Federal Reports

VA can authorize veterans to receive care in the community in specific circumstances. After the care occurs, the community provider must return associated medical records to VHA and community care staff close the consult. If records are not received, staff must administratively close consults (that is, update the status from “open” to “complete”) to indicate the veteran received care and make three requests for the records within 90 days of the appointment. The VA OIG reviewed whether VHA staff took appropriate action to retrieve and document medical records from community providers and import the records into veterans’ electronic health records.

The OIG found that, as of December 16, 2024, VHA closed nearly 3 million community care consults for appointments scheduled to occur between October 1, 2023, and April 1, 2024. Among these, over 2.4 million (82 percent) had medical records attached, and nearly 1 million were administratively closed (34 percent). In addition, for the same period, VHA had 71,447 open consults, virtually all of which were more than 90 days beyond the scheduled appointment date.

According to the OIG’s analysis, 62 facilities imported 90 percent or more of medical records for completed community care consults into veterans’ electronic health records. However, 11 facilities imported the records less than 60 percent of the time.

Staff said competing priorities reduced the amount of time available to request and process incoming records. Once records were received, community care staff did not always use the Consult Toolbox to document the receipt, and related policy was both unclear and inconsistently used. Furthermore, VHA facilities varied in meeting timeliness metrics.

VHA concurred with the OIG’s 10 recommendations (including concurrence in principle to recommendation 2) to direct the Office of Integrated Veteran Care to correct identified deficiencies related to processes, internal controls, timeliness, and oversight.

The U.S. Consumer Product Safety Commission (CPSC) OIG retained Williams, Adley, & Co.-DC LLP (Williams Adley, we), an independent public accounting firm, to perform the independent assessment of the CPSC’s implementation of FISMA for FY 2025 and to determine the effectiveness of its information security program. This report documents the results of the OIG’s FISMA evaluation. Specifically, we assessed the CPSC’s compliance with the annual Inspector General (IG) FISMA reporting metrics set forth by the DHS and OMB. 

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 Central Ohio Health Care System in Columbus. 

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 three domains:
   1.    Culture
     •    Standardized process for service-level communication
   2.    Environment of care
     •    Clean patient areas and intact walls
   3.    Veteran-centered safety net
     •    Housing and Urban Development–Veterans Affairs Supportive Housing program resources

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA Southern Nevada Healthcare System (facility) in Las Vegas to analyze facility leaders’ response to allegations that a dental hygienist failed to follow Veterans Health Administration and facility policies and provide quality care. The OIG determined that supervisors did not ensure the correction of patient safety concerns related to the dental hygienist’s practice after having knowledge of the repeated concerns for approximately two years. 

A supervisor requested a factfinding, which substantiated the dental hygienist falsified a patient’s electronic health record; however, the falsification went unaddressed. The factfinding was not completed timely and, although requested, a review of two medication storage violations was not included. Additionally, a supervisor considered but did not implement a performance improvement plan to address repeated clinical practice concerns and infection control violations. 

Due to conflicting recollections, the OIG was unable to determine whether a supervisor recommended a comprehensive review of the dental hygienist’s care to the credentialing and privileging manager, which is a step in the state licensing board (SLB) reporting process. Also, on the provider exit review form, a supervisor did not accurately reflect clinical care concerns regarding the dental hygienist. An accurate form would have prompted initiation of the SLB reporting process. Further, supervisors did not ensure that patient safety reports were submitted through the Joint Patient Safety Reporting system as required. 

The OIG determined that the Chief of Staff (COS) did not consider a management review of the dental hygienist’s care after receiving a recommendation from a risk manager to conduct a management review. The COS also did not effectively utilize high reliability organization principles to become aware of the full extent of patient safety concerns regarding the dental hygienist. 

The OIG made eight recommendations to the Facility Director.

As of February 2025, NASA had allocated over $26 billion in government property to contractors in support of six Artemis programs. Although NASA has policies in place to manage its government property, the Agency can strengthen its oversight by ensuring consistent application of those policies to decrease the risk of unnecessary costs and potential loss, theft, misuse, or destruction of government property.

The audit objectives were to determine whether program funds were managed in accordance with the ARC and Federal grant requirements.