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 Eastern Colorado Health Care System in Aurora. 

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

The OIG issued 10 recommendations for VA to correct identified deficiencies in three domains:
   1.    Environment of care
     •    Liquid nitrogen storage
     •    Expired supplies
     •    Multidose medication labels
     •    Clean and dirty storage
     •    Repeat findings
   2.    Patient safety
     •    Test result communication policy and workflows
     •    Radiology staffing
     •    Community care imaging results
     •    Root cause analyses
   3.    Primary care
     •    Staffing and panel sizes

Fiscal Year 2025 Financial Statement Audit Letter to Management

Our Objective(s)To perform a quality control review (QCR) of Allmond & Company, LLC's (Allmond) management letter related to the audit of the National Transportation Safety Board's (NTSB) financial statements for fiscal year 2025. We reviewed Allmond's management letter, dated January 7, 2026, and related documentation.
About This ReportWe contracted with the independent public accounting firm Allmond to audit NTSB's financial statements. Allmond also issued a management letter discussing internal control matters that Allmond was not required to include in its audit report.
What We FoundThe independent auditor, Allmond, found five internal control matters in NTSB's management of operations:

Financial statements and footnotes did not comply with Office of Management and Budget financial reporting requirements,
Improvements needed in internal controls relating to the processing and review of employee benefit assignments,
Improvements needed in internal control relating to performance of property inventories,
Improvements needed in processing personnel actions, and
Accounts payable accrual calculation duplicated expenses that were separately accrued.

Our QCR disclosed no instances in which Allmond did not comply, in all material respects, with U.S. generally accepted Government auditing standards.
RecommendationsWe agree with Allmond's nine recommendations to help strengthen NTSB's internal controls.

The VA OIG is required to report to Congress on the accuracy of VA’s annual special disabilities capacity report, which documents the department’s capacity to provide specialized treatment for veterans with spinal cord injuries and disorders, traumatic brain injuries, blindness, prosthetics and sensory aids, or mental health issues. 

Regarding the FY 2023 capacity report, the OIG team identified data inaccuracies and omissions. VA reported the wrong spending data for traumatic brain injury when it included obligations instead of expenditures data. VA also did not report traumatic brain injury spending data at the geographic service area and national levels as required. Further, the OIG found that blind rehabilitation bed data were not reported by geographic service area as required but were reported nationally. The capacity report also did not capture data on the services that veterans received through community care or the extent to which bed capacity was used at VA’s centers for spinal cord injuries and disorders.

As the OIG reported previously, VA cannot meet the requirement to compare its mental health capacity with 1996 levels as federal law requires because of changes in defining and tracking treatment outcomes of veterans with mental illness. The OIG continues to believe that such reporting would not provide Congress with assurances that VA’s capacity is adequate to provide care to these high-risk veterans. Finally, some medical facilities’ transitions to VA’s new electronic health record system have affected the completeness of some reported data elements at facility, regional, and national levels. The OIG notes that VA could give Congress insight into annual trends by correcting the data differences to define the measures consistently for comparability across facilities or by reporting capacity data separately for facilities using the new system.

Our Objective(s)To perform a quality control review (QCR) of Allmond & Company, LLC's management letter related to the audit of the Great Lakes St. Lawrence Seaway Development Corporation's (GLS) financial statements for fiscal year 2025. We reviewed Allmond's management letter, dated January 7, 2026, and related documentation.
About This ReportWe contracted with the independent public accounting firm Allmond & Company, LLC to audit GLS's financial statements. Allmond also issued a management letter discussing internal control matters that Allmond was not required to include in its audit report.
What We FoundThe independent auditor, Allmond, found five control deficiencies in GLS's internal controls over financial reporting:

Review of fund balance with treasury reconciliation did not identify errors and omissions,
Complementary user entity controls were not properly designed and implemented for the use of service organization systems,
Non-capitalized assets are not located during the performance of the annual property inventory,
Recording of transactions relating to prior year activity did not use the appropriate general ledger accounts for error corrections,
Accounts payable balance was incomplete.

Our QCR disclosed no instances in which Allmond did not comply, in all material respects, with U.S. generally accepted Government auditing standards.
RecommendationsWe agree with Allmond's 9 recommendations to help strengthen GLS's internal controls over financial reporting.