Federal Reports

This report presents the results of our verification inspection of the U.S. Small Business Administration’s (SBA) corrective actions for the recommendations from the Office of Inspector General (OIG) Audit of SBA’s Desktop Loss Verification Process (Report 19-23). A verification inspection is a review that focuses on the implementation of closed recommendations from prior OIG reports.

SBA made corrective actions in response to our prior audit and implemented a process to ensure all disaster assistance loans were verified before disbursing funds. However, the corrective actions the agency made in response to our prior audit no longer exist because SBA changed its loan processing management system and developed new processes. We found the same issues identified in our prior audit continue to persist because SBA did not address our recommendations when the agency transitioned to its new loan processing platform in 2023. In some cases, SBA weakened or eliminated internal controls even further.

In this verification inspection, we reviewed the files for 28 SBA disaster assistance loans approved in fiscal year 2025 and found 12 were missing photographs of the claimed damages. Only 1 of the 28 files contained contractor estimates for cost of repair or replacement, insurance reports, or repair receipts. The loss verifiers’ comments in the files were often minimal in supporting their conclusions from the documentation submitted. We will not reopen the recommendations from Report 19-23 but will instead incorporate our findings into a future audit of SBA’s disaster assistance loan loss verification process. SBA elected not to provide a formal response to this report.

We performed an audit of costs billed to the Tennessee Valley Authority (TVA) by Facilities Technology Alliance LLC (FTA) under Contract No. 15664 for staff augmentation electrical and telecommunication services.  Our objective was to determine if costs were billed in accordance with the contract’s terms.  Our audit scope included $15.1 million in costs paid to FTA from March 6, 2023, through February 28, 2025.

In summary, we determined FTA overbilled TVA $187,600, including (1) $69,790 in fuel and oil costs not provided for in the contract, (2) a net $65,805 due to duplicate and incorrectly billed invoices, (3) $48,257 in overbilled labor costs, and (4) $3,748 in unsupported travel costs. In addition, we found the contract’s pricing schedule did not include FTA’s billing rates.  Without billing rates, TVA’s field invoice approvers do not have sufficient information to effectively review invoices.

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

Fiscal Year 2025 Financial Statement Audit Letter to Management