Federal Reports

The OIG’s Mental Health Inspection Program (MHIP) evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on inpatient care delivered at the Martinsburg VA Medical Center (facility) in West Virginia. 

The facility met some VHA requirements for inpatient mental health units, including aspects of a recovery-oriented physical environment, such as artwork and natural lighting, and a plan for continued transformation to recovery-oriented services. However, the facility did not include veteran representation on its Mental Health Executive Council and did not have a full-time local recovery coordinator. Recovery-oriented, interdisciplinary programming also did not consistently occur as scheduled.

The OIG identified ongoing communication issues between facility executive and mental health leaders, including executive leaders being unaware of pertinent information related to mental health staffing and processes. Staff did not perform involuntary holds or admissions due to leaders’ incorrect interpretation of West Virginia state law, and the Veterans Integrated Service Network (VISN) did not identify that the facility’s involuntary hospitalization policy was inconsistent with state laws.

Electronic health records indicated that reviewed safety plans did not consistently address making the veteran’s environment safer from potentially lethal means, and staff did not consistently document medication risk and benefit discussions. Discharge instructions were typically difficult to understand, lacking important details for medication management. 

The OIG observed safety hazards, such as unapproved window coverings in most bedrooms and potentially unsafe equipment in a shower room. The OIG also found shower room monitoring practices could compromise veterans’ privacy and dignity. 

VA concurred with the OIG’s 16 recommendations. The VISN Director committed to ensuring establishment of state-compliant involuntary hold procedures. The Facility Director agreed to implementing a range of corrective actions, including enhanced leadership oversight, expanded veteran engagement, strengthened staff training, and improved coordination and documentation practices to support safe, recovery-oriented mental health care.

The VA Office of Inspector General (OIG) issued this preliminary result advisory memorandum to report significant suicide hazards identified during an on-site inspection of inpatient mental health units at the VA Boston Healthcare System in Brockton, Massachusetts, conducted November 18–19, 2025. The inspection revealed multiple environmental risks that pose a serious threat to patient safety, particularly the presence of anchor points and other objects that could facilitate self-harm.

The OIG observed several high-risk features inconsistent with the safety standards outlined in VHA Directive 1167 and the Mental Health Environment of Care Checklist. These included:
     •    toilets not securely mounted to both floor and wall, with removable seats creating potential anchor points;
     •    exposed plumbing that could be used for hanging or other forms of self-harm;
     •    sink faucets and handles lacking required tapered or rounded designs, increasing risk of ligature use;
     •    cabinet door handles with protrusions that could serve as anchor points; and
     •    unsecured medical equipment and cords, which were long enough to pose strangulation hazards.

These deficiencies were identified across four inpatient mental health units housing 111 authorized beds. The presence of such hazards represents a critical vulnerability in the facility’s suicide prevention infrastructure.

Following immediate notification to facility leaders between November 18–20, 2025, interim mitigation measures were implemented. These included removal of select hazardous items, initiation of 15-minute patient safety checks, staff education on environmental risks, and enhanced observation protocols. Facility staff conducted a formal risk assessment to guide long-term corrective actions.

The OIG continues to oversee the facility’s response and will provide a full analysis in the final inspection report. Given the seriousness of the issue and similar concerns identified at other facilities, these findings are being shared broadly to prompt proactive hazard mitigation across other VHA facilities. 

Beginning in 2021, the U.S. Department of Housing and Urban Development (HUD), Office of Inspector General (OIG), conducted several audits to assess HUD’s anti-fraud efforts and to develop inventories of fraud risks in HUD programs. Our previous work found that HUD’s fraud risk management program was in its early stages of development, and we recommended that HUD perform program-specific fraud risk assessments and incorporate these assessments into an agency-wide plan to further advance its program.  To continue assisting HUD in improving its anti-fraud efforts, we conducted this work to identify potential fraud risks and schemes that that could negatively impact the Capital Fund formula grant program, HUD, and its public housing agencies (PHAs).  We identified four program-specific fraud risk factors that increase the chance of fraud occurring by increasing the incentive, opportunity, and likelihood that an individual will consider committing fraud.  We used these risk factors, along with the results of brainstorming sessions, interviews, and reviews of audit reports, investigations, and press releases from HUD OIG, and other agencies to develop an inventory of 73 fraud schemes.  The 73 fraud schemes include 58 that were listed in HUD’s fraud risk catalog and 15 schemes that we identified.  These fraud schemes can be used to defraud HUD and its PHAs and undermine the integrity of the Capital Fund program, which awarded $3.1 billion in formula grants in fiscal year 2024. We recommend that HUD use the fraud risks and schemes inventory in this report and involve relevant stakeholders to create a program-specific fraud risk inventory to support its anti-fraud efforts and enhance oversight of the Capital Fund program.  We also recommend that these fraud risks and schemes be communicated to all stakeholders, including public housing agencies.  Additionally, we recommend that HUD determine how data currently being collected can be leveraged to identify and mitigate fraud risks. 

The VA Office of Inspector General (OIG) Mental Health Inspection Program (MHIP) evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on inpatient care delivered at the Margaret Cochran Corbin VA Campus (facility) in New York.

The facility met some VHA requirements for inpatient mental health units, such as the presence of a mental health executive council and completion of twice-yearly environment of care inspections. The OIG could not confirm if the facility had a formalized interdisciplinary safety inspection team. The facility’s multiyear plan to direct veteran-centered, recovery-oriented care did not have input from the local recovery coordinator.

Some electronic health records reviewed did not include evidence of timely suicide risk screenings and documentation of medication risk and benefit discussions. Discharge instructions lacked important details for follow-up appointment locations and medication management. Consistent with prior published reports, inpatient staff did not complete the other lethal means text field in safety plans for addressing ways to make veterans’ environments safer. 

The inpatient unit physical environment incorporated recovery-oriented elements such as artwork. However, communal rooms were locked and therefore inaccessible to veterans unless there were staff to monitor. The OIG identified unit fire doors with three-point hinges that posed ligature risks and a nonfunctional panic button. Many inpatient staff did not complete training on environment of care inspection requirements or suicide prevention strategies. 

VA concurred with the OIG’s 17 recommendations. The Under Secretary for Health agreed to require staff completion of the other lethal means text field within the safety plan template. The Facility Director agreed to implement a range of corrective actions, including strengthened processes and staff training, a formalized interdisciplinary safety inspection team, and improved coordination and documentation practices to support safe, recovery-oriented mental health care on the inpatient unit.

What OIG Inspected 

OIG inspected the executive direction, policy and program implementation, resource management, and information management operations of Embassy Wellington. This inspection included Consulate General Auckland.  

What OIG Found

• Mission New Zealand’s Chargé d’Affaires, ad interim, and acting Deputy Chief of Mission generally complied with Department of State standards for tone at the top and standards of conduct, execution of foreign policy goals and objectives, adherence to internal management controls, security and emergency planning, and equal employment opportunity. The Front Office emphasized professionalism in the workplace and fostered employee resiliency.
• The delineation of Embassy Wellington’s responsibilities for the U.S. Antarctic Program was unclear. Specifically, mission staff did not have clarity on who was responsible for emergency response and assistance, and law enforcement or security support if a disaster or crime occurs involving U.S. citizens in the Antarctic region.
• The mission had deficiencies related to public diplomacy, consular, resource management, and information management operations.  

What OIG Recommends

 OIG made 19 recommendations to Embassy Wellington. In its comments on the draft report, the embassy concurred with all 19 recommendations. OIG considers all 19 recommendations resolved. The embassy’s formal response is reprinted in its entirety in Appendix B. 

Summary of Audit

An independent external auditor, working on behalf of and under the direction of the Office of Inspector General, audited the U.S. Department of State’s (Department) annual financial statements as of, and for the year ended, September 30, 2025. The external auditor found that the financial statements present fairly, in all material respects, the financial position of the Department as of September 30, 2025, and its net cost of operations, changes in net position, and budgetary resources for the year then ended, in accordance with accounting principles generally accepted in the United States of America. The external auditor found certain reportable deficiencies in internal control. Specifically, the external auditor found significant deficiencies in the internal controls over property and equipment, unliquidated obligations, financial reporting, and IT. The external auditor also found an instance of reportable noncompliance with a provision of the Prompt Payment Act.