Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection of the VA Nebraska-Western Iowa Health Care System (facility) in Omaha from November 2024 through May 2025, following a congressional request to evaluate allegations related to the inpatient mental health unit’s environment of care. The OIG also evaluated allegations from another complainant regarding unit staffing and identified additional concerns related to training, policy guidance, and oversight.

The OIG substantiated facility leaders did not ensure adequate night lighting in patient rooms, which may affect patients’ sleep and hinder staff’s ability to conduct safety rounds. The OIG also substantiated the unit was not consistently staffed with the required number of employees trained in therapeutic containment for high-risk areas, placing patients and employees at risk. Although the OIG did not substantiate allegations that the unit was unclean and restroom doors did not lock, the OIG found female patients were unable to access the restroom without staff assistance.

The OIG found nursing leaders did not (1) develop a required patient safety rounding standard operating procedure, increasing the risk of inconsistent observation practices, and (2) ensure a clear process for using a risk for violence assessment, contributing to the inability to determine required staffing.

Additionally, facility leaders did not (1) consistently report root cause analysis action items, which may result in leaders being unaware of opportunities to improve care, and (2) notify Veterans Integrated Service Network (VISN) 23 leaders of bed closures exceeding 60 days, misrepresenting available bed capacity.

The Under Secretary for Health concurred with 2 OIG recommendations related to high-risk workplace staffing guidance; the VISN Director concurred with 1 recommendation regarding oversight of bed changes; and the Facility Director concurred with 10 recommendations regarding unit lighting, rounding procedures, mitigation planning, staffing and training requirements, and root cause analysis reporting.

Due to the importance of protecting the Tennessee Valley Authority’s (TVA) operations from external cyber events, we performed an audit of TVA’s transmission control center network cybersecurity. The audit objective was to determine if TVA has sustainable processes for identifying, implementing, and managing the network architecture to reduce the overall cybersecurity risk to TVA resources in their transmission networks.  The audit scope was limited to TVA’s transmission control center network.  We made one recommendation to TVA management. The specifics are being withheld from public release due to their sensitive nature in relation to TVA’s cybersecurity. 

The U.S. Small Business Administration (SBA) Office of Inspector General contracted with the independent certified public accounting firm KPMG LLP to conduct an audit of SBA’s consolidated balance sheet as of September 30, 2025 and the related notes. KPMG was not engaged to audit the consolidated statement of net cost, consolidated statement of changes in net position, and combined statement of budgetary resources. Our contract required KPMG to conduct the audit in accordance with Government Auditing Standards and Office of Management and Budget Bulletin No. 24-02, Audit Requirements for Federal Financial Statements.

KPMG issued a disclaimer of opinion on the consolidated balance sheet as of September 30, 2025. A disclaimer means that an auditor was unable to obtain sufficient information to determine whether the organization’s financial statements were accurate. The basis for the disclaimer was that because of control deficiencies identified, SBA was unable to provide adequate evidential matter in support of a significant number of transactions and account balances related to the Paycheck Protection Program and Economic Injury Disaster Loan programs. Additionally, management was unable to provide sufficient appropriate audit evidence to support the data used to develop assumptions used in the subsidy allowance estimate for SBA’s direct loan and loan guaranty programs.

During the audit, KPMG identified four material weaknesses and one significant deficiency in internal control over financial reporting. Material weaknesses are a serious concern that an organization’s financial reporting controls are not effective to detect major errors or fraud. We note that SBA made considerable progress addressing prior year audit findings, resulting in the successful remediation of two material weaknesses (controls over general information technology and controls over the evaluation of service organizations) and the downgrading of one material weakness (controls over monitoring Restaurant Revitalization Fund and Shuttered Venue Operators Grant programs) to a significant deficiency. Appendices I and II of this report describe details of KPMG’s conclusions about the material weaknesses and significant deficiency. KPMG also identified three instances of noncompliance with applicable laws or other matters, which are discussed in Appendix III of this report.

Why We Did This Report

This report describes an issue that the U.S. Environmental Protection Agency Office of Inspector General identified during its audit of the U.S. Infrastructure Investment and Jobs Act-funded IRL Council for the Indian River Lagoon National Estuary Program grant program.
 

Summary of Findings

The EPA OIG found that the IRL Council did not complete or submit any of the required Federal Financial Reports, or FFRs, for the first two years of its award and stated the reason was that the EPA did not request annual FFRs. This raised concerns that the EPA was not requiring any National Estuary Program, or NEP, award recipients to submit FFRs annually as mandated by 2 C.F.R. § 200.328.

Today, the U.S. Consumer Product Safety Commission Office of Inspector General released their semiannual report for the reporting period ending September 30, 2025.  The report is part of the semiannual requirement to communicate OIG oversight activities of the CPSC to Congress and the American people.

The Delivering For America: Our Vision and Ten-Year Plan to Achieve Financial Sustainability and Service Excellence (DFA plan), released in March 2021, outlines the U.S. Postal Service’s 10-year strategy to transform into a high-performing, financially sustainable organization. With the release of Delivering For America 2.0: Fulfilling the Promise in September 2024, the Postal Service provided a blueprint for its path forward.

We, the U.S. Postal Service Office of Inspector General (OIG), have provided essential oversight of the Postal Service for nearly 30 years, and since the release of the DFA plan, have integrated an independent and objective review of its implementation into our work. This is the third in our series of DFA oversight reports in which we focused on two core areas outlined in the DFA plan: achieving service excellence and attaining financial stability.

Overall, our analysis of progress toward key initiatives shows mixed results. While the Postal Service (USPS) has made meaningful investments in infrastructure, fleet modernization, and pricing reforms, service performance has been inconsistent, and financial outcomes have fallen short of break-even targets.

As the Postal Service’s transformation is ongoing, our oversight will continue to focus on whether these efforts deliver measurable improvements in reliability, customer experience, and fiscal health that would ensure the Postal Service remains a vital, self-sustaining part of the nation’s infrastructure.