Federal Reports

In accordance with the Reports Consolidation Act of 2000, OIG is submitting a statement on what it considers to be the most significant management and performance challenges facing the Peace Corps. At Peace Corps OIG, we base this statement on the following: our audit, evaluation, and investigative work; our knowledge of the Peace Corps’ activities and operations; and the insights of agency senior leaders who provide their perspectives and expertise. For fiscal year (FY) 2026, we identified the following challenge areas:  Volunteer Delivery System; Volunteer Health and Safety; Human Capital Management; and Information Technology Security Management.

Addressing the issues related to these challenge and performance areas will enhance the agency’s operational efficiencies, minimize potential fraud, waste, and abuse, and improve mission effectiveness.

We found that the company has started upgrading its maintenance facilities to support its major fleet acquisitions, but challenges in planning and managing this effort have delayed its progress. As a result, some facilities will not be ready in time to service the company’s new trains, which could hinder its ability to fully operate the new equipment at their intended service levels. Instead, the company may need to store some new trains intermittently, which could postpone the capture of additional revenue. Further facility delays—which remain a risk—would add to the existing delays in fully operating its new fleets.

Two factors contributed to these circumstances. First, the company’s facility planning has significantly lagged behind its fleet planning despite the two efforts being closely interconnected. Second, the company is separately managing dozens of facility projects rather than managing them as a single, coordinated effort, as called for by company and industry standards.

We recommended that the company continue to develop a joint strategic fleet/facilities plan that defines company goals, timelines, and next steps. We also recommended that the company develop a management framework for its facility upgrades, including a risk management process.

Background

Business mailers accounted for approximately $16.2 billion of the Postal Service’s revenue through marketing and other large-scale mailings, of which $9.4 billion (58 percent) was generated through the PostalOne! application in fiscal year 2024. PostalOne! provides business mailers with a web-based alternative to manual business mail acceptance processes and interfaces with 45 different Postal Service systems to provide mailers a streamlined process for mail entry, payment, tracking, and reporting. As such, it is critical that changes to PostalOne! are communicated and managed effectively to avoid disruptions in service.

What We Did

Our objective was to determine whether the Postal Service appropriately implemented and communicated changes to PostalOne!.

What We Found 

The Postal Service generally communicated PostalOne! changes to mailers effectively by using available resources—such as websites, alerts, briefings, and meetings—and made further improvements to communications with mailers. Further, although the Postal Service mostly followed its approved processes for change and problem management, opportunities exist to improve these processes. Specifically, the Postal Service can improve closure of changes, closure of high and critical incident tickets, and after-action reporting of incidents. Strengthening controls in the management of changes to PostalOne! can improve customers’ ability to use the application and reduce potential security risks.

Recommendations and Management’s Comments

We made four recommendations for the Postal Service to improve its change request processes, resolution of critical and high incident tickets, and after-action reporting and management agreed with all four. We consider management’s comments responsive to all four recommendations as corrective actions should resolve the issues identified in the report. Management’s comments and our evaluation are at the end of each finding and recommendation.

We substantiated allegations that Signal Peak Energy submitted false invoices and information to ONRR.

The OIG’s Mental Health Inspection Program (MHIP) evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on inpatient care delivered at the Martinsburg VA Medical Center (facility) in West Virginia. 

The facility met some VHA requirements for inpatient mental health units, including aspects of a recovery-oriented physical environment, such as artwork and natural lighting, and a plan for continued transformation to recovery-oriented services. However, the facility did not include veteran representation on its Mental Health Executive Council and did not have a full-time local recovery coordinator. Recovery-oriented, interdisciplinary programming also did not consistently occur as scheduled.

The OIG identified ongoing communication issues between facility executive and mental health leaders, including executive leaders being unaware of pertinent information related to mental health staffing and processes. Staff did not perform involuntary holds or admissions due to leaders’ incorrect interpretation of West Virginia state law, and the Veterans Integrated Service Network (VISN) did not identify that the facility’s involuntary hospitalization policy was inconsistent with state laws.

Electronic health records indicated that reviewed safety plans did not consistently address making the veteran’s environment safer from potentially lethal means, and staff did not consistently document medication risk and benefit discussions. Discharge instructions were typically difficult to understand, lacking important details for medication management. 

The OIG observed safety hazards, such as unapproved window coverings in most bedrooms and potentially unsafe equipment in a shower room. The OIG also found shower room monitoring practices could compromise veterans’ privacy and dignity. 

VA concurred with the OIG’s 16 recommendations. The VISN Director committed to ensuring establishment of state-compliant involuntary hold procedures. The Facility Director agreed to implementing a range of corrective actions, including enhanced leadership oversight, expanded veteran engagement, strengthened staff training, and improved coordination and documentation practices to support safe, recovery-oriented mental health care.

The VA Office of Inspector General (OIG) issued this preliminary result advisory memorandum to report significant suicide hazards identified during an on-site inspection of inpatient mental health units at the VA Boston Healthcare System in Brockton, Massachusetts, conducted November 18–19, 2025. The inspection revealed multiple environmental risks that pose a serious threat to patient safety, particularly the presence of anchor points and other objects that could facilitate self-harm.

The OIG observed several high-risk features inconsistent with the safety standards outlined in VHA Directive 1167 and the Mental Health Environment of Care Checklist. These included:
     •    toilets not securely mounted to both floor and wall, with removable seats creating potential anchor points;
     •    exposed plumbing that could be used for hanging or other forms of self-harm;
     •    sink faucets and handles lacking required tapered or rounded designs, increasing risk of ligature use;
     •    cabinet door handles with protrusions that could serve as anchor points; and
     •    unsecured medical equipment and cords, which were long enough to pose strangulation hazards.

These deficiencies were identified across four inpatient mental health units housing 111 authorized beds. The presence of such hazards represents a critical vulnerability in the facility’s suicide prevention infrastructure.

Following immediate notification to facility leaders between November 18–20, 2025, interim mitigation measures were implemented. These included removal of select hazardous items, initiation of 15-minute patient safety checks, staff education on environmental risks, and enhanced observation protocols. Facility staff conducted a formal risk assessment to guide long-term corrective actions.

The OIG continues to oversee the facility’s response and will provide a full analysis in the final inspection report. Given the seriousness of the issue and similar concerns identified at other facilities, these findings are being shared broadly to prompt proactive hazard mitigation across other VHA facilities.