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 VA Louisville Healthcare System in Kentucky. This evaluation focused on five key content domains:
•    Culture
•    Environment of care
•    Patient safety
•    Primary care
•    Veteran-centered safety net

The OIG issued 13 recommendations for VA to correct identified deficiencies in four domains:
1.    Culture
•    Telephone system improvements
2.    Environment of care
•    Exit signs
•    Detectable warning surfaces
•    Clean and safe patient care areas
•    Electrical cord management
•    Biological hazard signs
•    Biohazardous waste disposal
•    Liquid nitrogen use and storage
•    Environment of care trends, improvement plans, and outcome measures
3.    Patient safety
•    Service-level workflows for test result communications
•    Test result communication policy
•    Test result communication performance metrics
4.    Primary care
•    Panel sizes

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess care concerns and inadequate quality reviews related to a patient’s death at the VA Greater Los Angeles Healthcare System (facility). The OIG determined that clinical staff did not timely recognize, address, and investigate changes in the patient’s clinical condition. Although the outcome may not have changed, not recognizing an emerging condition hindered clinical staff considering modifications to the plan of care and discussing the course of action with the patient and family.

The OIG identified several factors that contributed to staff not recognizing the patient’s deterioration and intervening accordingly. The resident physician ordered laboratory tests, but neither the resident nor attending physician reviewed or acted upon the patient’s abnormal laboratory values. The resident ordered stat imaging studies to assess abdominal pain and evaluate for infection; however, the resident, attending, and nursing staff did not ensure imaging completion.

Nurses missed early warning signs of the patient’s deteriorating condition by not conducting National Early Warning Score (NEWS) assessments as required or intervene, as expected, with elevated NEWS scores. Nurses did not complete shift assessments within the required time frames. The OIG identified an 11-hour gap in nursing documentation before the patient’s death. Nurses lacked accurate on-call provider contact information and attempts to reach the on-call provider to address the patient’s pain were unsuccessful.

Facility leaders did not conduct a comprehensive review of the events that occurred prior to the patient’s death and were unsuccessful in their attempts to conduct an institutional disclosure with the patient’s family.

The Facility Director concurred with and submitted action plans to address the OIG’s seven recommendations related to comprehensive reviews of the patient’s care, NEWS assessment training, nursing assessment compliance, patient care escalation processes, and disclosure efforts.

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 Detroit Healthcare System in Michigan. This evaluation focused on five key content domains:
•    Culture
•    Environment of care
•    Patient safety
•    Primary care
•    Veteran-centered safety net

The OIG issued six recommendations for VA to correct identified deficiencies in one domain:
1.    Environment of care
•    Damaged furnishings
•    Maps for navigation
•    Clean equipment storage
•    Unobstructed hallways and exits
•    Defective equipment removal
•    Computer screen privacy filters

The Postal Service is a self-funded entity that primarily finances its operations through postage sales, with package delivery comprising a major portion of its services. During fiscal year (FY) 2024, the Postal Service shipped 7.3 billion packages, generating $32.3 billion in revenue. The Postal Service offers multiple options to purchase postage, including through third party vendors, its Click-N-Ship online service, and over the retail counter at local post offices. Every USPS package label contains specific information that can be used for multiple reasons, to include detecting and intercepting potentially fraudulent package labels.

The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered throughout Readjustment Counseling Service (RCS).

This inspection evaluated leadership stability, morbidity and mortality reviews, and the high risk suicide flag (HRSF) SharePoint site within Midwest District 3. 

There were no findings in leadership stability. The morbidity and mortality review identified that district leaders did not ensure reviews had the required RCS panel members and contained all required components. The HRSF review identified noncompliance with documentation requirements for high-risk client contacts and outcomes in both RCSNet and the HRSF SharePoint site. This noncompliance was attributed to unclear or insufficient guidance provided to staff. The OIG issued two recommendations for improvement to the District Director and one recommendation to the Chief Officer. 

An Amtrak Trackman/Watchman based in Wilmington, Delaware, was terminated from employment on October 14, 2025, following an administrative hearing. Our investigation found that the employee violated company policies by shipping baggage on Amtrak trains while traveling by other means, driving a company-leased vehicle without a valid license, using his company-leased vehicle for personal travel, and leaving work without authorization. The employee also violated company policy by being dishonest with our agents during his interview.

The U.S. Postal Service needs effective and productive operations to fulfill its mission of providing prompt, reliable, and affordable mail service to the American public. It has a vast transportation network that moves mail and equipment among approximately 315 processing facilities and 31,200 post offices, stations, and branches. The Postal Service is transforming its processing and logistics networks to become more scalable, reliable, visible, efficient, automated, and digitally integrated. This includes modernizing operating plans and aligning the workforce to meet marketplace needs; leveraging emerging technologies to provide world-class visibility and tracking of mail and packages in near real time; and optimizing the surface and air transportation network. The U.S. Postal Service Office of Inspector General (OIG) reviews the efficiency of mail processing operations at facilities across the country and provides management with timely feedback to further the Postal Service’s mission.

The U.S. Postal Service’s mission is to provide timely, reliable, secure, and affordable mail and package delivery to more than 160 million residential and business addresses across the country. The U.S. Postal Service Office of Inspector General (OIG) reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission.

The U.S. Postal Service’s mission is to provide timely, reliable, secure, and affordable mail and package delivery to more than 160 million residential and business addresses across the country. The U.S. Postal Service Office of Inspector General (OIG) reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission.

The U.S. Postal Service’s mission is to provide timely, reliable, secure, and affordable mail and package delivery to more than 160 million residential and business addresses across the country. The U.S. Postal Service Office of Inspector General  reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission.