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 Spokane Healthcare System in Washington. 

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

The OIG issued one recommendation for VA to correct identified deficiencies in one domain:
   1.    Environment of care
     •    Clean and soiled utility item storage, cleanliness, and expired item disposal
 

VA can authorize veterans to receive care in the community in specific circumstances. After the care occurs, the community provider must return associated medical records to VHA and community care staff close the consult. If records are not received, staff must administratively close consults (that is, update the status from “open” to “complete”) to indicate the veteran received care and make three requests for the records within 90 days of the appointment. The VA OIG reviewed whether VHA staff took appropriate action to retrieve and document medical records from community providers and import the records into veterans’ electronic health records.

The OIG found that, as of December 16, 2024, VHA closed nearly 3 million community care consults for appointments scheduled to occur between October 1, 2023, and April 1, 2024. Among these, over 2.4 million (82 percent) had medical records attached, and nearly 1 million were administratively closed (34 percent). In addition, for the same period, VHA had 71,447 open consults, virtually all of which were more than 90 days beyond the scheduled appointment date.

According to the OIG’s analysis, 62 facilities imported 90 percent or more of medical records for completed community care consults into veterans’ electronic health records. However, 11 facilities imported the records less than 60 percent of the time.

Staff said competing priorities reduced the amount of time available to request and process incoming records. Once records were received, community care staff did not always use the Consult Toolbox to document the receipt, and related policy was both unclear and inconsistently used. Furthermore, VHA facilities varied in meeting timeliness metrics.

VHA concurred with the OIG’s 10 recommendations (including concurrence in principle to recommendation 2) to direct the Office of Integrated Veteran Care to correct identified deficiencies related to processes, internal controls, timeliness, and oversight.

The U.S. Consumer Product Safety Commission (CPSC) OIG retained Williams, Adley, & Co.-DC LLP (Williams Adley, we), an independent public accounting firm, to perform the independent assessment of the CPSC’s implementation of FISMA for FY 2025 and to determine the effectiveness of its information security program. This report documents the results of the OIG’s FISMA evaluation. Specifically, we assessed the CPSC’s compliance with the annual Inspector General (IG) FISMA reporting metrics set forth by the DHS and OMB. 

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 Central Ohio Health Care System in Columbus. 

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

The OIG issued three recommendations for VA to correct identified deficiencies in three domains:
   1.    Culture
     •    Standardized process for service-level communication
   2.    Environment of care
     •    Clean patient areas and intact walls
   3.    Veteran-centered safety net
     •    Housing and Urban Development–Veterans Affairs Supportive Housing program resources