Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Western North Carolina VA Health Care System (system) to assess concerns brought forward in October 2025 by an OIG Healthcare Facility Inspection team regarding issue briefs related to sentinel events and falls at the North Carolina State Veterans Home (SVH) in Black Mountain, North Carolina (Black Mountain SVH). The OIG initiated the inspection on January 5, 2026, conducted a virtual site visit from January 20 through 22, 2026, and continued inspection activities through early February 2026.

The OIG determined facility, Veterans Integrated Service Network (VISN), and Veterans Health Administration (VHA) leaders were aware of patient safety events, including sentinel events, at the Black Mountain SVH as reported by SVH staff. From August 2024 through December 2025, facility staff completed 13 issue briefs in response to the reported patient safety events to alert VISN and VHA Geriatrics and Extended Care (GEC) leaders. Eleven of the issue briefs were related to resident falls, while two involved resident injuries unrelated to falls. The Black Mountain SVH determined 2 of the 13 events were sentinel events—resident falls resulting in injury and subsequent death—and were reported timely to the VA medical facility representative. Further, the OIG determined facility, VISN, and GEC leaders responded to SVH sentinel events as required by VHA—both sentinel event issue briefs, and associated updates, were provided to the VISN liaison for review, approval, and submission to the GEC SVH National Program Manager.

The OIG made no recommendations.

Authorized in 2007, the Advanced Research Projects Agency – Energy (ARPA-E) is a semi-autonomous agency within the Department of Energy, created to enhance the economic and energy security of the United States. Since its inception, ARPA-E has provided $4.21 billion in research and development funding to more than 1,700 projects designed to disrupt and create major shifts in the energy industry to the benefit of the U.S. In accomplishing its mission, ARPA-E funds projects in line with the U.S. manufacturing (USM) requirement, which stipulates that awardees substantially manufacture any products or processes created using Federal funds, also known as subject inventions, within the U.S.

Given the importance of the USM requirement to our national interests, we initiated this audit to determine whether ARPA-E was effectively implementing the domestic manufacturing requirement.

We found that ARPA-E could improve its oversight processes to more effectively implement the domestic manufacturing requirement. Specifically, we found that ARPA-E did not always perform site visits, as required. Further, we found that ARPA-E did not validate self-reported utilization data.

These issues occurred, in part, because ARPA-E did not always follow its policies and guidance. Further, APRA-E’s policies and guidance were limited, as it did not establish criteria for deviation from site visit expectations or prescribe documentation requirements. In addition, ARPA-E lacked policies and procedures for officials to validate utilization data related to disclosed subject inventions.

Without consistently performing and documenting site visits or validating utilization data, ARPA-E is unable to consistently apply oversight procedures related to the USM requirement.

To address the issues identified in this report, we made one recommendation that, if fully implemented, should help ensure that ARPA-E awardees are complying with the USM requirement.

Why We Did This Report

In November 2025, while planning for future grant audits, an OIG audit team could not find the 2021-2025 plan among the EPA’s online resources and inquired about it with the Office of Finance and Administration. Following that inquiry, the EPA made an updated 2021-2025 plan with changes publicly available through its grants web page. 

Summary of Findings

The updated plan does not note that the EPA changed the original publication. As a result, readers could erroneously conclude that the updated plan 1) is the same plan released by the former acting assistant administrator whose name and photograph appear on the foreword and 2) accurately reflects the message of the 21 Agency senior resource officials named in the plan.

This report provides an overview of the work of the Office of Inspector General during the period of October 1, 2025 through March 31, 2026.

The report summarizes the FTC OIG’s activities and accomplishments during the first half of the FY 2026 reporting period.

A Direct Examination (Attestation) Report to evaluate the design and implementation of the FEC’s internal control and enterprise risk management processes and determine whether the programs were operating in accordance with applicable criteria, including OMB Circular A-123, OMB Circular A-11 Section 200, the GAO Standards for Internal Control in the Federal Government (Green Book) and applicable provisions of the Government Performance and Results Modernization Act 2010 (GPRAMA), and Federal Managers’ Financial Integrity Act of 1982 (FMFIA).

Our Semiannual Report to Congress covering the period October 2025 to March 2026 highlights the OIG’s audit and investigative accomplishments during the past 6 months.