Federal Reports

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

The VA Home Loan Guaranty program is meant to help veterans finance the purchase of homes with favorable loan terms. Veterans typically pay a funding fee to defray the cost of administering the program; however, veterans who receive VA service-connected disability compensation are exempt from paying it. If veterans receive a disability determination with an effective date for receiving benefits before their loan closing date, they are entitled to a refund of any funding fee. As a result of the PACT Act, many veterans became eligible to receive refunds for the funding fees they had paid on home loans before receiving their disability compensation.

The audit team found deficiencies with funding fee refunds for veterans using dual entitlement (two or more veterans using some or all of their combined eligible loan benefits) on joint loans and also noticed that some veterans exempt from paying funding fees were inappropriately charged at their loan closings. The team estimated that 250 veterans were entitled to a funding fee refund due to either lenders’ errors at closing or retroactive disability determinations between October 1, 2021, and September 30, 2024. The estimated average for the refunds for the 250 veterans was $6,100, totaling $1.5 million during the review period. In the OIG’s sample, the range for these refunds was about $2,200 to $10,800 per veteran. The OIG determined that the Loan Guaranty Service’s automated system improperly charged a funding fee.

The VA Office of Inspector General made two recommendations to improve processes. The acting principal deputy under secretary for benefits, performing the delegable duties of the under secretary for benefits, concurred.

This report summarizes the oversight work performed by EAC OIG during the 6-month period ended September 30, 2025.

Background

The U.S. Postal Service manages over 31,000 facilities nationwide, both owned and leased. Regular maintenance is critical to keeping these spaces safe and operations efficient. The Postal Service spent about $5.5 billion on facility repairs between 2014 and 2024. However, in 2024, it reported a growing backlog of maintenance issues totaling approximately $20 billion.

What We Did

Our objective was to assess the effectiveness of the Postal Service’s process to identify, manage, and address its deferred maintenance. We analyzed maintenance calls and repair data and conducted site visits.

What We Found

The Postal Service did not consistently define and manage deferred maintenance and lacked accurate cost estimates to effectively prioritize resources. This occurred because it did not establish a common framework to track all deferred maintenance or ensure data integrity. As a result, the Postal Service projected $20 billion in deferred maintenance using limited definitions and data. Conversely, the U.S. Postal Service Office of Inspector General (OIG) created a more granular estimate of $13 billion using available data consisting of reported issues and current cost approximations — a baseline example for the Postal Service as it improves its data. We also identified $1.1 million in paid invoices where work was not completed. 

We additionally identified unreported maintenance issues during site visits and from required assessments. This occurred because staff did not understand the importance of their role in reporting facility issues, and the Postal Service did not sufficiently oversee its assessment program. As a result, maintenance issues went undetected, limiting visibility into facility conditions. Without a comprehensive understanding of the total scope of deferred maintenance, the Postal Service cannot accurately estimate future maintenance funding needs. Promoting a culture of timely reporting and resolution of maintenance needs can help prevent minor problems from escalating.

This report details the Office of Inspector General's Fall 2025 - Semiannual Report to Congress. The following topics are included:

• Overview of the SBA and the OIG
• Summary of OIG Oversight Work
• Small Business Access to Capital
• Disaster Assistance Program
• Contracting and Counseling Programs
• Agency Management
• Other Significant OIG Activities
• OIG Hotline
• Organizational Overview
• Appendices

Why We Did This Report

Under the provisions of the Inspector General Act of 1978 (Public Law 95-452), as amended, the U.S. Environmental Protection Agency Office of Inspector General reports to the Congress semiannually on its activities. 
 

Summary

This report summarizes EPA Office of Inspector General work and accomplishments from April 1, 2025 to September 30, 2025.

National Credit Union Administration (NCUA) Office of Inspector General (OIG) Semiannual Report to the NCUA Board and the Congress highlighting our accomplishments and ongoing work for the 6-month period ending September 30, 2025.

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.

This audit was performed by the independent public accounting firm KPMG LLP (KPMG) on behalf of the Department of Energy Office of Inspector General. KPMG audited the balance sheet of the Department Nuclear Waste Fund (NWF), as of September 30, 2025, and the related statements of net cost, changes in net position, and budgetary resources for the year then ended.

The audit’s objective was to obtain reasonable assurance about whether the financial statements, as a whole, are free from material misstatement, whether due to fraud or error, and to issue an auditors’ report that included an opinion.

KPMG performed the audit in accordance with generally accepted government auditing standards.

KPMG concluded that the financial statements present fairly, in all material respects, the financial position of the NWF as of September 30, 2025, and its net costs, changes in net position, and budgetary resources for the year ended, in accordance with U.S. generally accepted accounting principles.

As part of its review, KPMG also considered the NWF’s internal control over financial reporting and tested for compliance with certain provisions of laws, regulations, contracts, and grant agreements that could have a direct material effect on the financial statements. The review identified certain deficiencies in internal control that KPMG considered to be a significant deficiency as it related to internal controls over information technology systems. During testing of the NWF’s various financial systems, KPMG identified access control deficiencies associated with controls over provisioning of new or modified user access, recertification of existing user access, and terminating of user access. Furthermore, control deficiencies were identified over providing least privileged access and segregation of duties.

There were no formal recommendations for this particular review. As such, there was no formal response required.

This audit was performed by the independent public accounting firm of KPMG LLP (KPMG) on behalf of the Department of Energy Office of Inspector General. KPMG audited the balance sheet of the Department’s Federal Energy Regulatory Commission, as of September 30, 2025, and the related statement of net cost, changes in net position, custodial activity, and statement of budgetary resources for the year then ended.

The audit’s objective was to obtain reasonable assurance about whether the financial statements, as a whole, are free from material misstatement, whether due to fraud or error, and to issue an auditors’ report that included an opinion.

KPMG performed the audit in accordance with generally accepted government auditing standards.

KPMG concluded that the financial statements present fairly, in all material respects, the financial position of the Federal Energy Regulatory Commission as of September 30, 2025, and its net cost, changes in net position, custodial activity, and budgetary resources for the year then ended, in accordance with U.S. generally accepted accounting principles. KPMG also considered the Federal Energy Regulatory Commission’s internal control over financial reporting as part of their review and did not identify any deficiency in internal control over financial reporting that is considered a material weakness. KPMG tested for compliance with certain provisions of laws, regulations, contracts, and grant agreements that could have a direct material effect on the financial statements. The results of the auditors’ review disclosed no instances of noncompliance or other matters required to be reported under Government Auditing Standards, applicable Office of Management and Budget guidance, or the Federal Financial Management Improvement Act of 1996.

There were no formal recommendations for this particular review. As such, there was no formal response required.

DFC is at a pivotal juncture. The Trump administration has established government-wide priorities centered on making America safer, stronger, and more prosperous. To help advance these goals, DFC has been tasked with significant new responsibilities. These responsibilities include partnering with Ukraine on the United States–Ukraine Reconstruction Investment Fund and focusing investments in new sectors, such as nuclear energy technology, artificial intelligence, and drone technology. Further, DFC faces reauthorization and current proposals call for dramatically increasing the Corporation’s contingent liability and expanding the use of equity, among other changes.

In addition to new responsibilities, DFC has experienced leadership turnover. DFC did not have a permanent CEO for most of 2025, 3 and its public sector board members and politically appointed leadership are new to DFC. DFC also experienced a 25 percent workforce reduction with many employees retiring or taking the administration’s deferred resignation program. Thus, the Corporation must position itself to take on new responsibilities and prioritize investments in new sectors with fewer staff. This year’s Top Management Challenges identifies three key items DFC should consider: (1) Updating the Strategic Plan Due to Changes in Priorities and Leadership; (2) Developing a Strategic Workforce Plan; and (3) Streamlining the Origination Process. Addressing these challenges will help DFC achieve its mission.

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 Tennessee Valley Healthcare System in Nashville. 

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

The OIG issued two recommendations for VA to correct identified deficiencies in one domain:
   1.    Environment of care
     •    Preventive maintenance
     •    Permanent biomedical engineering chief and repeat environment of care findings

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

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

The OIG issued three recommendations for VA to correct identified deficiencies in one domain:
   1.    Environment of care
     •    Feminine hygiene products
     •    Secure medications
     •    Equipment inspection dates

This document discusses EAC OIG's planned oversight activities for fiscal year 2026.

The VA Office of Inspector General (OIG) reviewed aspects of community care utilization at the VA Boston Healthcare System for fiscal year 2024. The system, part of Veterans Integrated Service Network 1, includes three VA medical centers and several outpatient clinics. VA direct care (provided at VA facilities) and VA community care (delivered by providers in the community paid by VA) were compared.

The patient population consists of 58,324 patients who received medical care at the system or through community care paid for by the system. Nearly all received primary and mental health care through VA direct care. About 97 percent of patients received specialty care services exclusively through VA direct care. Inpatient community care accounted for 12 percent of acute care bed-days. Most community care referrals were requested due to drive times.

The OIG assessed referral processes, appointment timeliness, and use of disqualified providers for community care services. About 83 percent of direct and 84 percent of community care referrals were activated within two days. Appointment setting met timeliness standards in 55 percent of direct and 53 percent of community care referrals. Over 90 percent of referrals were completed within 90 days of the requested date. However, some referrals lacked documentation of scheduled appointments.

The OIG found no community care referrals for primary care and less than 3 percent for mental health care. About 66 percent of mental health and 61 percent of specialty care community appointments met timeliness standards. No disqualified providers were found. 

In response to three recommendations, the System Director concurred with two recommendations and described enhancing reports of metrics for scheduling, completed appointments, wait times, and facility access and identifying opportunities to improve and refine practices. The System Director concurred in principle with one recommendation and committed to educating staff on consult documentation practices.

In keeping with its responsibilities under the Inspector General Act of 1978, as amended, the OIG monitored the audit of TVA's fiscal year 2025 financial statements performed by Ernst and Young LLP (EY) to assure their work complied with Government Auditing Standards. Our review of EY's work disclosed no instance in which the firm did not comply in all material respects with Government Auditing Standards.

Under a contract monitored by the OIG, KPMG, an independent certified public accounting firm, performed an audit of the NCUA’s schedule of accounts receivable, net (other than intragovernmental) and other taxes and receipts as of and for the period ended September 30, 2025. KPMG conducted the audit in accordance with auditing standards generally accepted in the United States of America, in accordance with the standards applicable to financial audits contained in Government Auditing Standards issued by the Comptroller General of the United States, and in accordance with OMB Bulletin No. 24-02, Audit Requirements for Federal Financial Statements. Those standards and OMB Bulletin No. 24-02, require that KPMG plan and perform the audit to obtain reasonable assurance about whether the schedule is free from material misstatement. 

We contracted with the independent public accounting firm RMA Associates, LLC (RMA) to audit the consolidated financial statements of the United States International Development Finance Corporation (DFC) for the fiscal year ended September 30, 2025, report on internal control over financial reporting, and report on compliance with laws and other matters. The contract required the audit to be performed in accordance with U.S. generally accepted auditing standards, Office of Management and Budget audit guidance, and the Government Accountability Office’s and Council of the Inspectors General on Integrity and Efficiency’s Financial Audit Manual. 

In its audit of DFC, RMA reported 

• the consolidated financial statements were fairly presented, in all material respects, in accordance with U.S. generally accepted accounting principles;

• no material weaknesses1 and no significant deficiencies2 in internal control over financial reporting; and 

• no reportable noncompliance with provisions of laws tested and other matters. 

RMA is responsible for the attached auditor’s report dated November 14, 2025 and the conclusions expressed therein. We do not express opinions on DFC’s consolidated financial statements, or report on internal control over financial reporting, or report on compliance and other matters.

We performed an audit of costs billed to the Tennessee Valley Authority (TVA) by Kiewit Power Constructors Company (Kiewit) under Contract No. 13156 for work performed in support of TVA’s coal combustion residual conversion program.  Our audit objective was to determine if the costs billed to TVA were in accordance with the contract’s terms.  Our audit scope included approximately $133.7 million in costs billed to TVA between January 1, 2023, and September 30, 2024.

In summary, we determined Kiewit overbilled TVA $51,251, including (1) $24,192 in ineligible fee and general and administrative costs, of which $8,097 was due in part to contradictory language in the contract, (2) $15,957 in a duplicate materials cost, and (3) $11,102 in incorrect craft labor costs. We also determined Kiewit billed TVA for reimbursement of temporary living allowance (TLA) costs that were not supported.  Specifically, Kiewit billed TVA an average of $4,396 per month per employee for TLA.  However, Kiewit only provided documentation supporting an average of $2,310 per month per employee in TLA costs incurred. Based on our analysis and Kiewit’s inability to provide documentation supporting the full amount of TLA costs it incurred, we have referred this matter to the Office of the Inspector General Investigations for further review.  In addition, we noted opportunities to improve contract administration by TVA related to (1) tax exemption requests, (2) craft labor rate schedules that did not match the Project Labor Agreement, and (3) TLA employee certification forms that were not notarized as required by the contract. 

The Office of the Inspector General (OIG) performed the procedures, which were requested and agreed to by Tennessee Valley Authority management solely to assist management in determining the validity of the Winning Performance (WP)/Executive Annual Incentive Plan measures for fiscal year (FY) ending September 30, 2025.  Tennessee Valley Authority management is responsible for the WP measures data provided. In summary, procedures applied by the OIG found the:

• FY 2025 WP goals for the enterprise measures were properly approved.
• Actual FY to-date results for the enterprise measures agreed with the underlying support, without exception.
• FY 2025 WP, Executive Annual Incentive Plan, and Chief Executive Officer payout percentages provided by the Enterprise Financial and Performance Reporting organization on October 31, 2025, were mathematically accurate and agreed with the OIG’s recalculation.

The Occupational Safety and Health Administration states that establishing a safety and health program is one of the most effective ways of protecting workers.  The Tennessee Valley Authority (TVA) Standard Programs and Processes (SPP) 18.004, Contractor Safety Management, establishes the contractor safety program and defines oversight requirements for managed task contractors and subcontractors working on TVA-owned-or-controlled sites to meet state and federal safety and health regulations.  

TVA-SPP-18.004 outlines several contract pre-mobilization requirements, including requiring all contractors to submit a Site-Specific Safety and Health Plan (SSSHP), which should adequately identify hazards inherent to the work environment and address safe-work practices based on the scope of work identified in the contract.  In addition, the process requires (1) a TVA Contractor Oversight Representative (COR) be assigned as the single point of contact for providing appropriate technical direction and oversight of work performed by each contractor and (2) TVA Safety to conduct audits of contractor safety performance.  Due to the importance of the health and safety of personnel working at TVA sites, we performed an evaluation of TVA’s oversight of contractor safety.

We determined TVA was not providing adequate oversight of contractor safety in accordance with the contractor safety program.  While some oversight was provided through tracking and trending of contractor safety performance, there were several areas that were not adequate.  Specifically, TVA (1) could not provide completed SSSHPs for some contracts, (2) could not identify the COR for most of the contracts we reviewed or provide documentation that some of their responsibilities were being performed, and (3) did not perform safety audits as required.

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

An Electronic Specialist based in Boston, Massachusetts, resigned from her position on November 4, 2025, as a result of our investigation. We found that she violated company policies by misusing her rail pass privileges to provide pass travel tickets to unauthorized passengers. Our investigation identified 20 tickets booked in the employee’s name that were used by third parties while the employee was at work.

Letter to Office of Management and Budget regarding OIG’s fiscal year 2024 risk assessment for the Government Charge Card Abuse Prevention Act of 2012

Memorandum to the Chairman of the Board regarding OIG’s fiscal year 2024 risk assessments for the Government Charge Card Abuse Prevention Act of 2012

The Tennessee Valley Authority (TVA) operates four coal plants, which are required to comply with the Clean Air Act (CAA).  In 2023, changes to the CAA required the reduction of nitrogen oxide (NOx) from power plants.  To comply with the changes, TVA made the decision to install Selective Catalytic Reduction (SCR) systems at TVA’s Shawnee Fossil Plant (SHF) for Units 2, 3, 7, and 8 and entered into a $59.5 million contract for the design and delivery of SCR systems (SCR systems are emission control technology designed to remove NOx from flue gases emitted by combustion sources).  The contract included performance guarantees for meeting metrics such as NOx emissions, and system pressure drop.  Due to the importance of complying with environmental regulations and the cost of the project, we initiated an evaluation to determine whether performance guarantees were met for the SHF SCR project. 

We determined metrics associated with performance guarantees for the SHF SCR project were met.  However, TVA project support personnel performed the SCR tuning, which was a defined contractor responsibility.  This resulted in unnecessary risk and additional cost to TVA.

Quinton Johnson, a former Amtrak employee from Irvington, New Jersey, pleaded guilty on October 28, 2025, in U.S. District Court, District of New Jersey, to conspiracy to commit health care fraud. As a result, the court ordered Johnson to forfeit all property, real or personal, in the amount of $4,900. Our investigation found that Johnson and codefendants allowed health care providers to use their insurance information to bill Amtrak’s health care plan for false and fraudulent claims and for services that were not provided or medically unnecessary. In exchange, Johnson and codefendants accepted cash kickbacks worth thousands of dollars from the health care providers.

Judicial proceedings for the codefendants in this investigation are ongoing.

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

We substantiated allegations that an operator placed safety systems in bypass and did not immediately notify BSEE of the subsequent oil discharge. 

The Office of the Inspector General performed an audit of the Tennessee Valley Authority’s (TVA) Unmanned Aircraft Systems (UAS) Program due to the increased use of unmanned aircraft in TVA operations.  Our audit objectives were to determine if TVA's (1) UAS Program was in compliance with applicable federal requirements and (2) use of unmanned aircraft was in compliance with applicable TVA policies.  Our audit scope included TVA's use of unmanned aircraft from January 1, 2024, through December 31, 2024.

In general, we determined TVA's (1) UAS Program complied with applicable federal requirements and (2) use of unmanned aircraft complied with applicable TVA policies.  However, we determined 2 of 64 pilots did not have the remote pilot certificate required to operate UAS.  We made one recommendation to management to address verification of remote pilot certificates.

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

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

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

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 Louisville Healthcare System in Kentucky. This evaluation focused on five key content domains:
•    Culture
•    Environment of care
•    Patient safety
•    Primary care
•    Veteran-centered safety net

The OIG issued 13 recommendations for VA to correct identified deficiencies in four domains:
1.    Culture
•    Telephone system improvements
2.    Environment of care
•    Exit signs
•    Detectable warning surfaces
•    Clean and safe patient care areas
•    Electrical cord management
•    Biological hazard signs
•    Biohazardous waste disposal
•    Liquid nitrogen use and storage
•    Environment of care trends, improvement plans, and outcome measures
3.    Patient safety
•    Service-level workflows for test result communications
•    Test result communication policy
•    Test result communication performance metrics
4.    Primary care
•    Panel sizes

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess care concerns and inadequate quality reviews related to a patient’s death at the VA Greater Los Angeles Healthcare System (facility). The OIG determined that clinical staff did not timely recognize, address, and investigate changes in the patient’s clinical condition. Although the outcome may not have changed, not recognizing an emerging condition hindered clinical staff considering modifications to the plan of care and discussing the course of action with the patient and family.

The OIG identified several factors that contributed to staff not recognizing the patient’s deterioration and intervening accordingly. The resident physician ordered laboratory tests, but neither the resident nor attending physician reviewed or acted upon the patient’s abnormal laboratory values. The resident ordered stat imaging studies to assess abdominal pain and evaluate for infection; however, the resident, attending, and nursing staff did not ensure imaging completion.

Nurses missed early warning signs of the patient’s deteriorating condition by not conducting National Early Warning Score (NEWS) assessments as required or intervene, as expected, with elevated NEWS scores. Nurses did not complete shift assessments within the required time frames. The OIG identified an 11-hour gap in nursing documentation before the patient’s death. Nurses lacked accurate on-call provider contact information and attempts to reach the on-call provider to address the patient’s pain were unsuccessful.

Facility leaders did not conduct a comprehensive review of the events that occurred prior to the patient’s death and were unsuccessful in their attempts to conduct an institutional disclosure with the patient’s family.

The Facility Director concurred with and submitted action plans to address the OIG’s seven recommendations related to comprehensive reviews of the patient’s care, NEWS assessment training, nursing assessment compliance, patient care escalation processes, and disclosure efforts.

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 Detroit Healthcare System in Michigan. 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 VA to correct identified deficiencies in one domain:
1.    Environment of care
•    Damaged furnishings
•    Maps for navigation
•    Clean equipment storage
•    Unobstructed hallways and exits
•    Defective equipment removal
•    Computer screen privacy filters

The VA Office of Inspector General (OIG) issued this preliminary result advisory memorandum to communicate a serious patient safety risk related to acute ischemic stroke (AIS) management at the Wm. Jennings Bryan Dorn VA Medical Center (facility) in Columbia, South Carolina. During a healthcare inspection, the OIG found that the facility’s AIS practices did not align with Veterans Health Administration (VHA) or facility policy, resulting in delays in diagnosis, evaluation, treatment, and disposition of patients with stroke symptoms. These concerns were shared with Veterans Integrated Service Network and facility leaders during a site visit on August 28, 2025, prompting immediate interim corrective actions.

To promote proactive risk mitigation across the enterprise, the OIG is broadly sharing this preliminary finding with other VHA facilities.

VHA Directive 1155(1) requires VA medical centers to maintain a protocol for emergent stroke management. The OIG found that the facility’s actual practices contradicted its own policy, which outlined a code stroke protocol, stroke team responsibilities, emergency department evaluation for all suspected AIS cases, and use of the VA National Telestroke Program. In practice, inpatient units lacked a stroke team or code stroke protocol, and patients were not transferred to the emergency department or evaluated by telestroke neurologists unless already in the emergency department.

The OIG observed a case in which intensive care unit staff failed to promptly respond to a suspected stroke, resulting in delayed imaging, neurology evaluation, and transfer to a community stroke center. The absence of a clear transfer protocol further hindered timely care.

During the site visit, the OIG advised facility leaders to take corrective actions by September 5, 2025. The facility has since developed a new standard operating procedure, initiated staff training, and plans to revise its policy. The OIG will continue monitoring progress and include full findings in the final report.

The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered throughout Readjustment Counseling Service (RCS).

This inspection evaluated leadership stability, morbidity and mortality reviews, and the high risk suicide flag (HRSF) SharePoint site within Midwest District 3. 

There were no findings in leadership stability. The morbidity and mortality review identified that district leaders did not ensure reviews had the required RCS panel members and contained all required components. The HRSF review identified noncompliance with documentation requirements for high-risk client contacts and outcomes in both RCSNet and the HRSF SharePoint site. This noncompliance was attributed to unclear or insufficient guidance provided to staff. The OIG issued two recommendations for improvement to the District Director and one recommendation to the Chief Officer. 

An Amtrak Trackman/Watchman based in Wilmington, Delaware, was terminated from employment on October 14, 2025, following an administrative hearing. Our investigation found that the employee violated company policies by shipping baggage on Amtrak trains while traveling by other means, driving a company-leased vehicle without a valid license, using his company-leased vehicle for personal travel, and leaving work without authorization. The employee also violated company policy by being dishonest with our agents during his interview.