Federal Reports

This report includes EAC OIG’s independent assessment of the top management challenges facing the EAC in fiscal year 2026.

The OIG’s Mental Health Inspection Program (MHIP) evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on inpatient care delivered at the Martinsburg VA Medical Center (facility) in West Virginia. 

The facility met some VHA requirements for inpatient mental health units, including aspects of a recovery-oriented physical environment, such as artwork and natural lighting, and a plan for continued transformation to recovery-oriented services. However, the facility did not include veteran representation on its Mental Health Executive Council and did not have a full-time local recovery coordinator. Recovery-oriented, interdisciplinary programming also did not consistently occur as scheduled.

The OIG identified ongoing communication issues between facility executive and mental health leaders, including executive leaders being unaware of pertinent information related to mental health staffing and processes. Staff did not perform involuntary holds or admissions due to leaders’ incorrect interpretation of West Virginia state law, and the Veterans Integrated Service Network (VISN) did not identify that the facility’s involuntary hospitalization policy was inconsistent with state laws.

Electronic health records indicated that reviewed safety plans did not consistently address making the veteran’s environment safer from potentially lethal means, and staff did not consistently document medication risk and benefit discussions. Discharge instructions were typically difficult to understand, lacking important details for medication management. 

The OIG observed safety hazards, such as unapproved window coverings in most bedrooms and potentially unsafe equipment in a shower room. The OIG also found shower room monitoring practices could compromise veterans’ privacy and dignity. 

VA concurred with the OIG’s 16 recommendations. The VISN Director committed to ensuring establishment of state-compliant involuntary hold procedures. The Facility Director agreed to implementing a range of corrective actions, including enhanced leadership oversight, expanded veteran engagement, strengthened staff training, and improved coordination and documentation practices to support safe, recovery-oriented mental health care.

The VA Office of Inspector General (OIG) issued this preliminary result advisory memorandum to report significant suicide hazards identified during an on-site inspection of inpatient mental health units at the VA Boston Healthcare System in Brockton, Massachusetts, conducted November 18–19, 2025. The inspection revealed multiple environmental risks that pose a serious threat to patient safety, particularly the presence of anchor points and other objects that could facilitate self-harm.

The OIG observed several high-risk features inconsistent with the safety standards outlined in VHA Directive 1167 and the Mental Health Environment of Care Checklist. These included:
     •    toilets not securely mounted to both floor and wall, with removable seats creating potential anchor points;
     •    exposed plumbing that could be used for hanging or other forms of self-harm;
     •    sink faucets and handles lacking required tapered or rounded designs, increasing risk of ligature use;
     •    cabinet door handles with protrusions that could serve as anchor points; and
     •    unsecured medical equipment and cords, which were long enough to pose strangulation hazards.

These deficiencies were identified across four inpatient mental health units housing 111 authorized beds. The presence of such hazards represents a critical vulnerability in the facility’s suicide prevention infrastructure.

Following immediate notification to facility leaders between November 18–20, 2025, interim mitigation measures were implemented. These included removal of select hazardous items, initiation of 15-minute patient safety checks, staff education on environmental risks, and enhanced observation protocols. Facility staff conducted a formal risk assessment to guide long-term corrective actions.

The OIG continues to oversee the facility’s response and will provide a full analysis in the final inspection report. Given the seriousness of the issue and similar concerns identified at other facilities, these findings are being shared broadly to prompt proactive hazard mitigation across other VHA facilities. 

This report represents our current assessment of the U.S. Small Business Administration's programs and activities that pose significant risks, including those that are particularly vulnerable to fraud, waste, error, mismanagement, or inefficiencies. The Challenges are not presented in order of priority, as we believe that all are critical management or performance issues.

The report summarizes the activity of the FEC Office of Inspector General from April 1, 2025 through September 30, 2025.

In accordance with the Reports Consolidation Act of 2000, OIG is submitting a statement on what it considers to be the most significant management and performance challenges facing the Peace Corps. At Peace Corps OIG, we base this statement on the following: our audit, evaluation, and investigative work; our knowledge of the Peace Corps’ activities and operations; and the insights of agency senior leaders who provide their perspectives and expertise. For fiscal year (FY) 2026, we identified the following challenge areas:  Volunteer Delivery System; Volunteer Health and Safety; Human Capital Management; and Information Technology Security Management.

Addressing the issues related to these challenge and performance areas will enhance the agency’s operational efficiencies, minimize potential fraud, waste, and abuse, and improve mission effectiveness.

The independent public accounting firm of McBride, Lock & Associates, LLC, under contract with the Office of Inspector General, audited Help America Vote Act (HAVA) grants administered by the Oregon Secretary of State, totaling almost $22.1 million. This included federal funds, state matching funds, interest income, and program income earned on the reissued Section 251 and Election Security grants.

The Office of Inspector General (OIG) contracted with the independent certified public accounting firm Harper, Rains, Knight, & Company, P.A. (HRK) to audit the Commission’s financial statements and related footnotes as of September 30, 2025.  The contract requires that the audit be performed in accordance with U.S. generally accepted government auditing standards Office of Management and Budget audit guidance, Government Accountability Office/Council of the Inspectors General on Integrity and Efficiency Financial Audit Manual, and Audit Requirements for Federal Financial Statements.  HRK found:

• The financial statements present fairly, in all material respects, the Commission's financial position as of September 30, 2025, and its net cost of operations, changes in net position, and budgetary resources for the fiscal years then ended in accordance with accounting principles generally accepted in the United States of America.
• One material weakness related to the Commission not having appropriate controls in place to review the validity of material financial adjustment transactions recorded by their service provider on their behalf.
  While the report includes one material weakness related to a gap in controls over financial reporting by a shared service provider, HRK’s objective was not to provide an opinion on the effectiveness of the Commission's internal control or compliance.

The Inspector General Act of 1978, as amended, requires that the Inspector General take appropriate steps to ensure that any work performed by non-Federal auditors complies with the auditing standards established by the Comptroller General. We evaluated the independence, objectivity, and qualifications of the auditors and specialists; reviewed the plan and approach of the audit; monitored the performance of the audit; sought and obtained clarification of the auditor's methodology and findings; and reviewed HRK's reports and related audit documentation.

HRK is responsible for the attached independent auditor’s report and the conclusions expressed therein. The OIG does not express opinions on the Commission’s financial statements or internal control over financial reporting, or conclusions on compliance or other matters. The audit report provides an opinion on the Commission’s financial statements and communicates reporting requirements on internal control over financial reporting and compliance with laws and regulations.