Federal Reports

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the South Texas Veterans Health Care System in San Antonio. 

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

The OIG issued two recommendations for VA to correct identified deficiencies in two domains:
   1.    Environment of care
     •    Patient care area cleanliness and clean storage areas free of dirty items and equipment
   2.    Patient safety
     •    Service-level workflows for the communication of test results

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 Tampa Healthcare System in Florida. 

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

The OIG issued three recommendations for VA to correct identified deficiencies in two domains:
   1.    Environment of care
     •    Sinks and hand hygiene supplies
     •    Video laryngoscope supplies
   2.    Patient safety
     •    Service-level workflows for the communication of test results

Our Objective(s)To assess the Department of Transportation's (DOT) (1) progress implementing the Federal policy on return to in person work and (2) procedures for overseeing compliance with worksite requirements.
Why This AuditSenators Joni Ernst and Ted Cruz requested that our office review DOT's worksite practices in June 2024. We announced an audit shortly thereafter, but in January 2025, the Federal worksite landscape changed significantly. A Presidential Memorandum instructed all eligible Federal employees to return to full-time, in-person work as soon as practicable, essentially eliminating telework and remote work except in limited circumstances.
What We FoundDOT complied with current Federal return to in-person work requirements and guidance.

DOT previously expected telework-eligible staff to work in person 4 days per pay period but now requires full-time, in-person work with few exceptions.
DOT's data show its telework use substantially declined from approximately 38 percent of employees teleworking at least 1 day during a September/October 2024 pay period to just 8 percent by a March/April 2025 pay period.

DOT implemented procedures to oversee individual employee compliance with worksite requirements and began using a broader monitoring process.

DOT had worksite policies in place over the full period of our review that established roles and responsibilities for employees and supervisors participating in telework and remote work, including training requirements.
A few Operating Administrations identified limited instances of employee non-compliance with worksite policies and described corrective actions taken.
DOT began generating regular and recurring reports in June 2025 to review data in timekeeping and other systems to assess employee compliance with in-office requirements Departmentwide, but this process has not been documented.
DOT implemented a data accuracy review process to provide reasonable assurance that the Department's timekeeping and other worksite-related datasets are accurate.

RecommendationsWe made 1 recommendation to fully implement and document DOT's process for monitoring compliance with worksite requirements.

Why We Did This Report

The Office of Inspector General for the U.S. EPA, which also provides oversight for the U.S. Chemical Safety and Hazard Investigation Board, or CSB, contracted with the independent accounting firm SB & Company LLC to initiate an audit of the CSB’s compliance with the Federal Information Security Modernization Act of 2014, or FISMA. While conducting the audit of the CSB’s compliance with FISMA for fiscal year 2025, OIG Project No. OA-FY25-0042, SB & Company identified issues that may have a significant impact on the confidentiality, integrity, and availability of the CSB’s information technology resources. The OIG decided to issue this management alert to inform the CSB of these security concerns because they could affect the CSB’s ability to fulfill its mission and carry out its obligations under FISMA and Office of Management and Budget Memorandum M-25-04. 
 

Summary of Findings

Issues were identified that may have significant impact on the confidentiality, integrity, and availability of the agency’s IT resources. Improvements are needed related to managing privileged user access, availability of audit logs and maintaining an accurate inventory.

The independent public accounting firm of McBride, Lock & Associates, LLC, under contract with the Office of Inspector General, audited Help America Vote Act (HAVA) grants administered by the Montana Secretary of State, totaling $10.83 million. This included federal funds, state matching funds, and interest income earned on the Election Security grant.

With a requested fiscal year 2026 budget of about $3.5 billion for homelessness programs, the Veterans Health Administration (VHA) is committed to preventing and ending veteran homelessness. VHA’s Homeless Programs Office uses a required screening process to identify veterans who are experiencing or at risk of homelessness and need assistance. Medical facilities must complete screenings for veterans under their care, have a process for positive screenings, and ensure staff respond to requests for services within seven business days. Follow-up action must occur within 30 days.

From January through June 2024, VHA screened over 2.4 million veterans and identified 31,149 who reported either experiencing or being at risk of homelessness. About 59 percent (18,250) requested to be referred to social work or homelessness program staff for further assistance. At 42 of 140 facilities, 25 to about 71 percent of veterans (depending on the facility) who wanted to be referred for additional assistance during the screening did not receive follow-up action within 30 days.

The audit team evaluated screening reminder processes at four medical facilities and found weaknesses in the referral and follow-up processes that put veterans at risk of not receiving assistance after they indicated they were experiencing or at risk of homelessness. Deficiencies in the process occurred, in part, because facilities did not establish written local policies and procedures in accordance with federal internal control standards and VHA policy. In addition, the Homeless Programs Office did not ensure facilities had an effective mechanism to monitor follow-up action. The VA Office of Inspector General made four recommendations to improve controls over referral, follow-up, and monitoring processes to ensure veterans’ needs are addressed after positive homelessness screenings. VHA’s under secretary concurred with three recommendations and concurred in principle with one recommendation.

What OIG Inspected 

OIG inspected the executive direction, policy and program implementation, resource management, and information management operations of Embassy Bridgetown, Barbados. The inspection also included Embassy St. George’s, Grenada; Consular Agency Antigua and Barbuda; and Consular Agency Martinique. 

What OIG Found 

• Embassy Bridgetown’s Front Office generally complied with Department of State standards for tone at the top and standards of conduct, execution of foreign policy goals and objectives, security and emergency planning, and equal employment opportunity. The Chargé d’Affaires, ad interim, engaged all elements of the workforce, provided useful guidance, and responded to employee concerns.
• Embassy Bridgetown did not have a clear delineation of chief of mission security responsibilities for British and French territories in the Eastern Caribbean.
• The embassy had deficiencies in consular oversight.
• Embassy Bridgetown had several safety issues related to elevator mechanical deficiencies, fire protection, and workplace safety inspections.
• The embassy’s contract file management and contracting officer’s representative program did not fully comply with Department standards.
• The embassy had deficiencies related to the security of information systems and information technology assets, the emergency communications program, and mobile device management in Bridgetown and at Embassy St. George’s.  

What OIG Recommends

OIG made 30 recommendations: 29 recommendations to Embassy Bridgetown and 1 recommendation to the Bureau of Western Hemisphere Affairs. In its comments on the draft report, the Department concurred with 24 recommendations, partially concurred with 2 recommendations, and neither agreed nor disagreed with 4 recommendations. OIG considers all 30 recommendations resolved. The Department’s formal responses are reprinted in their entirety in Appendix B.