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Brought to you by the Council of the Inspectors General on Integrity and Efficiency
Federal Reports
Report Date
Agency Reviewed / Investigated
Report Title
Type
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Department of the Treasury
Audit of the Office of D.C. Pensions' Financial Statements for Fiscal Year 2025
The VA Office of Inspector General (OIG) conducted a national review of the Veterans Health Administration’s (VHA’s) suicide risk and intervention training, suicide risk screening practices, and implementation of progressive tinnitus management (PTM) in audiology settings from October 2023 through September 2024. Audiology services are key access points to VHA, with over 447,000 new patient appointments annually. Tinnitus, the most common service-connected disability, is associated with mental health conditions such as depression and anxiety, underscoring the need for integrated care.
The OIG found that Office of Suicide Prevention (OSP) leaders did not identify audiologists as clinical staff for suicide risk and intervention training purposes, which led to incorrect training assignments. Most audiologists (80 percent) completed nonclinical training instead of the required training for clinical staff.
Adherence to VHA’s required annual suicide risk screening in audiology services was 22 and 39 percent in fiscal years 2023 and 2024, respectively. During the same period, 15 facilities did not complete any screenings when due, representing 24,000 missed screenings. An Office of Audiology and Speech Pathology Services leader stated that audiologists receive limited training in suicide risk screening, and shared a perception that adherence improves with increased education.
While most facilities implemented PTM, facility audiology contacts identified limited scheduling, lack of collaboration, and absence of co-located services as barriers to mental health integration. Neither the Office of Audiology and Speech Pathology Services nor OSP provide oversight of PTM mental health integration.
The OIG made five recommendations to the Under Secretary for Health, including clarifying training requirements and delineating responsibility for completion, evaluating training assignment accuracy, improving screening adherence, and evaluating mental health integration oversight responsibilities. VHA concurred with the recommendations, highlighted a new performance metric, and indicated a plan to implement a directive that will include training requirements, definitions, and oversight responsibilities.
This report presents the results of the VA OIG’s supplemental review of service obligations for VHA’s recruitment, relocation, and retention incentives, which follows on a report published in June 2025. While completing that audit, the OIG team became aware of an issue occurring when some VA employees breached their required service obligations. Accordingly, the OIG initiated this supplemental review to determine whether VA issued debt notices for these employees.
Regional human resources staff could not consistently provide evidence that debt notices were initiated or issued to employees who breached an incentive service agreement. The breach of service obligation periods ranged from about one month to one and a half years. During FYs 2020–2023, VA did not initiate debt notices to at least 1,100 employees who moved to another region or left VA before fulfilling their agreements, resulting in VHA paying about $17.5 million for the breached service obligations. This occurred because regional human resources officials did not always accurately enter data into HR Smart, VA’s personnel system of record, and pop-up notifications in this system did not prevent staff from processing personnel actions even when service obligations would be breached. Furthermore, regional officials could not access personnel records when an employee left their network and, therefore, could not determine whether such employees met the required service obligations. VA concurred with all eight recommendations from the June 2025 report and the four new recommendations in this report and has taken action to improve how it governs the recruitment, relocation, and retention incentive process.
The independent public accounting firm of Allmond & Company, LLC, under contract with the Office of Inspector General, audited the EAC’s financial statements for the fiscal year ended September 30, 2025. The purpose of this letter is to convey information concerning control weaknesses that did not rise to the level of a significant deficiency or material weakness.