Federal Reports

The Semiannual Report to Congress summarizes the results of VA OIG oversight, provides statistical information, and lists all 103 oversight reports and other products issued from October 1, 2024, to March 31, 2025. During this reporting period, VA OIG audits, evaluations, investigations, inspections, and other reviews identified nearly $3.3 billion in monetary impact for a return on investment of $28 for every dollar spent. The OIG hotline received and triaged almost 17,200 contacts in the past six months—to help identify wrongdoing and address concerns with VA activities. Also, during the past six months, special agents opened 256 investigations and closed 213, with efforts leading to 144 arrests. Collectively, the OIG’s work also resulted in 598 administrative sanctions and corrective actions during the six-month reporting period.

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 Augusta Health Care System in Georgia. This evaluation focused on five key content domains:
•    Culture
•    Environment of care
•    Patient safety
•    Primary care
•    Veteran-centered safety net
The OIG issued five recommendations for improvement in three domains:
1.    Culture
•    The Under Secretary for Health evaluates facility leaders for appropriate supervisory behavior and professional communication, and takes actions as needed.
•    The Under Secretary for Health determines whether the Veterans Integrated Service Network Director and other leaders were aware of facility leaders’ unprofessional behavior and communication, and takes actions as needed.
2.    Environment of care
•    The Under Secretary for Health ensures the Veterans Integrated Service Network and facility directors oversee the inventory management system and resolve medical supply deficiencies, and monitor actions for sustained improvement.
3.    Patient Safety
•    Facility leaders develop action plans to ensure providers communicate test results to patients timely.
•    The Under Secretary for Health directs the national VHA Quality and Patient Safety Program staff to review the facility’s quality management program and determine whether actions by facility and Veterans Integrated Service Network leaders effectively addressed system issues affecting patient safety, including nursing leaders’ lack of access to safety reports, and missed opportunities for institutional disclosures, and takes action as needed.

We performed an audit of costs billed to the Tennessee Valley Authority (TVA) by Wright Brothers Contracting, Inc. (Wright Brothers) for site grading services and materials under Contract No. 16512.  The contract provided for TVA to compensate Wright Brothers for work on a fixed price basis for deliverables and materials and on a time and material (T&M) basis for performance of the work.  Our audit objectives were to determine (1) if costs were billed in accordance with the contract terms and (2) the reasonableness of TVA’s process for evaluating and awarding proposed fixed price tasks issued under the contract.  Our audit scope included approximately $28.7 million in costs paid by TVA between September 3, 2021, and May 31, 2024.  This included approximately $24.5 million for 17 fixed price tasks and $4.2 million for one T&M task.

In summary, we determined:

•    Wright Brothers billed TVA $1,401,563 in T&M billings for cost categories that were not included in the contract, Wright Brothers proposal, or TVA’s purchase order.  Additionally, the proposal and invoice documentation did not provide adequate detail for a field invoice approver to effectively review invoices. 
•    Wright Brothers billed TVA $49,355 in unsupported T&M costs, including (1) $43,860 in unsupported equipment costs and (2) $5,495 in unsupported labor costs.  (Note:  $11,320 of the $49,355 unsupported cost were also included in the $1,401,563 ineligible T&M billings.)
•    There were opportunities to strengthen TVA’s process for evaluating and awarding fixed price tasks.  Specifically, TVA did not always compete fixed price tasks as required by the contract.  In addition, when TVA received only one bid for a fixed price task, there were no policies or guidance for steps TVA should take to ensure the fairness of the fixed price amount. 

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations related to the care of a female patient who presented with “near constant” vaginal bleeding to the Martinsburg VA Medical Center (facility) Emergency Department. 

While no deficiencies were found in the care provided by emergency department physicians, the OIG identified multiple deficiencies in nursing care. The OIG also identified failures in leaders’ oversight to ensure deficiencies were sufficiently remediated.

The OIG determined that the emergency department was equipped to perform gynecologic exams. However, the gynecologic cart, which featured hinged foldable footrests used in extension with the emergency department bed, was not utilized by some providers due to concerns of discomfort for patients.

The OIG substantiated delays in the patient’s transfer to a higher level of care, with an avoidable delay by the facility fire department’s ambulance service. Facility fire department leaders attributed the delay to lack of available staff and inability to mandate overtime for transports. However, the OIG determined that the practice of prohibiting mandatory overtime for emergency transports was incongruent with facility policy and facility leaders’ expectations. The OIG also found that facility leaders failed to assess concerns about the transport delay identified during a factfinding. 

The OIG learned that while the facility initiated a formal review to address broader patient transport challenges in May 2023, more than a year later, recommended policy and protocols identified from the review had not yet been approved by facility leaders.

The OIG made 10 recommendations to the Facility Director related to emergency department communication, adherence to Veterans Health Administration and facility policies, review of implemented actions to ensure quality of care concerns are remediated, evaluation of emergency department equipment for gynecologic examinations, review of overtime practices for staff providing emergency transports, and review of transportation concerns.

This report details the Office of Inspector General's Spring 2025 - Semiannual Report to Congress. The following topics are included:

• Overview of the SBA and the OIG
• SBA's Top Management and Performance Challenges
• Summary of OIG Oversight Work
• Small Business Access to Capital
• Disaster Assistance Program
• Contracting and Counseling Programs
• Agency Management
• Other Significant OIG Activities
• OIG Hotline
• Organizational Overview
• Appendices

We are pleased to present our report for the period October 1, 2024, to March 31, 2025.  In this semiannual period, our audit, evaluation, and investigative activities identified more than $75.1 million in questioned costs; funds put to better use; restitutions, recoveries, fees, and fines; and opportunities for the Tennessee Valley Authority (TVA) to improve its programs and operations.

TVA’s mission of service was set forth in the TVA Act of 1933.  While the mandate to provide affordable electricity, manage the river systems, and promote economic development in the Tennessee Valley has remained constant for 92 years, TVA has had to transform itself in areas such as methods of electricity generation, funding approaches, skills, technology, and more.  Some transformations came about by opportunities like innovation, while others came about in reaction to constraints.  Today, TVA finds itself in another stage of transformation as it addresses significant requirements to grow clean generation capacity.  Our office will stand with TVA as we fulfill our mission to provide independent and objective oversight that promotes effective and efficient operations and prevents and detects fraud, waste, and abuse.