Federal Reports

The OIG’s Mental Health Inspection Program evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on the inpatient mental health care delivered at the James A. Haley Veterans’ Hospital (facility), part of VA Tampa Healthcare System in Florida. 

The facility met some VHA requirements for inpatient mental health units, such as an established Interdisciplinary Safety Inspection Team and completion of twice-yearly environment of care inspections. The facility had a mental health executive council but did not have veteran representation. Additionally, the facility did not meet the requirement for a standard operating procedure for staff training, education, and the implementation of recovery-oriented services on the unit.  

Facility leaders did not have formal written processes to monitor and track compliance with state involuntary commitment requirements. Staff completed the required documentation of legal commitment status and informed consent medication discussions. Not all inpatient staff completed suicide prevention or annual environmental safety hazards trainings.  

Most reviewed electronic health records included evidence of suicide risk screenings and safety plans. Safety plans did not address ways to make the veteran’s environment safer from potentially lethal means beyond firearms and opioids. Discharge instructions included difficult to understand language and lacked important details for appointment location follow-up.  

The OIG observed a recovery-oriented culture and veteran-centric care through staff’s presence and engagement with veterans on the inpatient unit. While veterans had unrestricted access to a day room and a large outdoor space, bedrooms lacked recovery-oriented elements such as calming paint colors. 

VA concurred with the OIG’s seven recommendations; the OIG closed two recommendations based on information provided. The Facility Director agreed to implement a range of corrective actions, including strengthened staff training, ensuring formalized written processes, and improved documentation practices to support safe, recovery-oriented mental health care on the inpatient unit. 

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 Beckley Healthcare System in West Virginia. 

This evaluation focused on five key content domains:
     •    Culture
     •    Environment of care
     •    Patient safety
     •    Integrated veteran care
     •    Veteran-centered safety net

The OIG issued no recommendations.

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 Eastern Colorado Health Care System in Aurora. 

This evaluation focused on five key content domains:
     •    Culture
     •    Environment of care
     •    Patient safety
     •    Integrated veteran care
     •    Veteran-centered safety net

The OIG issued 10 recommendations for VA to correct identified deficiencies in three domains:
   1.    Environment of care
     •    Liquid nitrogen storage
     •    Expired supplies
     •    Multidose medication labels
     •    Clean and dirty storage
     •    Repeat findings
   2.    Patient safety
     •    Test result communication policy and workflows
     •    Radiology staffing
     •    Community care imaging results
     •    Root cause analyses
   3.    Primary care
     •    Staffing and panel sizes

Our Objective(s)To perform a quality control review (QCR) of Allmond & Company, LLC's management letter related to the audit of the Great Lakes St. Lawrence Seaway Development Corporation's (GLS) financial statements for fiscal year 2025. We reviewed Allmond's management letter, dated January 7, 2026, and related documentation.
About This ReportWe contracted with the independent public accounting firm Allmond & Company, LLC to audit GLS's financial statements. Allmond also issued a management letter discussing internal control matters that Allmond was not required to include in its audit report.
What We FoundThe independent auditor, Allmond, found five control deficiencies in GLS's internal controls over financial reporting:

Review of fund balance with treasury reconciliation did not identify errors and omissions,
Complementary user entity controls were not properly designed and implemented for the use of service organization systems,
Non-capitalized assets are not located during the performance of the annual property inventory,
Recording of transactions relating to prior year activity did not use the appropriate general ledger accounts for error corrections,
Accounts payable balance was incomplete.

Our QCR disclosed no instances in which Allmond did not comply, in all material respects, with U.S. generally accepted Government auditing standards.
RecommendationsWe agree with Allmond's 9 recommendations to help strengthen GLS's internal controls over financial reporting.

An Amtrak machinist based in Beech Grove, Indiana, was terminated from employment on February 23, 2026, following an administrative hearing. Our investigation found that the former employee violated company policy by failing to report his felony conviction within 48 hours as required by the company’s Disclosure of Criminal Convictions policy. The former employee was convicted for pointing a firearm at another person. He is not eligible for rehire.

An Amtrak extra board train attendant based in Seattle, Washington, was terminated from employment on February 23, 2026, following his administrative hearing. Our investigation found that the former employee violated company policies by misrepresenting his role at the company to two individuals, inappropriately seeking their personal identifying information, and sending internal company information to outside parties. The former employee is not eligible for rehire.

The U.S. Department of Agriculture (USDA) Office of Inspector General (OIG) initiated an engagement across select USDA facilities to determine how much USDA space was being used by employees and contractors reporting to work in-person.