Federal Reports

The audit objectives were to determine whether program funds were managed in accordance with the ARC and Federal grant requirements.

Why We Did This Report

The Inspector General Act of 1978, as amended, requires each inspector general to prepare semiannual reports for Congress. As part of that reporting, the inspector general must identify all recommendations from the prior reporting period for which corrective actions have not been completed by the agency, as well as any management decisions with respect to audit, inspection, or evaluation reports issued during that prior reporting period.

Summary of Findings

For this compendium, we compiled recommendations that we had reported as resolved in the semiannual report to Congress that we issued on May 30, 2025. These 80 recommendations were originally issued to the EPA over a span of more than 15 years, from fiscal year 2008 through fiscal year 2024. As of May 31, 2025, 78 of those recommendations remained open, representing $43.3 million in potential cost savings. Of these 78 recommendations, 43 recommendations, with $33.3 million in potential cost savings, remained open after three years or will be older than three years by their expected completion dates. Additionally, 15 recommendations that were issued in reports between July 2022 and May 31, 2025, remain unresolved. We also identified 13 recommendations, 12 resolved and one unresolved, with potential monetary benefits of nearly $865.8 million, that we deem as high priority.

The OIG conducted this review after receiving a hotline allegation that the 2024 emergency department expansion and renovation at the Audie L. Murphy Memorial Veterans’ Hospital in San Antonio, Texas, did not meet standards. Some exam rooms were said to put patients at risk because the rooms were not equipped for urgent care.

The OIG confirmed the allegation. Fast-track exam rooms, used to quickly assess and treat patients with minor injuries or illnesses, did not have permanent medical air, oxygen, and vacuum outlets, nor did all the rooms have acceptable exam lights. In addition, in one room the contractor failed to install the required plumbing for permanent medical air, oxygen, and vacuum lines. The deficiencies occurred in part because the VHA directive guiding minor construction projects did not incorporate the legal requirement that the director of the Office of Construction and Facilities Management (CFM) manage and oversee the project. Other factors included the contractor’s use of the wrong template to design fast-track rooms and the project engineer’s approval of the room that lacked required plumbing.

When fast-track rooms and procedural and general exam rooms lack the necessary equipment for emergency care, patient care may be delayed while healthcare professionals locate portable equipment. VA officials agreed with the OIG’s four recommendations to ensure processes and guidance are in place for the CFM to provide appropriate oversight and management over minor construction projects, revise the VHA directive on minor construction projects to incorporate legal requirements, review emergency department exam and fast-track rooms for compliance with standards, and review a CFM assessment of emergency department for compliance with design and equipment requirements.

In its fiscal year (FY) 2009 budget request, VA identified the need for the Palo Alto major construction project to improve seismic safety at the Palo Alto Health Care System. The planned construction project would also provide ambulatory and polytrauma care. Over the next 15 years, the project’s cost and timeline increased. The OIG conducted this review to evaluate the significant events that led to cost increases, schedule slippages, and scope changes for the major construction project.

The OIG found VA has still not achieved two of its three critical project objectives and is more than 21 years behind its original schedule. As of February 2025, about $458.8 million had been spent on the project. Furthermore, because VA did not provide adequate justification for a significant scope increase proposed in the FY 2012 budget, the OIG questioned the expenditure of about $716.6 million. To proceed with the project, VA will need a total of about $1.6 billion.

Cost increases and delays occurred because VA did not have adequate formal procedures for governing major construction projects from 2009 to 2017. The OIG could not obtain evidence that the Palo Alto project was ever added to the Acquisition Program Management Framework, as required. VA must consider whether it is worth continuing the project or canceling efforts to complete it. Should VA be unable to justify the business need to continue funding the project, the OIG determined taxpayers could save about $907.8 million.

The OIG made four recommendations to the VA Secretary including ensuring the project is brought into the Acquisition Program Management Framework and ensuring a decision is made about the project’s future. VA concurred with the OIG’s recommendations.

Dragonfly, a rotorcraft lander that will fly like a large drone, isdesigned to gather samples from Saturn’s moon Titan, characterize Titan’s habitability, and look for precursors of the origin of life. However, the project has undergone multiple replans impacting cost and schedule, resulting in a life-cycle cost increase of nearly $1 billion and over 2 years of delays.