Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Lexington VA Healthcare System (system) in Kentucky to determine the validity of an allegation that patients seeking or receiving acute mental health treatment did not receive the care needed.

The OIG substantiated quality of care deficiencies for two patients seeking acute mental health treatment at the system. Multiple staff did not recognize one patient’s personally owned insulin pump as a potential lethal means, which allowed the patient to attempt suicide. Following the attempted suicide, leaders did not implement system-wide actions to mitigate the risk associated with insulin pumps for patients who have suicidal ideation. Additionally, a psychiatrist did not provide a second patient with emergency department discharge instructions or document care in the electronic health record (EHR) consistent with Veterans Health Administration (VHA) policy. The psychiatrist’s documentation included copied and pasted information and a derogatory, critical comment about the patient. 

The OIG determined the System Director and Chief of Staff did not ensure that quality management processes, including safety assessment scoring, a root cause analysis, and peer review, were conducted accurately and completely to address system vulnerabilities and patient safety risks for two patients.

The System Director concurred with and provided action plans for the OIG’s eight recommendations related to personally owned insulin pumps, an insulin pump policy, compliance with discharge instructions, review of a psychiatrist’s EHR entries, accuracy of safety assessment code scores, education on root cause analysis processes, and psychiatrist peer representation at the system Peer Review Committee for psychiatry case reviews. The OIG also published a separate report with one recommendation to the Under Secretary for Health to consider specific VHA guidance related to personally owned insulin pumps as a lethal means when patients are deemed at risk for suicide.

We are pleased to present our report for the period April 1, 2025, to September 30, 2025.  In this semiannual period, our audit, evaluation, and investigative activities identified more than $31.4 million in questioned costs; funds to be put to better use; recoveries, fees, and savings; and opportunities for the Tennessee Valley Authority (TVA) to improve its programs and operations.  This report also includes a feature, “40 Years of Making TVA Better,” that looks back at the last four decades—the environment TVA operated in each decade and the Inspectors General that lead our office as well as highlights some of the significant projects in each decade.

The national focus to be the leader in advancing nuclear technological innovation and artificial intelligence places TVA in a spotlight to drive and deliver additional energy sources that can both help meet growing energy demand in the Valley and set the standard for the utility industry.  This requires due diligence in areas that are emerging and have significant consequence. As TVA navigates these unprecedented times, our office will continue providing independent and object oversight that promotes effective and efficient operations and prevents and detects fraud, waste, and abuse.

The VA Office of Inspector General (OIG) issued this brief report to highlight a concern regarding the Veterans Health Administration’s (VHA’s) lack of national guidance regarding patients who use personally owned insulin pumps to manage their diabetes and present to emergency departments or inpatient units with suicidal ideation and are at risk for suicide.

This report is in response to an OIG inspection involving a patient with suicidal ideation who used a personally owned insulin pump to attempt suicide while admitted to an inpatient unit. The OIG learned that multiple clinical staff did not recognize the patient’s personally owned insulin pump as a lethal means (an object, including medication, that could be used for suicidal or self-directed violence) and did not remove the pump as a safety measure.

The OIG sought input from leaders of VHA National Emergency Medicine Office, VA Office of Specialty Care, National Endocrinology and Diabetes Program, Office of Nursing Service, Office of Suicide Prevention, and Pharmacy Benefits Management Services regarding patients using personally owned insulin pumps who present with suicidal ideation in VHA emergency departments and inpatient units. The responses confirmed there are no VHA policies or guidance specific to patients with personally owned insulin pumps and suicidal ideation.

The OIG concluded that VHA facilities would benefit from national guidance regarding staff recognition of insulin pumps as a lethal means and the management of personally owned insulin pumps for patients receiving care in emergency departments and inpatient units who have suicidal ideation and are at risk for suicide. Guidance could decrease the risk of patient harm, improve quality of care, and prevent patients from attempting suicide using a personally owned insulin pump in these settings.

The OIG made one recommendation to the Under Secretary for Health who concurred in principle and provided an action plan.

We assessed the effectiveness of the Department’s program for managing public-reported vulnerabilities in its public-facing information technology systems. We found that the Department established a vulnerability disclosure program; however, it was not fully effective. Specifically, the Department’s vulnerability disclosure policy (VDP) did not include all internet-accessible systems, the VDP’s testing guidelines restricted the tools public security researchers could use to identify system vulnerabilities, the Department did not always fully remediate reported vulnerabilities, and the Department did not always remediate vulnerabilities within established deadlines.

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the Miami VA Healthcare System in Florida. 

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

The OIG issued five recommendations for VA to correct identified deficiencies in one domain:
   1.    Environment of care
     •    Address environment of care deficiencies
     •    Preventive maintenance for medical equipment
     •    Supply storage
     •    Expired medical supplies and patient food
     •    Door signs

The Minority Business Development Agency’s (MBDA’s) Business Center program is a network of centers supporting minority business enterprises that are funded through cooperative agreements with private-sector entities, state entities, native entities, and institutes of higher education. MBDA has an oversight role to ensure that Business Centers meet the terms and conditions of their cooperative agreements and report accomplishments in a consistent, accurate manner.

We conducted this audit to follow up on a 2017 audit that found issues with how MBDA administers the Business Center program. The objective for this audit was to determine the adequacy of MBDA’s oversight of the MBDA Business Center program to ensure requirements are met.

We found significant issues with MBDA’s oversight and monitoring of its Business Center program, similar to our 2017 audit. Specifically, we found that MBDA did not (1) sufficiently monitor Business Center activities for compliance with award requirements, (2) ensure performance metrics reported by Business Centers were accurate and reliable, (3) address Business Center single audit findings, and (4) perform required Business Center site inspections. Consequently, MBDA cannot ensure that Business Centers comply with award terms and conditions. Further, MBDA cannot ensure that Business Center program goals are being met.

We recommended that MBDA consider improvements to monitoring and oversight when finalizing its plan for continuing operations as it implements Executive Order 14238.