Federal Reports

In 2020, the Department of Energy implemented Department Order 486.1A, Foreign Government Sponsored or Affiliated Activities (Order), which prohibits Department and Laboratory employees from participating in foreign Government-sponsored talent recruitment programs and restricts other foreign Government-sponsored activities or affiliated activities with a foreign country of risk.

We initiated this inspection to determine if the Department and its National Laboratories are complying with the Order.

We determined that the Department and its National Laboratories did not consistently comply with Department Order 486.1A requirements. Specifically, we found issues surrounding reporting disclosures, and the submission and review of quarterly disclosure reports. Additionally, we found that the Federal Oversight Advisory Body did not adhere to the Order.

If the Department and its National Laboratories are not consistently complying with the Order, then U.S. competitive and national security interests and Department program objectives may not be protected; potential conflicts of interest may arise; and the unauthorized transfers of scientific and technical information may occur.

We have made five recommendations that, if fully implemented, should help ensure that the issues identified in this report are corrected.
 

The Veterans Access, Choice, and Accountability Act (VACAA) of 2014 and VA Choice and Quality Employment Act (VCQEA) of 2017 requires the VA Office of Inspector General (OIG) to determine, annually, a minimum of five clinical and five nonclinical Veterans Health Administration (VHA) occupations with the largest staffing shortages within each VHA medical center (facility). Pursuant to this requirement, the OIG conducted a review to identify those severe staffing shortages by occupation. The OIG also compared the number of severe occupational staffing shortages against the previous seven years’ reports to assess changes.

The OIG surveyed VHA-identified facility points of contact to determine severe occupational staffing shortages at each facility. Among the most significant findings in this year’s staffing report were the following:
•    In fiscal year (FY) 2025, VHA facilities reported a total of 4,434 severe occupational staffing shortages, a 50 percent increase from FY 2024 in which facilities reported 2,959 total shortage occupations.
•    Ninety-four percent of facilities reported severe occupational staffing shortages for Medical Officer occupations, and 79 percent of facilities reported severe shortages for Nurse occupations.
•    Psychology was the most frequently reported severe clinical occupational staffing shortage and also the most frequently reported Hybrid Title 38 severe shortage occupation, with 57 percent of facilities reporting it as a shortage.
•    Police was reported as a shortage by 58 percent of facilities, making it the most frequently reported severe nonclinical occupational staffing shortage and the most frequently reported of all occupations.
•    All 139 VHA facilities identified staffing shortages.

VACAA and VCQEA established authority for the VA Secretary to grant VHA the authority to waive veterans’ preference requirements for external applicants to Hybrid Title 38 occupations, expanding the candidate pool for these occupations based on severe shortages.

The OIG made no recommendations.

The U.S. Postal Service needs effective and productive operations to fulfill its mission of providing prompt, reliable, and affordable mail service to the American public. It has a vast transportation network that moves mail and equipment among approximately 315 processing facilities and 31,200 post offices, stations, and branches. The Postal Service is transforming its processing and logistics networks to become more scalable, reliable, visible, efficient, automated, and digitally integrated. This includes modernizing operating plans and aligning the workforce; leveraging emerging technologies to provide world-class visibility and tracking of mail and packages in near real time; and optimizing the surface and air transportation network. The U.S. Postal Service Office of Inspector General reviews the efficiency of mail processing operations at facilities across the country and provides management with timely feedback to further the Postal Service’s mission. 

This report presents the results of our audit of the efficiency of operations at the St. Louis Processing and Distribution Center in St. Louis, MO. We selected the St. Louis area based on congressional inquiries from U.S. senators and representatives from Missouri and Illinois to conduct an audit of post offices and distribution centers in the St. Louis metro area.

The U.S. Postal Service’s mission is to provide timely, reliable, secure, and affordable mail and package delivery to more than 160 million residential and business addresses across the country. The U.S. Postal Service Office of Inspector General reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission. 

This interim report presents the results of our audit of delivery operations and property conditions at the Maryville Gardens Station in St. Louis, MO. We selected the St. Louis area based on a congressional inquiry issued April 1, 2025, from U.S. senators and representatives from Missouri to conduct an audit of post offices and distribution centers in the St. Louis metro area. The Maryville Gardens Station is in the Kansas-Missouri District of the Central Area and serves ZIP Codes 63104, 63111, and 63118. These ZIP Codes serve about 63,912 people in predominantly urban communities.

The U.S. Postal Service’s mission is to provide timely, reliable, secure, and affordable mail and package delivery to more than 160 million residential and business addresses across the country. The U.S. Postal Service Office of Inspector General reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission. 

This interim report presents the results of our audit of delivery operations and property conditions at the Clayton Branch in St. Louis, MO. We selected the St. Louis area based on a congressional inquiry issued April 1, 2025, from the U.S. senators and representatives from Missouri to conduct an audit of post offices and distribution centers in the St. Louis metro area. The Clayton Branch is in the Kansas-Missouri District of the Central Area and serves about 28,786 people in ZIP Codes 63105 and 63117, which are considered urban communities.

The U.S. Postal Service needs effective and productive operations to fulfill its mission of providing prompt, reliable, and affordable mail service to the American public. It has a vast transportation network that moves mail and equipment among approximately 315 processing facilities and 31,200 post offices, stations, and branches. The Postal Service is transforming its processing and logistics networks to become more scalable, reliable, visible, efficient, automated, and digitally integrated. This includes modernizing operating plans and aligning the workforce; leveraging emerging technologies to provide world-class visibility and tracking of mail and packages in near real time; and optimizing the surface and air transportation network. The U.S. Postal Service Office of Inspector General reviews the efficiency of mail processing operations at facilities across the country and provides management with timely feedback to further the Postal Service’s mission. 

This report presents the results of our audit of the efficiency of operations at the St. Louis Network Distribution Center in Hazelwood, MO. We selected the St. Louis area based on a congressional inquiry issued April 1, 2025, from U.S. senators and representatives from Missouri and Illinois to conduct audits of post offices and distribution centers in the St. Louis metro area. 

The U.S. Postal Service’s mission is to provide timely, reliable, secure, and affordable mail and package delivery to more than 160 million residential and business addresses across the country. The U.S. Postal Service Office of Inspector General (OIG) reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission. 

This interim report presents the results of our audit of delivery operations and property conditions at the O’Fallon Main Post Office (MPO) in O’Fallon, MO. We selected the St. Louis area based on a congressional inquiry issued April 1, 2025, from U.S. senators and representatives from Missouri to conduct an audit of post offices and distribution centers in the St. Louis metro area. The O’Fallon MPO is in the Kansas-Missouri (KS-MO) District of the Central Area and serves about 122,121 people in ZIP Codes 63366, 63367, and 63368 which are considered predominantly urban areas (see Figure 1). Specifically, 117,632 (96 percent) live in urban communities and 4,529 (four percent) live in rural communities.

The U.S. Postal Service’s mission is to provide timely, reliable, secure, and affordable mail and package delivery to more than 160 million residential and business addresses across the country. The U.S. Postal Service Office of Inspector General reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission. 

This interim report presents the results of our audit of delivery operations and property conditions at the Southwest Station in St. Louis, MO. We selected the St. Louis area based on a congressional inquiry issued April 1, 2025, from U.S. senators and representatives from Missouri to conduct an audit of post offices and distribution centers in the St. Louis metro area. The Southwest Station is in the Kansas-Missouri District of the Central Area and serves about 48,897 people in ZIP Codes 63109 and 63139, which are considered urban areas.

The U.S. Postal Service’s mission is to provide timely, reliable, secure, and affordable mail and package delivery to more than 160 million residential and business addresses across the country. The U.S. Postal Service Office of Inspector General reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission. 

This interim report presents the results of our audit of delivery operations and property conditions at the St. Charles Main Post Office in St. Charles, MO. We selected the St. Louis area based on a congressional inquiry issued April 1, 2025, from the U.S. senators and representatives from Missouri to conduct an audit of post offices and distribution centers in the St. Louis metro area. The St. Charles MPO is in the Kansas- Missouri District of the Central Area and serves about 50,902 people in ZIP Code 63301, which is considered a predominantly urban area. Specifically, 49,662 (98 percent) live in urban communities and 1,240 (2 percent) live in rural communities.1 The unit also services ZIP Code 63302 for Post Office Box routes.

The U.S. Postal Service’s mission is to provide timely, reliable, secure, and affordable mail and package delivery to more than 160 million residential and business addresses across the country. The U.S. Postal Service Office of Inspector General reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission. 

This interim report presents the results of our audit of delivery operations and property conditions at the Creve Coeur Branch in St. Louis, MO. We selected the St. Louis area based on a congressional inquiry issued April 1, 2025, from the U.S. senators and representatives from Missouri to conduct an audit of post offices and distribution centers in the St. Louis metro area. The Creve Coeur Branch is in the Kansas-Missouri District of the Central Area and serves about 33,550 people in ZIP Codes 63124 and 63141 which are considered urban communities.

The U.S. Postal Service’s mission is to provide timely, reliable, secure, and affordable mail and package delivery to more than 160 million residential and business addresses across the country. The U.S. Postal Service Office of Inspector General reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission. 

This interim report presents the results of our audit of delivery operations and property conditions at the Ballwin Main Post Office (MPO) in Ballwin, MO. We selected the St. Louis area based on a congressional inquiry issued April 1, 2025, from U.S. senators and representatives from Missouri to conduct an audit of post offices and processing facilities in the St. Louis metro area. The Ballwin Main Post MPO is in the Kansas-Missouri District of the Central Area and serves about 94,150 people in ZIP Codes 63011 and 63021, which are considered a predominantly urban area. Specifically, 92,390 (98 percent) live in urban communities and 1,760 (2 percent) live in rural communities.

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 Spokane Healthcare System in Washington. 

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

The OIG issued one recommendation for VA to correct identified deficiencies in one domain:
   1.    Environment of care
     •    Clean and soiled utility item storage, cleanliness, and expired item disposal
 

VA can authorize veterans to receive care in the community in specific circumstances. After the care occurs, the community provider must return associated medical records to VHA and community care staff close the consult. If records are not received, staff must administratively close consults (that is, update the status from “open” to “complete”) to indicate the veteran received care and make three requests for the records within 90 days of the appointment. The VA OIG reviewed whether VHA staff took appropriate action to retrieve and document medical records from community providers and import the records into veterans’ electronic health records.

The OIG found that, as of December 16, 2024, VHA closed nearly 3 million community care consults for appointments scheduled to occur between October 1, 2023, and April 1, 2024. Among these, over 2.4 million (82 percent) had medical records attached, and nearly 1 million were administratively closed (34 percent). In addition, for the same period, VHA had 71,447 open consults, virtually all of which were more than 90 days beyond the scheduled appointment date.

According to the OIG’s analysis, 62 facilities imported 90 percent or more of medical records for completed community care consults into veterans’ electronic health records. However, 11 facilities imported the records less than 60 percent of the time.

Staff said competing priorities reduced the amount of time available to request and process incoming records. Once records were received, community care staff did not always use the Consult Toolbox to document the receipt, and related policy was both unclear and inconsistently used. Furthermore, VHA facilities varied in meeting timeliness metrics.

VHA concurred with the OIG’s 10 recommendations (including concurrence in principle to recommendation 2) to direct the Office of Integrated Veteran Care to correct identified deficiencies related to processes, internal controls, timeliness, and oversight.

The U.S. Consumer Product Safety Commission (CPSC) OIG retained Williams, Adley, & Co.-DC LLP (Williams Adley, we), an independent public accounting firm, to perform the independent assessment of the CPSC’s implementation of FISMA for FY 2025 and to determine the effectiveness of its information security program. This report documents the results of the OIG’s FISMA evaluation. Specifically, we assessed the CPSC’s compliance with the annual Inspector General (IG) FISMA reporting metrics set forth by the DHS and OMB. 

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 Central Ohio Health Care System in Columbus. 

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 three domains:
   1.    Culture
     •    Standardized process for service-level communication
   2.    Environment of care
     •    Clean patient areas and intact walls
   3.    Veteran-centered safety net
     •    Housing and Urban Development–Veterans Affairs Supportive Housing program resources

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA Southern Nevada Healthcare System (facility) in Las Vegas to analyze facility leaders’ response to allegations that a dental hygienist failed to follow Veterans Health Administration and facility policies and provide quality care. The OIG determined that supervisors did not ensure the correction of patient safety concerns related to the dental hygienist’s practice after having knowledge of the repeated concerns for approximately two years. 

A supervisor requested a factfinding, which substantiated the dental hygienist falsified a patient’s electronic health record; however, the falsification went unaddressed. The factfinding was not completed timely and, although requested, a review of two medication storage violations was not included. Additionally, a supervisor considered but did not implement a performance improvement plan to address repeated clinical practice concerns and infection control violations. 

Due to conflicting recollections, the OIG was unable to determine whether a supervisor recommended a comprehensive review of the dental hygienist’s care to the credentialing and privileging manager, which is a step in the state licensing board (SLB) reporting process. Also, on the provider exit review form, a supervisor did not accurately reflect clinical care concerns regarding the dental hygienist. An accurate form would have prompted initiation of the SLB reporting process. Further, supervisors did not ensure that patient safety reports were submitted through the Joint Patient Safety Reporting system as required. 

The OIG determined that the Chief of Staff (COS) did not consider a management review of the dental hygienist’s care after receiving a recommendation from a risk manager to conduct a management review. The COS also did not effectively utilize high reliability organization principles to become aware of the full extent of patient safety concerns regarding the dental hygienist. 

The OIG made eight recommendations to the Facility Director.

As of February 2025, NASA had allocated over $26 billion in government property to contractors in support of six Artemis programs. Although NASA has policies in place to manage its government property, the Agency can strengthen its oversight by ensuring consistent application of those policies to decrease the risk of unnecessary costs and potential loss, theft, misuse, or destruction of government property.

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

In response to a congressional request, our objective was to determine whether the fiscal year 2021 Environmental Justice Collaborative Problem-Solving, or EJCPS, Program was achieving project objectives and whether the U.S. Environmental Protection Agency’s monitoring of these projects ensured that funds were used as intended.

Summary of Findings

We were unable to determine whether the EJCPS cooperative agreements we reviewed fully achieved the project objectives described in work plans, as well as whether the EPA’s monitoring of these projects ensured that the funding was being used as intended. Specifically, (1) four of six work plans did not consistently contain well-defined measurable outputs and expected outcomes, (2) three of six recipients’ performance reports lacked details to fully measure progress, and (3) the project officers for four of six projects did not document their review of recipients’ performance reports.

This report provides the results of Objective 1, in which we determined whether the State of Pennsylvania used Food and Nutrition Service (FNS) SNAP administrative funds to provide benefits to participants.

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 Cincinnati Healthcare System in Ohio. This evaluation focused on five key content domains:
•    Culture
•    Environment of care
•    Patient safety
•    Primary care
•    Veteran-centered safety net
The OIG issued nine recommendations for VA to correct identified deficiencies in two domains:
1.    Environment of care
•    Correct deficiencies found during comprehensive environment of care inspections
•    Fire drills
•    Medical equipment inspections and maintenance labels
•    Clean patient care areas in the Emergency Department
•    Exit pathways free from obstructions
2.    Patient safety
•    Service-level workflows for the communication of test results
•    Monitoring providers’ communication of urgent, noncritical test results to patients
•    Root cause analysis actions
•    Patient safety program

On November 5, 2024, Senator Bill Hagerty requested that the OIG assess VA’s compliance with statutory transfer of funds limitations listed in relevant appropriations laws in effect during the continuing resolution. According to Senator Hagerty, the statutory transfer of funds authority and change of program requirements under the Consolidated Appropriations Act, 2024 would continue to apply during the presidential transition and continuing resolution. The OIG limited its review to the eight sections of the Consolidated Appropriations Act, 2024 that Senator Hagerty listed in a letter to the previous VA Secretary. The OIG reviewed sections 202, 217, 218, 227, 230, 231, 245, 405, and this management advisory memorandum conveys the results of the review.

The OIG found no issues with six of the eight sections. For the four sections that included transfers, the team noted that there were no applicable transfers during the review period. Additionally, VA received advanced approval for the reprogramming of major construction project funds greater than $7 million as required in section 231. The team also analyzed conversions and did not identify any that qualified for the requirements under section 245; VA confirmed no qualifying conversions occurred. While the OIG found quarterly reports provided under section 217 were late, it is not requesting action because a recommendation from a previously published OIG report in this area remains open. Finally, under section 227, the team found, in some cases, VA did not notify Congress 15 days before organizational changes that resulted in the transfer of 25 or more full-time equivalents from one organizational unit of the department to another as required. The OIG requested that the Office of Management inform the OIG what action, if any, is taken to notify Congress 15 days before any organizational changes involving the transfer of 25 or more full-time equivalents.

The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered at vet centers. This inspection report evaluated four randomly selected vet centers throughout Midwest district 3 zone 1: Fort Wayne, Indiana; Detroit and Escanaba, Michigan; and Cincinnati, Ohio.

This OIG inspection focused on four review areas: suicide prevention; consultation, supervision, and training; outreach; and environment of care. The suicide prevention review evaluated vet center staff participation in VA medical facility mental health executive council meetings, resulting in one recommendation across three of the four inspected vet centers. The consultation, supervision, and training review evaluated external clinical consultation, monthly client record reviews, and completion of select trainings resulting in two recommendations related to external clinical consultation and training across all four inspected vet centers. The outreach review evaluated outreach plan completion, inclusion of strategic components, and tailoring of outreach activities to eligible individuals, which resulted in one recommendation across all four inspected vet centers. The environment of care review evaluated vet centers’ physical environment and general safety resulting in four recommendations across all four inspected vet centers and two recommendations to the Readjustment Counseling Service Chief Officer.

The OIG issued a total of 10 recommendations for improvement.

The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered at vet centers. This inspection report evaluated four randomly selected vet centers throughout Midwest district 3 zone 3: Des Moines and Sioux City, Iowa; Kansas City, Missouri; and Rapid City, South Dakota.

This OIG inspection focused on four review areas: suicide prevention; consultation, supervision, and training; outreach; and environment of care. The suicide prevention review evaluated vet center staff participation in VA medical facility mental health executive council meetings and all four inspected vet centers were compliant. The consultation, supervision, and training review evaluated external clinical consultation, monthly client record reviews, and completion of select trainings resulting in one recommendation related to training at one of the four inspected vet centers. The outreach review evaluated outreach plan completion, inclusion of strategic components, and tailoring of outreach activities to eligible individuals, which resulted in one recommendation at three of the inspected four vet centers. The environment of care review evaluated vet centers’ physical environment and general safety resulting in three recommendations across all four inspected vet centers.

The OIG issued a total of five recommendations for improvement.
 

This report presents the results of our evaluation of the U.S. Small Business Administration’s (SBA) handling of cash contributions and gifts. We found SBA generally complied with established guidance over the solicitation, acceptance, holding, and use of cash contributions and gifts totaling $520,000 during fiscal year 2024 from National Small Business Week cosponsors. However, we found SBA should improve its agency vetting form to show that each potential cosponsor was clear of conflicts of interest concerns before agency officials signed cosponsorship agreements.

As a result of our review, the SBA Office of Strategic Alliances took immediate actions to update the form used to vet conflicts of interest for cosponsors showing the Office of General Counsel’s review and clearance of potential conflicts of interest. Therefore, we did not make any recommendations in this report.

A sheet metal worker based in Los Angeles, California, was terminated from employment on August 5, 2025, following an administrative hearing. Our investigation found that the former employee violated company policy by making profane, sexually explicit remarks to a female co-worker while on duty. Three other employees corroborated the incident. The former employee is not eligible for rehire.

NASA missions are dependent on infrastructure, including testing facilities, laboratories, and launch pads, that face the threat of extreme weather events. To address weather-related vulnerabilities of its infrastructure, NASA has integrated resilience efforts into existing processes across various Agency programs. However, this approach lacks clear communication and formal guidance, and the Agency is not effectively tracking or measuring the success of its efforts to address weather-related risks.

Our objective was to evaluate the effectiveness of the Defense Intelligence Agency’s (DIA’s) overall information security program based on DIA’s implementation of the Federal Information Security Modernization Act. We issued our results in a classified report on August 4, 2025.

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

The OIG found approximately half of the DNFSB’s planned Review Agendas for Fiscal Years 2019 through 2024 were carryovers from prior years.  Some of these carryover reviews were delayed, and in those cases, justifications for delays were not consistently recorded.  Moreover, the OIG found that the DNFSB does not have a structured Knowledge Management Program, and DNFSB Review Agenda guidance is not aligned with its current process.

The report contains three recommendations to update and improve the agency’s Review Agenda process.  

Standing Review Boards (SRB) conduct independent assessments of programs and projects and offer recommendations to improve performance and reduce risk. However, the SRB process lacks Agency-level oversight, improved SRB composition and training can add greater value to the assessments, improvements are needed to ensure adequacy of SRB engagement and accuracy of information provided to decision-makers, and the SRB process does not adequately capture lessons learned.

The VA Office of Inspector General (OIG) conducted a healthcare inspection related to the care of a resident at the Batavia community living center (CLC), a part of the VA Western New York Healthcare System (system).

In late winter 2024, Resident A was admitted to the Buffalo VA Medical Center (VAMC) for combativeness, agitation, and confusion. After the resident’s dementia-related behaviors were controlled, the resident was admitted to the Batavia CLC and received 21 doses of injectable antipsychotic medications throughout the 23-day stay. On CLC day 20, the resident’s elevated fingerstick blood sugar level was not reported to a physician for treatment and on CLC day 23, the level was more than four times the system’s upper limit of normal. The resident was admitted to a community hospital, then hospice at the Buffalo VAMC, and died shortly thereafter.

The OIG substantiated that ongoing and cumulative deficiencies, including (1) physician and nursing staff management of Resident A’s dementia and diabetes and (2) nursing documentation of medication administration and nutritional intake, may have contributed to the resident’s preventable decline in health, which necessitated end-of-life care. 

The OIG found similar deficiencies in care for a second resident and identified concerns regarding leaders’ response to clinical care deficiencies, including a failure to enter a patient safety report regarding Resident A’s elevated fingerstick blood sugar result on CLC day 20. Once aware of care concerns, system leaders’ response included temporarily removing the chief geriatric physician and initiation of clinical and administrative investigations. Further, the OIG identified deficiencies in provider staffing and nurse education that increase risk to patient safety and may have contributed to Resident A’s functional decline.

The OIG made 10 recommendations to the System Director regarding dementia and diabetes care, quality assurance performance improvement, and focused review of the chief geriatric physician’s care. 

The objective of the FY 2025 Federal Information Security Modernization Act (FISMA) audit was to determine whether the U.S. Department of Education’s (Department) overall information technology (IT) security program and practices are effective as they relate to Federal information security requirements. To determine the effectiveness of the Department’s information security program, the audit team utilized the FY 2025 Inspector General FISMA reporting metrics, which required that an independent assessor evaluate core and supplemental reporting metrics identified by the Office of Management and Budget. To properly conclude on the effectiveness of the Department’s information security program and practices, a rotational strategy was used to select five in-scope systems not evaluated in the previous year’s audit. Overall, the audit team found that the Department’s information security programs and practices were effective supporting the five in-scope systems, as nine out of 10 FISMA domains were effective, and one FISMA domain was not effective. Additionally, a total of 16 conditions were identified and 5 recommendations were made across the ten FISMA domains indicating potential areas of improvement for the Department. 

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA New Mexico Healthcare System (facility) to assess allegations and concerns related to the care of a patient who was labeled as ineligible for care and senior leaders’ associated response.

In early 2024, the patient was admitted to the facility and applied for healthcare benefits. The patient inaccurately reported income on the application, and benefits were declined. Social work staff, aware of the inaccuracies, did not ensure information was corrected. Additionally, staff attempted to arrange post-hospital services only available to eligible patients and failed to coordinate follow-up care after discharge.

In spring 2024, the patient returned to the facility, was admitted, and then discharged the same day due to being labeled as ineligible for care. The OIG did not substantiate that a podiatrist was forced to discharge the patient. However, knowledge and communication deficits contributed to the following deficiencies:
•    The emergency department provider did not follow stated practice to transfer or admit the patient. 
•    Staff missed another opportunity to update the patient’s financial information.
•    The podiatrist did not seek Chief of Staff approval to continue care at the facility or transfer the patient to a community hospital.
•    Staff did not provide an adequate discharge plan. Instead, the patient was left alone on a bench to await ambulance transport and did not receive written discharge instructions.
•    The podiatrist did not contact the community hospital to share information.
•    The nurse officer of the day failed to address a nurse’s attempt to escalate concerns.

The OIG found senior leaders did not effectively use root cause analysis processes or apply High Reliability Organization principles to assess the spring 2024 discharge. First-year podiatry residents were not supervised according to Veterans Health Administration policy.

The OIG made 15 recommendations to the Facility Director.

This is the audit of the NEA's information technology systems security. Due to security concerns, this report is not published on the internet. You can obtain a copy of this report through a freedom of information act request at the following link: https://www.arts.gov/freedom-information-act-guide

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 objective was to determine if the  Defense Nuclear Facilities Safety Board (DNFSB) is effectively managing the Drug-Free Workplace Program.  

The OIG found that the DNFSB effectively manages its Drug-Free Workplace Program to meet basic program objectives.  However, the agency should update its Drug-Free Workplace Plan to align with current practices.  The agency should also improve its internal and external communications to support more efficient program implementation and ensure that it achieves its goal of a drug-free workplace.

The report contains three recommendations to update the agency’s Drug-Free Workplace Plan, create implementation guidance, and improve communication.

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.

Evaluation of the Federal Labor Relations Authority’s Compliance with the Federal Information Security Modernization Act of 2014, Fiscal Year 2025

FISMA

We found issues with timeliness in correcting deficiencies, facility management system accuracy, emergency management, and security at Riverside. 

We found that DOI ensured that grant funds and license revenue were used for allowable activities and complied with applicable laws and requirements. 

VBA has long-standing challenges processing military sexual trauma claims and centralizing the expertise of this work. The OIG conducted this review to assess VBA’s planning and implementation of the Military Sexual Trauma Operations Center and its governance structure for processing claims.

The OIG found the center struggled to hire and retain experienced claims processors and to recruit processors with expertise in military sexual trauma claims. The center’s turnover rate in fiscal year (FY) 2024 was 22.6 percent; the nationwide rate at VA regional offices was 7.5 percent.

Although the center implemented some quality assurance processes, improvements are still needed. From FY 2019 to FY 2024, military sexual trauma claims accuracy dropped almost 10 percentage points; in response, VBA’s Compensation Service began quarterly quality spot checks. The results of the checks showed improvement in denials, but accuracy was still below the 96 percent goal. Errors included failing to get all records, insufficient medical opinions due to missed evidence, and not ordering necessary medical exams.

Further, the center’s two-signature process is not sufficient to evaluate the competency of claims processors or the competency of designated reviewers. The OIG found that about 34 percent of denied claims had errors despite a designated reviewer agreeing with the original decision. Because reviewers grant claims more often than they deny them, fewer denials than grants were reviewed in the two-signature process even though OIG and VBA quality reviews showed denied claims had more errors.

VBA concurred with the OIG’s three recommendations to adjust statistics reporting for the center, update the two-signature process to include more denials, and develop a process to assess designated reviewers’ competency.

This Office of Inspector General (OIG) Care in the Community healthcare inspection program report describes the results of a focused evaluation of community care processes at eight Veterans Integrated Service Network (VISN) 4: VA Healthcare medical facilities with a community care program. 

This evaluation focused on five domains:
   •    Leadership and Administration of Community Care
   •    Administratively Closed Community Care Consults
   •    Community Care Provider Requests for Additional Services
   •    Care Coordination Activities for Patients Referred for Community Care
   •    Community Urgent Care Coordination and Management

The OIG issued 13 recommendations for VA to correct identified deficiencies in the five domains:
   •    Leadership and Administration of Community Care
     o    Community care oversight councils
     o    Staffing tool reassessments
     o    Patient safety events
     o    Patient safety trends, lessons learned, and corrective actions
     o    Community care document importing
   •    Administratively Closed Community Care Consults
     o    Community care appointment confirmation
     o    Medical documents
   •    Community Care Provider Requests for Additional Services
     o    Request processing
     o    Approval and denial letters for community providers and patients
   •    Care Coordination Activities for Patients Referred for Community Care
     o    Community Care–Care Coordination Plan note use to document care coordination activities
     o    Appointment confirmation
   •    Community Urgent Care Coordination and Management
     o    Community Care–Urgent Care Record note creation

The OIG Audit Division conducted an audit to assess the effectiveness of GPO’s inventory management and identify opportunities for cost savings and program improvements. Our audit focused on non-moving inventory.