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 Durham VA Health Care System. This evaluation focused on five key content domains:
   •    Culture
   •    Environment of care
   •    Patient safety
   •    Primary care
   •    Veteran-centered safety net

The OIG issued 11 recommendations for improvement in two domains:
1.    Environment of care
   •    High-alert medications in a secure or locked area
   •    Expired medical supplies and clean supply areas
   •    Cleaning and disinfection
   •    Safety of crossing area
   •    Accurate directories
   •    Navigational features for sensory-impaired veterans
   •    Staff communication with sensory-impaired veterans
   •    Environment of care trends
2.    Patient safety
   •    Joint Patient Safety Reporting system
   •    Communication and follow-up for urgent, noncritical abnormal test results
   •    Patient safety trends

The VA OIG contracted with the independent public accounting firm CliftonLarsonAllen LLP (CLA) to audit VA’s financial statements as of the end of fiscal years (FYs) 2024 and 2023. CLA provided an unmodified opinion and noted material weaknesses and significant deficiencies in internal control and instances of noncompliance with laws and regulations. Regarding internal control, CLA identified three material weaknesses. A material weakness is a deficiency, or combination of deficiencies, in internal control over financial reporting such that there is a reasonable possibility that a material misstatement of the entity’s financial statements will not be prevented or detected and corrected on a timely basis. CLA also identified three significant deficiencies. A significant deficiency is a deficiency, or combination of deficiencies, in internal control over financial reporting that is less severe than a material weakness yet important enough to merit attention by those charged with governance.

CLA is responsible for the attached audit report dated November 15, 2024, and the conclusions expressed in the report. The OIG does not express opinions on VA’s financial statements, internal control, or compliance with FFMIA, nor does the OIG express conclusions on VA’s compliance with laws and regulations. The independent auditors will follow up on these internal control and compliance findings and evaluate the adequacy of corrective actions taken during the FY 2025 audit of VA’s financial statements.

The U.S. Postal Service’s mission is to provide timely, reliable, secure, and affordable mail and package delivery to more than 160 million residential and business addresses across the country. The U.S. Postal Service Office of Inspector General (OIG) reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission.