Federal Reports

The VA Office of Inspector General reviewed acute inpatient mental health care at the Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin. Inspectors evaluated care in five areas. The OIG inspection team provided preliminary observations to leaders and later issued seven recommendations. The mental health leadership structure relied on shared responsibilities across multiple managers, which leaders perceived led to improved workload management and coverage. The Mental Health Executive Council did not include required veteran representation, limiting opportunities for veterans to influence the quality of care. The inpatient unit implemented recovery oriented practices. Veterans had daily interdisciplinary programming and access to natural light, a sunroom, and computer kiosks. Staff engaged consistently with veterans, and leaders supported recovery focused approaches. Inspectors identified gaps in clinical care coordination. Staff did not always document veterans’ legal status at admission or discussions about medication risks and benefits. Discharge instructions sometimes used undefined abbreviations or did not explain the purpose of medications, which could hinder veterans’ ability to safely manage their medications.

Staff completed required suicide risk screenings and safety plans before discharge. However, some staff had not completed mandatory suicide prevention training. Required safety inspections on the inpatient unit were completed and a ligature risk was corrected quickly, but a key team member did not attend inspections consistently. Several staff and volunteers also did not complete required training. The recommendations called for veteran participation on the Mental Health Executive Council, improved documentation practices, clearer discharge instructions, completion of required suicide prevention training, and full participation in environmental safety processes. VA leaders concurred with all recommendations and began corrective actions, including strengthening oversight, updating training requirements, improving documentation workflows, adding veteran input to governance, and monitoring compliance through established committees. These efforts are intended to improve the safety, quality, and recovery orientation of inpatient mental health care.

Why We Did This Report

The Hazardous Waste Electronic Manifest Establishment Act requires the EPA to prepare and the OIG to audit the accompanying financial statements of the EPA’s Hazardous Waste Electronic Manifest System Fund. Our primary objectives were to determine whether the:

• Fund’s financial statements were fairly stated in all material respects.
• EPA’s internal control over financial reporting was in place.
• EPA’s management complied with applicable laws, regulations, contracts, and grant agreements.

Summary of Findings

We found the fund’s financial statements to be fairly presented and free of material misstatement. We did not identify any matters that we consider to be material weaknesses or significant deficiencies in the fund.

Why We Did This Report

The Federal Insecticide, Fungicide, and Rodenticide Act, or FIFRA, as amended by the Food Quality Protection Act, requires the EPA OIG to perform an annual audit of the financial statements for the Pesticides Reregistration and Expedited Processing Fund. Our primary objectives were to determine whether:

• The financial statements were fairly stated in all material respects.
• The EPA’s internal controls over financial reporting were in place.
• The EPA’s management complied with applicable laws, regulations, contracts, and grant agreements.

Summary of Findings

We found the fund’s financial statements to be fairly presented and free of material misstatement. We noted the following material weakness: The EPA did not appropriately allocate an expense paid to the U.S. General Services Administration for the use of government facilities.

The VA Office of Inspector General’s (OIG’s) Mental Health Inspection Program evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on inpatient mental health care delivered at the VA Ann Arbor Healthcare System in Michigan. 

The facility met some VHA requirements for inpatient mental health units, such as having a plan for continued transformation to recovery-oriented services. The facility had a mental health executive council, but the council did not have veteran representation. Facility staff conducted biannual environment of care inspections; however, the OIG could not determine whether the facility had a formalized interdisciplinary safety inspection team.

The OIG observed a recovery-oriented physical environment with communal areas for socialization. Staff offered veterans the required amount of interdisciplinary programming on weekdays but not on weekends.

The OIG identified inconsistencies in the number of operating inpatient mental health beds reported in facility data and by leaders at various facility and Veterans Integrated Service Network levels. Network leaders did not ensure accurate reporting of available beds.

Facility leaders did not have written processes to monitor compliance with state laws regarding involuntary hospitalization. Staff did not document veterans’ legal commitment statuses in the required template. Not all inpatient staff completed suicide prevention or safety hazards training. 

Some electronic health records did not include evidence of timely suicide risk screening. All reviewed records included the required discharge summary; however, some summaries were not completed within two business days of discharge. Discharge instructions included difficult-to-understand language and lacked important details for appointment location follow-up and medication management.

VA concurred with the OIG’s 14 recommendations; the OIG closed 1 recommendation prior to publication. Facility leaders committed to implementing corrective actions, including written compliance processes for involuntary commitment, mental health environment of care standards, interdisciplinary weekend programming, discharge instruction improvements, and staff training completion.

Background

The U.S. Postal Inspection Service’s mission is to support and protect the U.S. Postal Service and its employees, infrastructure, and customers; enforce the laws that defend the nation’s mail system from illegal or dangerous use; and ensure public trust in the mail. According to the Postal Inspection Service mail theft strategy, employees have come under increased attack by criminals seeking to perpetrate financial crimes using stolen mail. In 2023, the U.S. Postal Service Office of Inspector General (OIG) conducted the U.S. Postal Service’s Response to Mail Theft audit, which discussed the Postal Service’s and Postal Inspection Service’s strategic and technical solutions to address mail theft and combat carrier robberies occurring across the nation.  

What We Did

Our objective was to evaluate the Postal Service’s and the Postal Inspection Service’s progress on its mail theft strategy, including actions taken in response to our 2023 report. To assess the effectiveness of the agencies’ mail security processes, we also examined controls over arrow keys — often a target in carrier robberies and used to commit mail theft — and collection box security and management at several Postal Service facilities within associated Postal Inspection Service divisions. 

What We Found

In response to our 2023 report, the Postal Inspection Service finalized its Mail Theft strategy and developed standard operating procedures to define its Mail Theft Analytics Program. The Postal Service also developed a plan to acquire and deploy enhanced security measures to replace outdated technologies. While we found that these actions improved some policies, operations, and decision making related to mail theft, greater controls are needed to protect the mail and employees. Specifically, we found many of the same deficiencies identified in prior OIG reports regarding arrow key inventory, scanning, safeguarding, and reporting processes, and we identified a need to increase oversight of arrow key accountability training completion. We also found that collection box system data was not always accurate, the condition of collection boxes should be improved, and updated security information was not always shared internally.

Recommendations and Management Comments

We made four recommendations to address the findings and management agreed with recommendations 1, 3, and 4 but disagreed with recommendation 2. Management’s comments and our evaluation are at the end of each finding and recommendation. Regardless of the disagreement with recommendation 2, we consider management’s comments responsive.

We audited the U.S. Department of Housing and Urban Development (HUD), Federal Housing Administration (FHA) Claims Without Conveyance of Title (CWCOT) program.  We selected this review to assist HUD in recovering improper payments and to reduce the risk of losses to the FHA insurance fund. The objective of our audit was to assess whether HUD is appropriately demanding and collecting improper payments identified for CWCOT loans by its Mortgagee Compliance Manager (MCM).  

We found that HUD has not been making demands for or collecting repayment of improper payments identified by the MCM contractor during its CWCOT reviews.  As a result, HUD paid improper claims and failed to recapture more than $10.5 million determined to be owed.  CWCOT’s review is critical for HUD to receive reimbursement from lenders for its improper payments, in turn preserving and protecting the FHA insurance fund.
 

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

The Tennessee Valley Authority’s (TVA) Enterprise Risk Management (ERM) business unit focuses on identifying and prioritizing enterprise risks.  Annually, ERM leads the preparation of an enterprise risk portfolio, which includes risks across TVA, to aid leadership in strategic and business planning processes.  Each business unit includes their specific risks in the portfolio and documents the probability of occurrence, financial impact, and actions to manage the risk.  TVA Labor Relations included Lack of Robust Pathways and Pipelines to Support Workforce Readiness and Availability risk in the fiscal year 2025 ERM risk portfolio. The risk description stated, "Failure to take swift and strategic action to develop and execute a comprehensive and holistic workforce strategy could result in our inability to take on new projects, innovate sustainable technology, and continue to deliver on TVA's mission."  The actions to address the risk included apprentice recruitment and utilization measures, the establishment of a workforce development team and portal, and an hourly layoff process.  Due to the importance of workforce readiness and availability, we conducted an audit to determine if TVA was taking planned actions and measuring the impact of completed actions. 

We determined TVA has taken actions to address the workforce readiness risk. TVA Labor Relations has completed 13 of 14 mitigating actions identified for this risk.  However, we determined TVA was not effectively measuring the impact of completed actions on the risk’s probability of occurrence and financial impact. In addition, some risk information was not documented accurately.