Federal Reports

The OIG conducted this review after receiving a hotline allegation that the 2024 emergency department expansion and renovation at the Audie L. Murphy Memorial Veterans’ Hospital in San Antonio, Texas, did not meet standards. Some exam rooms were said to put patients at risk because the rooms were not equipped for urgent care.

The OIG confirmed the allegation. Fast-track exam rooms, used to quickly assess and treat patients with minor injuries or illnesses, did not have permanent medical air, oxygen, and vacuum outlets, nor did all the rooms have acceptable exam lights. In addition, in one room the contractor failed to install the required plumbing for permanent medical air, oxygen, and vacuum lines. The deficiencies occurred in part because the VHA directive guiding minor construction projects did not incorporate the legal requirement that the director of the Office of Construction and Facilities Management (CFM) manage and oversee the project. Other factors included the contractor’s use of the wrong template to design fast-track rooms and the project engineer’s approval of the room that lacked required plumbing.

When fast-track rooms and procedural and general exam rooms lack the necessary equipment for emergency care, patient care may be delayed while healthcare professionals locate portable equipment. VA officials agreed with the OIG’s four recommendations to ensure processes and guidance are in place for the CFM to provide appropriate oversight and management over minor construction projects, revise the VHA directive on minor construction projects to incorporate legal requirements, review emergency department exam and fast-track rooms for compliance with standards, and review a CFM assessment of emergency department for compliance with design and equipment requirements.

In its fiscal year (FY) 2009 budget request, VA identified the need for the Palo Alto major construction project to improve seismic safety at the Palo Alto Health Care System. The planned construction project would also provide ambulatory and polytrauma care. Over the next 15 years, the project’s cost and timeline increased. The OIG conducted this review to evaluate the significant events that led to cost increases, schedule slippages, and scope changes for the major construction project.

The OIG found VA has still not achieved two of its three critical project objectives and is more than 21 years behind its original schedule. As of February 2025, about $458.8 million had been spent on the project. Furthermore, because VA did not provide adequate justification for a significant scope increase proposed in the FY 2012 budget, the OIG questioned the expenditure of about $716.6 million. To proceed with the project, VA will need a total of about $1.6 billion.

Cost increases and delays occurred because VA did not have adequate formal procedures for governing major construction projects from 2009 to 2017. The OIG could not obtain evidence that the Palo Alto project was ever added to the Acquisition Program Management Framework, as required. VA must consider whether it is worth continuing the project or canceling efforts to complete it. Should VA be unable to justify the business need to continue funding the project, the OIG determined taxpayers could save about $907.8 million.

The OIG made four recommendations to the VA Secretary including ensuring the project is brought into the Acquisition Program Management Framework and ensuring a decision is made about the project’s future. VA concurred with the OIG’s recommendations.

Dragonfly, a rotorcraft lander that will fly like a large drone, isdesigned to gather samples from Saturn’s moon Titan, characterize Titan’s habitability, and look for precursors of the origin of life. However, the project has undergone multiple replans impacting cost and schedule, resulting in a life-cycle cost increase of nearly $1 billion and over 2 years of delays. 

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Jackson Healthcare System in Mississippi. This evaluation focused on five key content domains:
•    Culture
•    Environment of care
•    Patient safety
•    Primary care
•    Veteran-centered safety net
The OIG issued one recommendation for VA to correct an identified deficiency in one domain:
1.    Primary care
•    Panel size accuracy