Federal Reports

The OIG’s Mental Health Inspection Program evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on the inpatient mental health care delivered at the James A. Haley Veterans’ Hospital (facility), part of VA Tampa Healthcare System in Florida. 

The facility met some VHA requirements for inpatient mental health units, such as an established Interdisciplinary Safety Inspection Team and completion of twice-yearly environment of care inspections. The facility had a mental health executive council but did not have veteran representation. Additionally, the facility did not meet the requirement for a standard operating procedure for staff training, education, and the implementation of recovery-oriented services on the unit.  

Facility leaders did not have formal written processes to monitor and track compliance with state involuntary commitment requirements. Staff completed the required documentation of legal commitment status and informed consent medication discussions. Not all inpatient staff completed suicide prevention or annual environmental safety hazards trainings.  

Most reviewed electronic health records included evidence of suicide risk screenings and safety plans. Safety plans did not address ways to make the veteran’s environment safer from potentially lethal means beyond firearms and opioids. Discharge instructions included difficult to understand language and lacked important details for appointment location follow-up.  

The OIG observed a recovery-oriented culture and veteran-centric care through staff’s presence and engagement with veterans on the inpatient unit. While veterans had unrestricted access to a day room and a large outdoor space, bedrooms lacked recovery-oriented elements such as calming paint colors. 

VA concurred with the OIG’s seven recommendations; the OIG closed two recommendations based on information provided. The Facility Director agreed to implement a range of corrective actions, including strengthened staff training, ensuring formalized written processes, and improved documentation practices to support safe, recovery-oriented mental health care on the inpatient unit. 

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 Beckley Healthcare System in West Virginia. 

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

The OIG issued no recommendations.

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.

An Amtrak extra board train attendant based in Seattle, Washington, was terminated from employment on February 23, 2026, following his administrative hearing. Our investigation found that the former employee violated company policies by misrepresenting his role at the company to two individuals, inappropriately seeking their personal identifying information, and sending internal company information to outside parties. The former employee is not eligible for rehire.