarding. One might reasonably ask: if your staff doesn’t know how to write clear project specifications, how can they be expected to estimate what those (unclear) specifications should cost?

    The Institutional Abdication

    The most corrosive finding in the OIG report concerns what the VA system failed to catch before irreversible harm occurred. VISN 16, the regional oversight body, explicitly offered technical assistance through a construction management support contract designed to help facilities identify architectural and engineering design deficiencies. The Fayetteville medical center declined to use it. The facility’s chief of engineering service said the center couldn’t identify a “resource gap” that the contract would fill. Yet three of the projects reviewed by the OIG were either in the design phase or early construction phases at the time this assistance was available. The most charitable interpretation is that the facility’s leadership couldn’t recognize its own incompetence; less charitable interpretations are equally plausible.

    The OIG made four recommendations. The facility concurred with all of them. One recommendation has been closed based on documentation provided by the facility showing that design review procedures are now being tracked in the VA’s Support Service Center Capital Assets database. Recommendations 2, 3, and 4 remain open, pending evidence that the facility has actually implemented meaningful changes to how engineering staff are trained, how independent government cost estimates are developed, and how design reviews are documented and approved.

    Here’s what the OIG report demonstrates, in the accumulated weight of its findings: the VA possesses process frameworks, oversight structures, and technical guidance that should prevent exactly this kind of failure. The fact that none of these prevented failure isn’t an indictment of the systems themselves; it’s evidence of how thoroughly an institution can hollow out its own operational capacity. Training exists but isn’t taken. Technical assistance is offered but declined. Design standards are documented but not communicated. Contract requirements are supposed to be reviewed but are circulated via email and spreadsheet instead. The machinery of federal construction management is present. The people running it simply chose not to operate it.

    As of July 2025, the water storage facility project remained in limbo after three unsuccessful contract solicitations. The facility planned to resolicit the project in 2027, if funding was received in 2026. That’s the institutional pace at which the VA operates: catastrophic delay, followed by planning to attempt delay again, followed by a faint hope that future budget cycles might permit another try.

    The veterans served by this facility waited for facilities that should have been ready six years ago. They’re still waiting. The OIG report documents why, in exhausting bureaucratic detail. The question now is whether anyone at the Veterans Health Administration will actually read it. For broader context on VA institutional capacity, see The VA’s Staffing Crisis, As Reported by the VA, to Itself, on a Web Form — on how staffing shortage data is collected with no verification — and Cameras Rolling, Signs Missing, on a San Antonio psychiatric ward that waited six years for basic safety repairs.

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  • The VA Knows How to Help Pregnant Veterans. It Isn’t Doing It Consistently.

    VA Maternity Care Coordination Delivers The Easy Parts And Drops The Rest

    The premise sounds almost elegant. The Veterans Health Administration assigns a dedicated maternity care coordinator to each pregnant veteran. That coordinator is supposed to translate VA coverage into real care. Help schedule prenatal and postpartum visits. Connect veterans to community providers when VA facilities do not offer maternity services. Untangle billing in a system originally built for male patients and acute care, not pregnancy.

    The program exists because VA finally acknowledged what veterans and frontline staff already knew. Pregnancy inside a large, fragmented federal health system is a moment when complexity can hurt people if no one is minding the gaps.

    So the Office of Inspector General pulled fiscal year 2025 data to see how that promise is playing out in practice. The findings follow a familiar VA pattern. The structured, front end tasks are mostly done. The work that happens after delivery, where coordination actually earns its name, is where the program starts to fray.

    Where the Prenatal Numbers Hold Up

    Credit belongs where it is due. The OIG review, Review of VHA Maternity Care Coordination and Women Veterans’ Experience (Report No. 24-00818-208, August 10, 2026), found that VA providers largely met prenatal referral requirements. Seventy seven percent of veterans in the sample made it to a first community prenatal appointment in the first trimester. For a program that routes most maternity care to community providers, that is not a trivial accomplishment. It means the intake forms are completed, the consults are placed, the Community Care Network plumbing is working often enough to get most pregnant veterans into care when it matters most for fetal development and maternal risk assessment. Maternity care coordinators are doing the early paperwork and phone calls that the design demands. Where the rules are clear and the timeline is short, the system behaves.

    That matters for another reason. It establishes that the maternity care coordination program is not a caricature of VA failure. It is a partial success in the early phase of pregnancy. The coordinators exist. The referrals are flowing. The first trimester access metric is something many large private systems would be happy to claim.

    The OIG did not find systemic refusal to engage with pregnant veterans or wholesale breakdown of the front end processes. Instead, it found something both more mundane and more telling. Once the baby is born and the simple checklist items run out, the system loses interest.

    The Postpartum Drop-Off

    The postpartum phase is where the compliance picture deteriorates. The OIG reports that facilities were not yet in compliance with postpartum care coordination requirements, and it does not soften the point. Unlike the prenatal side, the report does not put a tidy percentage on postpartum coordination performance. That in itself is a clue.

    Postpartum coordination is inherently less tidy. It involves multiple follow up contacts, depression and safety screenings, contraception counseling, primary care scheduling, and handoff back into the broader VA system that will manage chronic conditions long after the baby shower balloons have deflated. It is work that stretches over months and cuts across services that still treat maternity as an exception, not a core line of business.

    The billing finding is more concrete and far less flattering. In roughly one in four records reviewed, OIG staff found documentation of billing issues related to maternity care. That is not a stray coding error. It is a pattern. Community care billing has been a persistent weak point across VA programs, and maternity services are no exception.

    In a June 27, 2024 national review of perceived barriers in coordinating maternity care, about 80 percent of maternity care coordinators surveyed told the OIG that billing processes were the top area that needed improvement. Two years and a fresh FY 2025 data pull later, the 2026 maternity coordination review confirms that billing trouble remains baked into the experience for too many pregnant and postpartum veterans.

    The clinical follow through is not much better. The report found that veterans were not consistently completing postpartum primary care visits within three months of delivery. That is not a small administrative miss. Those visits are where postpartum depression screening should happen. Where contraception options are revisited and chronic conditions like hypertension, diabetes, and PTSD are reassessed after pregnancy.

    When those visits fall off the schedule, the whole pitch of maternity care coordination looks thinner. The prenatal phase gets documented and counted. The messy reality of postpartum health, which rarely fits into a neat six week follow up, slides back into the same gaps that prompted VA to create maternity coordinators in the first place.

    A Structural Problem, Not an Isolated One

    None of this occurs in a vacuum. Community care billing problems are endemic across VA programs, not unique to maternity. The VA OIG has spent years documenting slow or failed resolution of community care claims. The postpartum coordination gap fits a broader pattern as well.

    Across service lines, VA has trouble maintaining intensive coordination once the acute episode is over and the veteran is supposed to flow smoothly back into routine care. For women veterans in particular, that handoff occurs inside an institution that is still catching up to its own demographic reality. VA likes to point to its expansion of women veterans clinics and services, and there is real progress there, documented in VA materials and in external reporting. Yet the infrastructure that supports those services, particularly billing and care coordination, often looks like it was bolted on in a hurry.

    In September 2023, VA extended maternity care coordinator availability to one year after delivery, an acknowledgment covered in contemporaneous reporting that postpartum needs do not vanish after the traditional six week check. The FY 2025 coordination review suggests that the requirements attached to that extended availability have not yet caught up with the ambition.

    The policy recognizes a year long postpartum reality. The execution still reaches only some veterans, some of the time. The result is a familiar VA split screen. On one side, a well worded policy statement. On the other, incomplete documentation, missed primary care follow up, and unresolved community care billing that lands in veterans mailboxes.

    Closed Recommendations, Open Questions

    The OIG did not leave its findings in abstract terms. It issued four recommendations to the Under Secretary for Health. All four have been closed as implemented. The recommendations called on VA to review postpartum coordination compliance and fix deficiencies, evaluate how facilities identify and resolve community care billing problems, improve scheduling of postpartum primary care visits, and close documentation gaps in coordination records. On paper, that is a clean result. The department agreed with every recommendation and reported specific corrective actions, which convinced the OIG to close the items.

    Closure, however, is an administrative milestone, not a victory lap. OIG recommendations come off the list when VA shows it has put a policy, process, or training in place, not when veterans lives measurably improve.

    The real test will come in the next review cycle, when inspectors can ask a simpler question. Did postpartum coordination rates rise? Are fewer maternity care records littered with billing disputes? Are more veterans keeping postpartum primary care visits within three months of delivery? Until those numbers move, the existence of closed recommendations mostly proves that VA knows where the problems are.

    The Map Is Not the Territory

    Maternity care is not a side project for a modern veterans health system. The number of women veterans continues to grow, and VA itself has framed maternity care coordination as proof that it can adapt. The department touts its maternity benefits on its own womenshealth.va.gov site. It promotes the Community Care Network as a flexible way to connect veterans to non VA providers when VA cannot provide a service directly.

    The FY 2025 OIG review is a cold measure of how that rhetoric holds up against the record. Early referrals work reasonably well. The harder, quieter labor of postpartum coordination and billing cleanup still falters.

    One in four maternity care records with documented billing issues does not describe a theoretical risk. It describes veterans receiving inaccurate bills or facing potential collections for care that should have been covered. That is not a harmless paperwork glitch. It is a pregnant or postpartum veteran who should be tracking blood pressure or sleep, instead tracking appeal deadlines and resubmitted claims.

    VA created the maternity care coordination program because it understood that unmanaged complexity can do real harm at a vulnerable moment. The OIG has now provided a clear map of where that complexity still wins.

    For more on VA institutional performance, see Paying for Nothing — on how the VA spent $11.2 million on a Veterans Crisis Line backup contractor that never answered a call — and Drug Companies Told the VA What Their Best Customers Pay. Two-Thirds of Them Lied. — on how pharmaceutical pricing disclosures for VA federal supply contracts fare under OIG review.

  • Drug Companies Told the VA What Their Best Customers Pay. Two-Thirds of Them Lied.

    When Veterans Become Test Cases For Drug Pricing Honesty

    The Department of Veterans Affairs runs the largest integrated health care system in the country. It buys enormous volumes of drugs through the VA Federal Supply Schedule, a program that was supposed to solve a simple problem: if manufacturers tell the government what they charge their best commercial customers, the government will not get fleeced.

    The contract paperwork calls this a Commercial Sales Practices disclosure. The theory is that the VA should get a price at least as good as the most favored commercial customer identified in that disclosure, consistent with the pricing rules in 38 U.S.C. § 8126.

    In practice, the VA Office of Inspector General keeps finding problems. In its latest summary of pre-award reviews of pharmaceutical proposals for fiscal year 2025, the OIG reports that 11 of 16 manufacturers submitted proposals with deficiencies in those required disclosures, covering contracts with an estimated value of about $21 billion and 1,043 offered items.1 That is just under 69 percent. You do not need a graduate seminar in procurement policy to understand what that ratio means. You just have to be able to count.

    How The VA Drug Pricing Gate Is Supposed To Work

    The VA National Acquisition Center in Hines, Illinois, runs the pharmaceutical side of the Federal Supply Schedule program under a delegation from the General Services Administration.2 Drug companies that want in on that steady government demand submit proposals that include a Commercial Sales Practices disclosure.

    On paper, it is straightforward. The manufacturer identifies its most favored commercial customer, lists the prices and discounts that customer receives, and explains any deviations from standard commercial pricing that might matter when the VA negotiates its own rates.

    The OIG does not rubber stamp those claims. For selected high value proposals, it conducts what the agency calls a pre-award review. Investigators compare the disclosure against underlying sales data, rebates, and price concessions to see whether the manufacturer described its commercial pricing accurately and completely before the contract is awarded.1

    The point is simple: the VA should not pay more than commercial customers pay for the same drug, especially when Congress has already told manufacturers in statute that prices for the VA and certain other agencies are capped at no more than a fixed percentage of the nonfederal average manufacturer price.

    For fiscal year 2025, the OIG summary covers 16 pharmaceutical proposals with a combined estimated value of about $21 billion, offering 1,043 line items into the Federal Supply Schedule.1 These are not discount contracts for aspirin at the corner store. These are large volume, multi year deals that set the baseline for what the government pays and what manufacturers earn on veterans health care.

    What Fiscal Year 2025 Actually Found

    The headline number is astounding: 11 out of 16 proposals had disclosure deficiencies, as the OIG defines them. That category includes errors, omissions, or inaccuracies in the commercial sales practices data that manufacturers are required by contract to provide truthfully and completely.1

    In seven of those 16 proposals, the OIG went further and made explicit pricing recommendations that helped contracting officers obtain about $24.7 million in savings before the contracts were awarded. That figure is not a theoretical projection, but one that reflects savings that VA contracting staff actually realized after the reviews.

    The names of the manufacturers do not appear in the public record. Individual pre-award reports are sealed because they contain commercially sensitive pricing information that federal law protects from public release.1 So the taxpayers who funded the drugs, and the veterans who will take them, see only the aggregate scorecard. They get the failure rate and the total savings, but not which company left what out of its disclosure, or how hard the government had to push to fix it.

    What that aggregate view does show is a pattern over time. The 2025 summary does not appear in isolation. In fiscal year 2023, the OIG reviewed 17 proposals and recommended approximately $120.6 million in savings for VA contracting officers.3

    In fiscal year 2024, it reviewed 14 proposals and estimated about 54.9 million dollars in potential savings, of which the VA sustained $36.8 million after negotiations.4 The $24.7 million in 2025 is realized savings, not just a recommendation.

    Whether that lower figure reflects cleaner initial proposals, a shift in which proposals the OIG chose to review, or less aggressive follow through by contracting officers is a question the public summary raises by implication and then leaves on the table.

    Why Deficiencies Are The Point, Not A Glitch

    The federal pricing rules for covered drugs exist because of a basic information gap. Drug manufacturers know exactly what they charge their best customers and what quiet concessions they make to close big commercial deals. The government generally does not, unless manufacturers are required to disclose it as a condition of doing business. Under the Veterans Health Care Act and its implementing contracts, that disclosure is not optional etiquette. It is a binding promise.

    Getting it wrong can carry real penalties. If a manufacturer obscures or misstates its commercial pricing, the government can seek price adjustments, refunds, or more severe remedies. In some cases, that pattern of conduct turns into False Claims Act exposure. That is not a hypothetical risk. The Justice Department has used that statute against pharmaceutical companies that overcharged the VA by failing to live up to their pricing obligations.

    Sanofi Pasteur, for example, agreed to pay $19.8 million to resolve allegations that it overcharged the department for certain vaccines by misreporting its pricing under the relevant federal program.5

    The OIG pre-award review program exists to keep more of those problems from maturing into retroactive enforcement cases years later. Seen that way, 11 out of 16 proposals requiring correction is not proof that the process failed. It is proof that the process is catching something real every time it is used. It is also a reminder that without this gatekeeping, those same deficiencies could have gone straight into long term contracts with no one the wiser until a whistleblower or analyst stumbled over the gap.

    What The Screen Misses By Design

    The pre-award reviews have one unavoidable limitation, in that the OIG does not review every pharmaceutical proposal that comes through the Federal Supply Schedule door. For fiscal year 2025, it examined 16. The broader VA FSS pharmaceutical portfolio is bigger than that, and the OIG is candid that it selects high risk, high value targets rather than running a universal check.1

    The individual pre-award reports remain confidential. The public does not see which manufacturers needed corrections or which contracting officers accepted, modified, or ignored OIG pricing recommendations. The $24.7 million in savings for 2025 is a documented floor, the confirmed amount that VA obtained after the reviews. How much was recommended but not sustained, as in 2024 when $54.9 million in potential savings yielded $36.8 million in actual reductions, is not broken out for 2025 in the public record.4

    What the record does say is simple enough. The VA is the largest buyer of prescription drugs in the federal system. The OIG reviews only a fraction of the proposals, and roughly two thirds of those examined contain problems in mandatory pricing disclosures. The screen catches something. It does not catch everything.

    Why Veterans Should Care Who Gets The Best Price

    Veterans health care spending is not an abstraction on a chart. The VA pharmaceutical budget comes from public money and buys medicines for people who served in uniform. When a manufacturer submits an inaccurate Commercial Sales Practices disclosure on a contract worth hundreds of millions or billions of dollars, and the OIG flags it before award, that is oversight doing its job.

    When about 69 percent of the proposals the OIG reviews contain deficiencies, year after year, that is the oversight system sending a message. The pre-award review program itself is relatively small compared with the volume of contracts it could examine. The path to catching more overcharging before it happens is not complicated. It involves more reviews, more often, with the same unglamorous insistence on accurate data.

    The harder question is how to get accurate disclosures from the start. The summary reports, properly, stay out of that policy fight. They just present the numbers and leave the rest to the people who decide how much risk they are willing to run with other peoples medicine.

    For more on VA oversight and institutional accountability, see Paying for Nothing — on how the VA paid $11.2 million for Veterans Crisis Line backup services never delivered — and The VA Knows How to Help Pregnant Veterans. It Isn’t Doing It Consistently. — on where the maternity care coordination program holds up and where it frays.

  • The Leviathan’s Paperwork Problem: How the VA Quietly Shortchanged Veterans and Called It Due Process

    Closed Means Nothing If the Work Was Never Done

    Here is the sentence that should be carved above the entrance to every regional VA office in America: the claim status “closed” is defined as “the claim is complete with no further action possible.” That is the government’s own definition, straight from VBA Manual 21-4.

    Now consider that the Office of Inspector General just spent thirteen months proving that VBA staff closed thousands of these supposedly complete, no-further-action-possible claims while the actual required action, the one affecting a veteran’s monthly paycheck, had never happened at all.

    Somewhere a bureaucrat defined “closed” and somewhere else an entirely different bureaucrat closed a case that was, by any honest reading, wide open. This is the kind of contradiction that would get you fired from a lemonade stand. At the VA, it just gets you a “concur” stamp and a target completion date sometime next year.

    A Third of Cases, A Thousand Ways to Fail a Veteran

    The report in question, released last week and quietly filed under a review number nobody will remember, examines how the Veterans Benefits Administration handles “adverse actions,” the bureaucratic euphemism for cutting a disabled veteran’s monthly check. Under 38 C.F.R. Section 3.103, before VA can reduce or terminate a veteran’s disability compensation, it has to notify them, give them sixty five days to respond with evidence, and offer a hearing.

    This is not some newfangled progressive innovation. It is basic due process, the kind of thing that has been settled law in this country since well before most of the claims processors involved were born.

    The OIG sampled 229 cases out of an estimated pool of 27,100 and found errors in roughly a third of them, projecting that about 9,300 cases involved at least one mistake (see the report’s Appendix C for the full statistical gymnastics, margin of error and all). Break down the error types and you get a portrait of an agency that treats due process as optional homework.

    About 4,000 cases involved insufficient notice to the veteran, meaning VA moved to cut a check before telling the person whose money it was. Nearly 2,900 involved uncorrected “codesheets,” the internal ledgers that track a veteran’s disability history, left inaccurate after the fact. Another 2,900 had botched effective dates, sometimes off by a month in either direction (see Example 2 in the report, where a claims processor miscounted sixty days and cost a veteran an extra month of benefits they were never entitled to, an overpayment of roughly $300 that will eventually have to be clawed back from someone who did nothing wrong).

    Then there is Example 3, which deserves its own museum exhibit. A veteran’s lung cancer rating was proposed for reduction from 100 percent to 30 percent. The due process letter went out. The veteran did not respond. So far, bureaucratically unremarkable. Then a different claims processor, working an entirely separate benefit for the same veteran, canceled the “end product” tracking the reduction, which under VA’s own system definitions automatically closed the case as complete.

    The reduction that was supposed to happen never did. VA overpaid the veteran about $43,000 over sixteen months, at a running rate of $2,700 a month, and nobody noticed until the OIG went looking. This is not fraud. Nobody here is a villain twirling a mustache. It is simply a records system so brittle that one employee’s unrelated paperwork can silently erase another employee’s entire adjudication, and an agency with no automated way to notice when that happens.

    If this sounds familiar, it should. Federal courts have spent decades wrestling with agencies that treat procedural notice requirements as a formality to be checked off rather than a substantive right to be honored. The Supreme Court’s own due process jurisprudence in the benefits context traces back to Mathews v. Eldridge, which set the very balancing test the VA is nominally supposed to be applying here. And this is far from the VA’s first rodeo with the OIG on exactly this theme.

    Earlier reviews have flagged similar breakdowns in how VBA tracks pending claims through its “end product” workload system, a structure originally built to measure employee productivity rather than to safeguard veterans’ rights, which may explain why it is so good at counting closed cases and so bad at noticing which ones should not have been closed.

    They Knew in 2024. They Made a Video.

    What makes this report more than a dry compliance exercise is the timeline buried in its own pages. In March 2024, over two years before this report’s publication, a senior quality reviewer at VBA’s Compensation Service flagged on an internal call that an “alarming number” of adverse action claims were being closed without final decisions. The recommended fix was to remind new staff to finish their paperwork.

    Nobody followed up.

    The OIG then found the exact same problem persisting through September 2025, in nine of twenty sampled cases, a 45 percent failure rate that is arguably worse than the original estimate. This is bureaucracy’s favorite trick: identify the problem, hold a call about the problem, and mistake the call for the fix.

    Meanwhile, VBA officials proudly told the OIG team about a new training initiative called “Minute Videos,” rolled out in December 2025 with more planned for March 2026. The OIG actually watched them. The December batch had nothing to do with adverse actions. The March batch addressed the topic but, in the OIG’s own words, did not address the deficiencies identified in this review or the actions recommended to mitigate them.

    Somewhere in a windowless conference room, someone approved a training video series that fails to train anyone on the thing it needed to train them on, and that someone almost certainly got a positive performance review for shipping content on schedule.

    VA’s own fix for the letter generating problem, meanwhile, has a “tentative delivery timeline” stretching from a 2023 start date to early 2027, a four year odyssey to standardize a form letter.

    For context, the Government Accountability Office has spent years documenting how federal agencies routinely blow through their own modernization timelines, sometimes by a decade or more, for systems far more complex than a rating decision letter.

    The Bare Minimum, Arriving Four Years Late

    The dollar figures here, at least $16.9 million in improper payments and nearly $1 million a month in ongoing overpayments and underpayments, are almost beside the point, though Congress will fixate on them because dollar figures are legible in a way that human suffering is not.

    The real story is that a veteran who lost a leg or a lung in service to this country can have their monthly check quietly reduced, restored, reduced again, or simply left in bureaucratic limbo because two different employees in two different systems never talked to each other, and no software exists to flag the contradiction.

    VA concurred with every finding. VA agreed to every recommendation. VA has, as of this writing, resolved 184 of the 191 specific errors the OIG identified, which sounds impressive until you remember those 191 are drawn from a sample that represents thousands more the agency has not yet found.

    The recommendations themselves (standardized letters, an extra layer of signoff, an automated tracking report) are not radical. They are the bare minimum any competent organization would have built a decade ago. That the largest disability benefits system in the country is only now getting around to it, under OIG pressure, with completion dates stretching into 2027, tells you less about incompetence than about priorities.

    Building a system that reliably protects a veteran’s paycheck has simply never been urgent enough. It took an audit to make it urgent for exactly as long as this news cycle lasts.

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  • Paper Workflows and Empty Corridors: The VA’s Mountain Home Problem

    Mountain Home Has Been Here Since 1903. It Still Needs Written Instructions To Call You Back.

    VA Mountain Home Healthcare System sits on a historic campus that opened around 1903 as the Mountain Branch of the National Home for Disabled Volunteer Soldiers. A century and change later, the institution that learned how to treat trench lung and mustard gas injuries just received a formal reminder from its own watchdog that staff should have written instructions for telling patients their test results. Not how to interpret the results. Not how to treat the disease. How to pick up the phone.

    On August 28, 2026, the VA Office of Inspector General released an inspection of the VA Mountain Home Healthcare System in Johnson City, Tennessee, also known as the James H. Quillen VA Medical Center. The system serves veterans across a 32 county patch of northeastern Tennessee, southwestern Virginia, and southeastern Kentucky. After examining quality, leadership, and patient care, the OIG landed on a single recommendation: the facility must create written, service level workflows for communicating test results, consistent with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

    In plainer English, the oldest veteran campus in the system needed Washington to tell it to write down who calls whom, when, and how, after a lab machine finishes humming. The OIG closed that recommendation the same day the report came out. Which raises a blunt question. If the paperwork looks fixed in a single afternoon, how long have the patients been living with the gap?

    What VHA Directive 1088(1) Actually Demands

    VHA Directive 1088(1), issued July 11, 2023, is not exactly beach reading. It sets requirements for timely, traceable communication of test results to both providers and patients. The directive spells out responsibilities, time frames, and documentation so there is a clear trail from the lab to the chart to the patient. The whole point is to stop test results from vanishing into the electronic equivalent of a desk drawer.

    When the OIG tells Mountain Home to develop written, service level workflows, it is saying that each clinic and service line needs a step by step process that matches the directive. Who reviews the result. How quickly. How abnormal findings reach the treating clinician. How and when the patient gets notified. How the contact gets documented so supervisors and inspectors can verify that someone actually did the job.

    That may sound bureaucratic. It is also the difference between a caught tumor and a missed one. Directive 1088(1) exists because the system has a long history of test results that fell through cracks wide enough to swallow an entire oncology ward.

    Staffing Shortages Meet Paper Thin Workflows

    The inspection of Mountain Home does not land in a vacuum. In the VA OIG’s fiscal year 2023 staffing shortages report, the same system shows up in Table C.58 with shortages across a familiar roster of jobs. Social workers. Nurse anesthetists. Practical nurses. Nursing assistants. Custodial workers. Food service workers. In other words, the people who stabilize a patient, keep the operating room moving, and make sure the place does not literally fall apart.

    Short staffing does not just mean longer waits in the lobby. It means that nurses race between beds, clerks juggle phones and inboxes, and supervisors quietly accept that some tasks will not get done. When there is no clear, written workflow for test result communication, the missing tasks often involve calls that no one can see. A lab result comes back. The ordering provider is off, or already drowning in alerts. A nurse means to follow up after the next medication round. A reminder gets buried. No policy pins responsibility on a specific role, within a specific time frame, with a specific way to document closure. The patient never hears a word.

    The scheduling breakdown at Mountain Home is not isolated. As covered in our report on the VA community mental health system, 128 out of 133 VA healthcare systems failed to meet the department’s own seven-day standard for scheduling mental health consults in FY2025 — a pattern that begins with the same undocumented, untracked workflow gaps visible at Mountain Home.

    That is the context in which the Mountain Home inspection tells leaders to put workflows on paper. Not because veterans need more binders. Because in an understaffed system, anything that is not written, tracked, and measured will be the first thing to disappear.

    Mountain Home Is Not An Outlier

    The OIG did not invent concern about test result communication for Mountain Home. It has been walking this same trail across the country. At the VA Dublin Healthcare System in Georgia, an April 2024 root cause analysis documented 25 patient safety events tied to failures in communicating test results. The OIG’s March 2025 report on Dublin tied those events directly to gaps in how results moved from lab to provider to patient.

    In February 2025, the OIG reported on the VA Salem Healthcare System in Virginia and found problems with communication of urgent and noncritical test results, again citing VHA Directive 1088(1). In December 2024, the OIG’s review of VA Durham in North Carolina concluded that leaders lacked hospital wide oversight to validate whether providers followed requirements for communicating test results. That is the same directive number haunting multiple campuses from Georgia to North Carolina to Virginia to Tennessee.

    Meanwhile, Mountain Home has drawn attention for issues well beyond lab results. In 2024, the House Committee on Veterans Affairs announced an investigation into allegations of workplace misconduct at the Quillen VA Medical Center. The same campus that now needs to formalize how it tells patients their test results was already on the congressional radar for broader cultural and management concerns.

    Layer on top of that a broader federal critique. A Government Accountability Office report, GAO 26 107528, examines how VA reviews and reports providers with clinical care concerns and calls for better training and oversight. Different investigators. Different document numbers. Same theme. The system struggles to consistently identify, track, and respond when patient care depends on staff following through.

    What A Missed Test Result Really Means

    The phrase “test result communication failure” sounds like something you fix with a software patch. The reality is uglier. A missed pathology report can mean a cancer that moves from treatable to terminal. A lab value that never reaches a clinician can mean sepsis that runs unchecked. An imaging finding that sits unreviewed can turn a manageable condition into a permanent disability.

    Every inspection and directive cited above exists because somewhere, a veteran sat at home waiting for a call that never came. Families do not sue over high level policy memos. They sue, and grieve, over the scan that no one followed up.

    This is why the timing in the Mountain Home report deserves scrutiny. The OIG issued the recommendation on August 28, 2026 and closed it the same day. On paper, that means the facility responded quickly and accepted the requirement to create those written workflows. In practice, the same day closure tells the public very little about whether the new procedures exist on the ground, whether staff know them, or whether anyone will check compliance three months from now.

    When a watchdog closes a recommendation the day it appears, it signals trust in leadership promises and in the documentation provided. It does not tell us how many veterans experienced delayed or missed results before the paperwork caught up. It does not tell us whether the same staffing shortages that drove the problem will sabotage the solution.

    So the question practically asks itself. In a system that needed a 2023 directive to spell out how to communicate test results, a string of OIG reports from Dublin to Durham to Mountain Home, a congressional investigation, and a GAO warning about weak oversight of problematic providers, how confident should a veteran feel that a normal lab result and a life changing one will both trigger the right call, at the right time, from the right person?

    Mountain Home has stood for veterans since 1903. Its history is carved in stone on a National Historic Landmark campus. The real test now is written somewhere else. In the workflows, checklists, and audit trails that show whether a twenty first century veteran will hear about a dangerous test result before it is too late.

    The deeper context for these failures is documented in our coverage of the $1.7 billion blind spot in VHA eligibility determinations — a systemic audit of how the VA’s internal guidance, broken scheduling software, and phantom wait times combine to fail veterans at every step of the care access chain.

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  • 128 Out of 133 VA Medical Centers Can’t Schedule a Mental Health Appointment Within Seven Days

    Seven Days, Five Systems, and a Community Care Promise Still on Paper

    The Department of Veterans Affairs has a seven day standard for one very specific step in mental health care. When a VA clinician refers a veteran to the community care program for mental health services, the consult is supposed to be scheduled within seven days. In fiscal year 2025, according to the VA Office of Inspector General, five of 133 VA healthcare systems met that standard. The other 128 did not.

    The community care program exists because the VA concluded, years ago, that it could not meet all veterans health care needs inside its own walls. Congress passed the VA MISSION Act to formalize that decision and to expand veterans access to care through outside providers.

    The model is straightforward: when VA cannot provide timely or appropriate care, it buys that care from the community through contracted administrators. The premise is sound. The execution, as laid out in VA OIG Report 25 03623 147 covering October 2024 through September 2025, is lagging behind the VA standard the department set for itself.

    How community care mental health scheduling is supposed to work

    The referral chain on paper is not that complicated. A VA provider decides a veteran needs mental health care that is better delivered outside the VA system. That may be because of local capacity, specialty needs, or geography. The provider enters a community care consult in the VA system. From there, the case routes to one of two third party administrators that manage the VA Community Care Network. Veterans in Regions 4 and 5 go to TriWest Healthcare Alliance, while veterans in Regions 1 through 3 go to Optum Public Sector Solutions.

    The contractor is responsible for taking that consult and turning it into an appointment with a community mental health provider. The job sounds mundane: 1) reach the veteran, 2) confirm preferences, 3) find an in network provider with capacity, and 4) schedule a date and time.

    The VA tracks two separate metrics for this process. The first is the seven day standard for how quickly the consult is scheduled. The second is a 30 day contract metric for when the appointment itself is supposed to occur.

    Those are different thresholds that measure different parts of the pipeline, but both matter. If the consult stalls before it is scheduled, the clock on the 30 day metric never really starts from the veteran point of view.

    The OIG review found that the system frequently slowed down or stopped at the scheduling step, where staff tried to reach veterans, confirm provider availability, and reconcile preferences with real world options.

    What the OIG actually found

    The headline number in the August 10, 2026 report is blunt. One hundred twenty-eight of 133 VA healthcare systems averaged more than seven days to schedule community mental health consults in fiscal 2025. Five systems met the standard. That is not a near miss. It is a system wide miss on a metric the VA defined as its own expectation for timely scheduling.

    The picture is more mixed on the 30 day contract metric for when appointments occurred. The OIG found that approximately 80 percent of community mental health appointments happened within 30 days. For the remaining 20 percent or so that did not meet that benchmark, veterans waited an average of 56 days for the actual appointment. That 56 day figure does not describe all community mental health visits. It describes the subset where the system already failed the 30 day standard.

    The OIG did not attribute that gap to a single dramatic breakdown. It pointed instead to a cluster of mundane but consequential problems. First, VA staff and contractors relied heavily on phone calls and postal mail to reach veterans. In many cases, they did not use more efficient or reliable digital contact methods that could shorten back and forth.

    Second, community providers did not always offer appointment types that matched what veterans wanted or needed. Preferences about in person visits versus telehealth, or about certain modalities, were not consistently captured in systems in a way that schedulers could act on. That mismatch produced more calls, more rescheduling, and more delay.

    Third, schedulers reported difficulty getting timely responses from community providers to confirm availability and lock in appointment slots. Unreturned calls, limited office hours, and fragmented communication channels all translated into longer waits between referral and scheduled date.

    A fourth problem sat on top of that. Some community providers insisted on duplicate documentation that the VA had already included in the original referral package. That meant more requests back to VA facilities for forms and records the system had already sent once.

    None of this would impress a management consultant. There is no exotic algorithmic failure here. The VA set a seven day standard for scheduling. The system repeatedly tripped over phone tag, partial preference data, hard to reach providers, and redundant paperwork.

    The structural problem behind the scheduling problem

    The OIG findings land in a landscape that was already crowded with warnings about the VA community mental health network. In November 2024, the Government Accountability Office reported in GAO 24 106410 that the VA assessment of its community care network adequacy for mental health needed improvement. GAO highlighted gaps in how VA evaluated whether the network had enough providers to meet demand.

    An April 2024 VA OIG audit on network adequacy and contractor performance came to a similar conclusion. It found that oversight of the community care network and of contractor performance needed strengthening, including how VA evaluated whether contractors met access standards. On paper, VA relies on TriWest and Optum to maintain a network that can actually deliver the care veterans are referred to receive.

    The provider directories that veterans and schedulers depend on have their own problems. A 2022 GAO report, GAO 23 105290, found that veterans sometimes could not book appointments with providers who appeared in the Community Care Network directory as available. Inaccurate entries, providers who were not accepting new patients, and outdated information all contributed.

    Viewed against that backdrop, the FY2025 scheduling failures are not a stand alone surprise. They are downstream of a network with thin provider supply in some regions, directories that do not always match reality, and oversight that has not kept pace with the size and importance of the community care program. You can streamline the scheduling workflow, and the OIG suggests ways to do that. You still cannot schedule an appointment with a provider who is not actually available.

    The six recommendations and the scorecard so far

    The August 2026 OIG report made six recommendations to the Under Secretary for Health. Two have already been closed as implemented. One directed VA to consider contractual adjustments with third party administrators to improve timeliness of community mental health scheduling. The other required the department to issue standardized guidance that makes clear community providers should not request documentation that VA already includes in referral packets.

    Four recommendations remain open. The first calls for VA to identify and share best practices for contacting veterans in ways that actually reach them quickly. The second focuses on ensuring scheduling systems capture and use the full range of veteran preferences when matching to appointments. The third directs VA to evaluate whether TPA network adequacy standards are sufficient for both in person and telehealth mental health providers, given demand. The fourth urges a review of ways to increase community provider use of VA systems so that communication and documentation flow through consistent channels instead of scattered faxes and phone calls.

    The two closed recommendations nibble at the edges of process friction. The four that remain open go to the structure of how VA, its contractors, and its provider networks actually operate. Whether those structural fixes move from recommendation to enforcement before the next oversight report arrives is an open question.

    Why the delay metrics matter

    Mental health care for veterans who reach the point of a community referral is not elective. A VA clinician has already determined that care is needed and that the department cannot provide it internally in the required way or time frame. For the roughly one in five community mental health appointments that missed the 30 day contract metric in FY2025, the average 56 day wait was not a trivial inconvenience. It represented weeks in which needed care did not occur.

    The veteran population relying on these services carries a documented and elevated risk of suicide and other serious mental health outcomes. That is part of the reason the VA adopted a seven day scheduling standard in the first place. It reflects an institutional understanding that long gaps between referral and first appointment are dangerous.

    The VA, GAO, and the OIG have been writing versions of this story for years. Reports on scheduling, network adequacy, directory accuracy, and contractor oversight repeat the same themes with new data and new report numbers.

    The 25 03623 147 review does not reveal a hidden crisis. It documents, again, a pattern of missed standards, modest corrective steps, and partial follow through. Meanwhile, the metric on the books remains seven days. Five out of 133 systems met it.

    The scheduling crisis documented here is one thread in a larger pattern of VA care access failures. The $1.7 billion blind spot in VHA eligibility determinations shows how the same system sends hundreds of thousands of veterans to outside providers they’re ineligible for, while simultaneously failing to inform eligible veterans they have any outside option at all. The Mountain Home test result crisis illustrates what happens inside the facilities where veterans land when those referrals don’t materialize. And for veterans whose caregivers depend on the VA’s program stability, the 2028 caregiver sunset is the next cliff approaching.