Federal Reports

This report provides an overview of the work of the Office of Inspector General during the period of April 1, 2025 through September 30, 2025.

This report highlights the accomplishments achieved through our oversight and investigative activities for the 6-month period ending September 30, 2025. 
 

The VA Office of Inspector General (OIG) initiated a healthcare inspection at the VA Central Texas Healthcare System (system) in Temple to assess allegations that two pain management advanced practice registered nurses (pain management APRNs) were not appropriately supervised and were unqualified to prescribe controlled substances. The complainant also reported concerns regarding the potential for patient harm; however, the complainant was not aware of any patient safety events. The OIG did not substantiate the allegations and made no recommendations.

The OIG reviewed the pain management APRNs’ proficiency reports and practice evaluations from October 2022 through March 2025, did not identify any competency concerns, and found the supervisor completed the reports properly. The OIG also reviewed reports entered into the Veterans Health Administration’s (VHA’s) patient safety event reporting system during the same time frame and did not find any patient safety events related to the pain management APRNs.

The OIG reviewed the pain management APRNs’ credentialing and privileging documentation and found the APRNs had active Texas-issued registered nurse licenses and nurse practitioner certifications, Drug Enforcement Administration registrations, and system-approved clinical privileges with authorization to prescribe controlled substances. Further, the OIG did not identify any reported patient complaints or patient safety events. 

The OIG concluded that the pain management APRNs’ service chief provided supervision as required by VHA and the APRNs were authorized and qualified to prescribe controlled substances.

The VA Office of Inspector General (OIG) issued a preliminary result advisory memorandum to inform the Veterans Health Administration (VHA) Under Secretary for Health of significant and recurring fire system and life safety deficiencies identified during a Healthcare Facility Inspection of the East Orange VA Medical Center in New Jersey, conducted in August 2025. These deficiencies pose ongoing risks to the safety of patients, staff, and visitors.

Key issues identified include a fire-extinguishing standpipe that had not been tested every five years, fire barrier doors that could not be closed, and incorrect exit signage. These findings mirror and, in some cases, repeat deficiencies previously cited in the facility’s fiscal years 2024 and 2025 Annual Workplace Evaluations (AWEs) and The Joint Commission’s 2024 inspection. Prior concerns also included untested fire-extinguishing systems in the canteen kitchen, uninspected fire-rated doors, and persistent signage errors.

The Interim Facility Director acknowledged the issues, and the Associate Director submitted a corrective action plan on September 17, 2025, with target completion dates extending through fiscal year 2028. Interim life safety measures have been implemented, but the OIG expressed concern about the protracted remediation timeline and the significant resources required to maintain safety during this period.

The Veterans Integrated Service Network (VISN) 2 Director was previously informed of these deficiencies as documented in earlier AWEs, and communicated them to the facility’s leadership. Despite this awareness, the recurrence of issues suggests a need for stronger oversight and more immediate corrective action.

The OIG is not taking further action at this time but requests the Under Secretary for Health evaluate the adequacy of current oversight and ensure timely implementation of all necessary measures to safeguard the facility’s environment.

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

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 Tampa Healthcare System in Florida. 

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 two domains:
   1.    Environment of care
     •    Sinks and hand hygiene supplies
     •    Video laryngoscope supplies
   2.    Patient safety
     •    Service-level workflows for the communication of test results

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the South Texas Veterans Health Care System in San Antonio. 

This evaluation focused on five key content domains:
     •    Culture
     •    Environment of care
     •    Patient safety
     •    Primary care
     •    Veteran-centered safety net

The OIG issued two recommendations for VA to correct identified deficiencies in two domains:
   1.    Environment of care
     •    Patient care area cleanliness and clean storage areas free of dirty items and equipment
   2.    Patient safety
     •    Service-level workflows for the communication of test results

The independent public accounting firm of McBride, Lock & Associates, LLC, under contract with the Office of Inspector General, audited Help America Vote Act (HAVA) grants administered by the Montana Secretary of State, totaling $10.83 million. This included federal funds, state matching funds, and interest income earned on the Election Security grant.