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 Connecticut Healthcare System in West Haven. 

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

The OIG issued four recommendations for improvement in three domains:
  1.    Culture
     •    Unanswered phone calls from veterans
  2.    Environment of care
     •    Performance improvement plans and outcome measures for environment of care trends
     •    Preventive maintenance for beds and stretchers
  3.    Primary care
     •    Veterans Integrated Service Network call center

We highlight the risks with how BOR administers IRA drought mitigation funds.

The U.S. AbilityOne Commission's Office of the Inspector General has issued an OIG Alert to inform Program stakeholders of recent activities of a third party. Specifically, the third party entity has published incorrect and misleading information regarding OIG activities and has insinuated that they have confidential OIG information. 

Our Objective(s)To assess the Special Crash Investigations (SCI) Program's (1) selection of crashes for investigation, (2) collection and analysis of special crash investigation data, and (3) use of this data to improve vehicle safety.
Why This AuditNHTSA estimates that 40,990 people died in motor vehicle crashes in the United States in 2023. A key component to reduce these fatalities is the SCI Program. The purpose of the SCI Program is to save lives and prevent injuries by collecting timely crash investigation information for the automotive safety community to improve the performance of advanced safety systems.
What We FoundNHTSA's SCI Program lacked a documented process to select and prioritize crashes for investigation.

The SCI Program has been successful in conducting crash investigations but lacked a documented process for selecting crashes for investigation.
The SCI Program lacked written procedures for prioritizing the crash types it investigates.

NHTSA's SCI Program procedures for collecting and analyzing special crash investigation data were insufficient.

NHTSA established an overall goal to conduct timely crash investigations and provide data that improves the performance of advanced driver safety systems. However, the Agency did not meet its timeliness goals for completing special crash investigation reports, partially due to delays in collecting crash data for analysis.
The SCI Program's procedures for retaining collected crash investigation documents did not comply with Federal Records Retention requirements.

NHTSA's SCI Program did not have a process to assess how investigation reports improve vehicle safety.

SCI Program officials pointed to examples of the positive impacts the program's investigations have had.
However, NHTSA did not have a process to formally document the extent to which special crash investigations played a role in addressing specific safety issues.

RecommendationsWe made 3 recommendations to improve NHTSA's SCI Program.