Federal Reports

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.

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 to meet marketplace needs; 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 (OIG) 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.

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.

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.

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. 

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. 

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.