Federal Reports

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

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the North Florida/South Georgia Veterans Health System to assess an allegation that a patient was “misled” by staff and incorrectly involuntarily admitted to the inpatient mental health unit, and that VA staff actions led to the patient's disengagement from VA mental health care and eventual death by suicide. The OIG reviewed the patient's care in accordance with the Veterans Health Administration (VHA) policy and Florida Mental Health Act (the Baker Act), which provides criteria for involuntary mental health care. The OIG identified deficiencies in staff adherence and leaders’ oversight pertaining to VHA policy and the Baker Act, but was unable to determine whether a change in care would have altered the patient’s outcome.The OIG substantiated that system staff admitted the patient under involuntary status despite the patient’s request for voluntary admission and that staff incorrectly applied the involuntary inpatient Baker Act examination hold criteria.The OIG found that during outpatient mental health appointments prior to admission, the patient was not offered evidence-based psychotherapy for posttraumatic stress disorder (PTSD) or informed of available treatment options. The OIG determined that turnover in mental health providers was a contributing factor in the patient's decision to withdraw from mental health care and that despite the patient voicing concerns about being involuntarily admitted, staff did not document a response to the patient’s concerns, likely contributing to feelings of being “misled” by staff.

The attached final report summarizes Ernst & Young LLP’s (Ernst & Young) review of the information technology security controls of common control providers. Under a contract the Office of Audit monitored, Ernst & Young, an independent certified public accounting firm, reviewed the security of common control providers. Ernst & Young interviewed Social Security Administration staff and management and reviewed evidence the Agency provided.

In March 2021, the Veterans Benefits Administration (VBA) began transitioning to a Digital GI Bill platform designed to improve education benefits delivery. The original plan called for implementing the new platform through a contractor for 10 years at a projected cost of $453 million. The VA Office of Inspector General (OIG) conducted this audit to assess VBA’s progress in implementing the platform.The OIG found VBA encountered delays due to unclear contract requirements and unrealistic expectations. The original contract required VA to provide three test environments by October 2022, but resource and infrastructure limitations resulted in only one test environment, which was undergoing testing in January 2024. Further, the platform relies on the decommissioning of older systems such as the Benefits Delivery Network (BDN); however, BDN’s decommissioning has been pushed back from September 2023 to as late as spring 2025, which will delay platform completion and may increase costs.The OIG found VBA did not follow the Government Accountability Office’s best practices for a project’s integrated master schedule, which plots a project’s entire scope. Until February 2023, the platform project had no overall master schedule, and once one was established, it was not consistently shared with the contractor. The OIG also found that poor communication contributed to failures in the critical path—a schedule’s continuous sequence of activities—that resulted in delays and increased costs.VBA has renegotiated the original contract, further delaying implementation and increasing project costs by $479 million, more than doubling the original contract to $932 million.The OIG made three recommendations to the under secretary for benefits to increase the chances of successful implementation under the new contract through better monitoring, stronger communication with the platform contractor, a consistent and updated master schedule, strategies to address critical path failures, and a clear timeline.