Federal Reports

A former AmeriCorps grantee staff member (“Complainant”) alleged that management at the grantee terminated the Complainant’s employment after the Complainant made a protected disclosure related to the Complainant’s concerns about the grantee’s financial management and stewardship. AmeriCorps OIG concluded that the evidence did not support the allegations of whistleblower retaliation. The grantee terminated the Complainant based on performance issues that predated any protected disclosure.

The Inspector General is pleased to present the Office of Inspector General (OIG) Oversight Plan for Calendar Year 2025. This risk-based plan intends to serve as a roadmap for the OIG’s independent and objective oversight of the U.S. AbilityOne Commission’s programs and operations through reviews, such as audits and evaluations, focused on preventing and detecting fraud, waste and abuse, and enhancing economies and efficiencies.

Throughout the oversight cycles, the OIG continues to focus on high-risk areas in the program and operations. The OIG's process to assess and prioritize the planned work included, among other factors, assessing the top management and performance challenges, congressional interests, key risks for which the Commission and other stakeholders expressed concern, and the results of our prior work. The OIG then used this information to inform the design of oversight reviews for usefulness to the Commission for its work and operations.

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 Hampton Healthcare System in Virginia. 

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

The OIG issued six recommendations for improvement in three domains:
 1.    Environment of care
   •    Accessible parking space access aisles and pavement markings
   •    Crosswalk visibility and pedestrian safety
   •    Doorway safety
   •    Hand hygiene supplies
 2.    Patient safety
   •    Communication of test results
 3.    Veteran-centered safety net
   •    Social work positions

Jacksonville State University (Jacksonville State) did not always account for and expend Federal Emergency Management Agency (FEMA) grant funds according to Federal regulations and FEMA guidelines. Specifically, Jacksonville State did not fully comply with Federal regulations and FEMA guidelines to include federally required contract provisions in its disaster contracts. Jacksonville State’s exclusion of the required contract provisions exposed FEMA funding to unnecessary risks.

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to a congressional referral regarding the care of a patient who was admitted for alcohol withdrawal and later died at the Hampton VA Medical Center (facility) in Virginia.

The OIG identified failures in the management of alcohol withdrawal symptoms of this complex patient by nursing staff and providers. Nursing staff failed to accurately and timely assess the patient’s alcohol withdrawal symptoms and consistently administer medications in adherence with the facility’s Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-AR) protocol used to determine the severity of the symptoms and clinical response. Additionally, the OIG found concerns with the timeliness of nursing staff’s electronic health records (EHR) documentation of CIWA-AR assessment scores. Delayed entries of assessment scores may affect providers’ clinical decisions. These failures may have affected the overall management of the patient’s alcohol withdrawal symptoms.

The OIG determined that facility providers failed to recognize the severity of the patient’s alcohol withdrawal. Based on past medical history and admissions, the patient was considered high risk for developing delirium, a severe form of alcohol withdrawal. According to clinical guidelines, delirium can be effectively treated with a benzodiazepine medication such as lorazepam. The OIG found one provider did not confirm the availability of lorazepam before making a clinical decision to use another medication that was not a benzodiazepine. Another provider documented symptoms suggestive of severe alcohol withdrawal but failed to identify several risk factors of severe withdrawal and treat the symptoms. These failures likely contributed to the patient not being afforded evidence-based care for prevention of delirium and severe alcohol withdrawal.

The OIG made seven recommendations to the Facility Director related to compliance with facility CIWA-AR protocol, CIWA assessment, and the management of severe alcohol withdrawal.