Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Syracuse VA Medical Center (facility) to assess allegations of reduced clinical services, poor leadership communication, and staff resignations. The OIG also identified concerns about patient transfer delays and oversight of infrastructure requirements.

The OIG substantiated that clinical services were reduced. The former Facility Director closed the neurosurgery program without submitting a required clinical restructuring request, bypassing national oversight. Facility leaders allowed contracts for infectious disease and endocrinology services to lapse and did not implement contingency plans upon the lapses. The OIG also substantiated eight physicians resigned due to clinical service reductions and deficient communication. Further, coverage requirements of the facility’s complexity designation were not met, which reduced the availability of clinical services. Although the OIG did not identify any adverse patient outcomes, the OIG is concerned about the potential risk.

Facility leaders did not have a process to monitor patient transfer timeliness; therefore, the OIG was unable to determine if delays occurred. Veterans Integrated Service Network and facility leaders also did not provide compulsory oversight of facility infrastructure requirements, increasing risks to patient care. 

In response to the OIG’s recommendations, the Acting Under Secretary for Health outlined plans for communicating expectations for infrastructure deficiency waivers. The Interim Veterans Integrated Service Network Director committed to evaluating circumstances that led to facility leaders not following clinical restructuring requirements as well as ensuring accurate infrastructure reviews. The Interim Facility Director also reported plans to verify accurate infrastructure reviews, enhance communication strategies, and examine contracting and patient transfer processes.

USDA OIG'S objective was to determine whether Food and Nutrition Service has taken actions to secure IT hardware to effectively prevent Supplemental and Nutrition Assistance Program (SNAP) benefit theft through card skimming, card and terminal cloning, and other similar fraudulent methods.
 

The VA Office of Inspector General (OIG) identified a potential patient safety risk related to the Veterans Health Administration’s (VHA’s) use of generative artificial intelligence (AI) chat tools for clinical care and documentation. Generative AI creates new, original content by learning patterns from existing data.  During a national review initiated on October 16, 2025, the OIG found that VHA lacks a formal process to report, track, and respond to safety issues associated with generative AI use. Not having a process precludes a feedback loop and a means to detect patterns that could improve AI tools used in clinical settings.

VHA authorizes two general-purpose AI chat tools, VA GPT and Microsoft 365 Copilot Chat, for use with patient health information. These tools rely on clinical prompts. The output from an AI chat tool can be used to support medical decision-making and copied into the electronic health record. However, generative AI can produce inaccurate outputs, which may affect diagnosis and treatment decisions.

VHA Directive 1050.01(1) requires the Office of Quality Management and the National Center for Patient Safety (NCPS) to provide oversight of VHA quality programs and VHA patient safety programs. Interviews with leaders from VHA’s NCPS and National AI Institute and the Office of Information Technology’s Chief AI Officer team revealed that generative AI chat tools deployment occurred without coordination with NCPS. The OIG is concerned about VHA’s ability to promote and safeguard patient safety.

The OIG continues to monitor this issue and will include further analysis in its final report.

Background

The U.S. Postal Service paid out more than $866 million in resolution of almost 3.5 million grievance payments from fiscal years (FY) 2022-2024. Grievances are typically complaints lodged by individual employees or unions about the implementation or interpretation of collective bargaining and local agreements concerning wages, hours, and conditions of employment.

What We Did 

Our objective was to evaluate the Postal Service’s management of grievances. We analyzed data from various Postal Service systems to identify trends, risk areas, and anomalies. We reviewed 25 facilities and labor relations offices in eight districts and conducted interviews with management and employees at those locations to gain an understanding of their grievance payments.

What We Found

Although total grievance payments nationwide trended slightly downward from FYs 2022-2024, some districts and facilities incurred high payment amounts or experienced significant increases in payments. Grievance issues related to overtime and improper work assignments accounted for some of the most significant and recurring grievance payments nationwide. In addition, field management entered into binding local agreements with unions that contained escalating remedies, did not always align with current operational needs, and did not have defined end or revision dates. Lastly, management did not always maintain a standardized, centralized repository that contained local agreements and did not consistently complete all required elements of decision letters in the Grievance and Arbitration Tracking System for payments.

Recommendations and Management’s Comments 

We made eight recommendations for the Postal Service to improve its management of grievances, reduce recurring grievances, clarify policy, and improve tracking. Postal Service management agreed with seven and disagreed with one. We consider management’s comments responsive to recommendations 1, 2, 3, 4, 5, 7, and 8, and will pursue recommendation 6 through the audit resolution process. Management’s comments and our evaluation are at the end of each finding and recommendation.