Federal Reports

Our Objective(s)To assess FHWA's process for approving Advanced Transportation Congestion Management Technologies Deployment Reimbursements grant program (ATCMTD) disbursements by reviewing and verifying that program disbursements are supported and valid.
Why This AuditFHWA's ATCMTD grant program reimbursed its grant recipients approximately $89 million from fiscal years 2021 to 2023 to improve safety, efficiency, system performance, and infrastructure return on investment. To protect Federal grant funds from misuse, it is key that FHWA has strong financial management and sufficient oversight of the ATCMTD program.
What We FoundFHWA approved direct recipients' ATCMTD reimbursement requests without always validating the sufficiency of supporting documentation.

The effectiveness of FHWA's ATCMTD financial oversight relies on the Agency reviewing direct recipients' supporting documentation prior to approving reimbursement requests for payment.
For one ATCMTD direct recipient in our sample, there was not enough detail in the supporting documentation to support almost $1.9 million in reimbursements.
FHWA's quarterly reports, used to validate ATCMTD direct recipients' supporting documentation for reimbursement requests, did not identify that $1.9 million in costs were not adequately supported.
FHWA's Office of Acquisition and Grants Management made $1.9 million in payments for unsupported costs.

FHWA does not sufficiently monitor State DOTs' oversight and internal controls for validating ATCMTD reimbursement requests.

FHWA's Stewardship and Oversight agreements largely delegate financial oversight to State DOT ATCMTD grant recipients but the Agency must maintain sufficient internal control processes to validate State DOTs are adhering to fiscal expectations.
However, FHWA was not aware there was insufficient information for approving officials to verify costs State DOTs submitted for our six sampled reimbursements. Also, State DOTs in our sample were not maintaining supporting documentation on all ATCMTD reimbursement requests as required by their Stewardship and Oversight Agreements.

RecommendationsWe made 5 recommendations to strengthen FHWA oversight of ATCMTD reimbursement requests.

The U.S. Department of Education administers the Individuals with Disabilities Education Act (IDEA), which authorizes formula grants to States under Part B to assist them in meeting the excess costs of providing special education and related services (services) to children ages 3 through 21 with disabilities. Most of the Federal funds provided to States must be passed on to local educational agencies (LEA). Federal funds are combined with State and local funds to provide a free appropriate public education to children with disabilities. Under IDEA, a free appropriate public education is provided through an individualized education program (IEP) based on the individual needs of the child. Omaha Public Schools (Omaha), the largest LEA in Nebraska, was awarded approximately $15.3 million in IDEA Part B funds for school year 2023–2024. We conducted an inspection to determine whether Omaha designed and implemented sufficient processes for overseeing the development of IEPs for children with disabilities and ensuring that those children receive the services described in their IEPs. The inspection covered Omaha’s processes in these areas from July 1, 2023, through June 30, 2024. We found that Omaha generally designed and implemented sufficient processes for overseeing the development of IEPs and ensuring that children with disabilities receive the services as described in their IEPs. However, there were a small number of instances where IEPs and related documentation did not show that all applicable IEP requirements were met or that students received all of the services described in their IEPs.  When documentation is lacking or does not exist, stakeholders do not have sufficient assurances that the IEP teams considered all required elements when developing the IEPs, the IEPs contained all required information, or all services described in the IEPs were provided to children with disabilities. We made two recommendations to improve Omaha’s oversight of IEP development and documentation of IEP services provided.

The OIG’s Mental Health Inspection Program (MHIP) evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on inpatient care delivered at the Martinsburg VA Medical Center (facility) in West Virginia. 

The facility met some VHA requirements for inpatient mental health units, including aspects of a recovery-oriented physical environment, such as artwork and natural lighting, and a plan for continued transformation to recovery-oriented services. However, the facility did not include veteran representation on its Mental Health Executive Council and did not have a full-time local recovery coordinator. Recovery-oriented, interdisciplinary programming also did not consistently occur as scheduled.

The OIG identified ongoing communication issues between facility executive and mental health leaders, including executive leaders being unaware of pertinent information related to mental health staffing and processes. Staff did not perform involuntary holds or admissions due to leaders’ incorrect interpretation of West Virginia state law, and the Veterans Integrated Service Network (VISN) did not identify that the facility’s involuntary hospitalization policy was inconsistent with state laws.

Electronic health records indicated that reviewed safety plans did not consistently address making the veteran’s environment safer from potentially lethal means, and staff did not consistently document medication risk and benefit discussions. Discharge instructions were typically difficult to understand, lacking important details for medication management. 

The OIG observed safety hazards, such as unapproved window coverings in most bedrooms and potentially unsafe equipment in a shower room. The OIG also found shower room monitoring practices could compromise veterans’ privacy and dignity. 

VA concurred with the OIG’s 16 recommendations. The VISN Director committed to ensuring establishment of state-compliant involuntary hold procedures. The Facility Director agreed to implementing a range of corrective actions, including enhanced leadership oversight, expanded veteran engagement, strengthened staff training, and improved coordination and documentation practices to support safe, recovery-oriented mental health care.

The VA Office of Inspector General (OIG) issued this preliminary result advisory memorandum to report significant suicide hazards identified during an on-site inspection of inpatient mental health units at the VA Boston Healthcare System in Brockton, Massachusetts, conducted November 18–19, 2025. The inspection revealed multiple environmental risks that pose a serious threat to patient safety, particularly the presence of anchor points and other objects that could facilitate self-harm.

The OIG observed several high-risk features inconsistent with the safety standards outlined in VHA Directive 1167 and the Mental Health Environment of Care Checklist. These included:
     •    toilets not securely mounted to both floor and wall, with removable seats creating potential anchor points;
     •    exposed plumbing that could be used for hanging or other forms of self-harm;
     •    sink faucets and handles lacking required tapered or rounded designs, increasing risk of ligature use;
     •    cabinet door handles with protrusions that could serve as anchor points; and
     •    unsecured medical equipment and cords, which were long enough to pose strangulation hazards.

These deficiencies were identified across four inpatient mental health units housing 111 authorized beds. The presence of such hazards represents a critical vulnerability in the facility’s suicide prevention infrastructure.

Following immediate notification to facility leaders between November 18–20, 2025, interim mitigation measures were implemented. These included removal of select hazardous items, initiation of 15-minute patient safety checks, staff education on environmental risks, and enhanced observation protocols. Facility staff conducted a formal risk assessment to guide long-term corrective actions.

The OIG continues to oversee the facility’s response and will provide a full analysis in the final inspection report. Given the seriousness of the issue and similar concerns identified at other facilities, these findings are being shared broadly to prompt proactive hazard mitigation across other VHA facilities.