Featured Stories
VA IG: Review of VHA Maternity Care Coordination and Women Veterans' Experience
WASHINGTON, Aug. 17 (TNSLrpt) -- The Veterans Affairs Inspector General issued the following report (No. 24-00818-208) entitled "Review of VHA Maternity Care Coordination and Women Veterans' Experience."
Here are excerpts:
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Executive Summary
The VA Office of Inspector General (OIG) conducted a national healthcare review to assess the Veterans Health Administration's (VHA) coordination of maternity care using standards set forth in VHA Directive 1330.03(2), Maternity Health Care and Coordination.
The OIG's review included access to prenatal care, compliance with VHA maternity care coordination
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WASHINGTON, Aug. 17 (TNSLrpt) -- The Veterans Affairs Inspector General issued the following report (No. 24-00818-208) entitled "Review of VHA Maternity Care Coordination and Women Veterans' Experience."
Here are excerpts:
* * *
Executive Summary
The VA Office of Inspector General (OIG) conducted a national healthcare review to assess the Veterans Health Administration's (VHA) coordination of maternity care using standards set forth in VHA Directive 1330.03(2), Maternity Health Care and Coordination.
The OIG's review included access to prenatal care, compliance with VHA maternity care coordinationservices for pregnant and postpartum patients, and women veterans' experience. The review was initiated in August 2024 and concluded in April 2026.
In fiscal year 2025, over 740,000 women veterans used VHA for health care with approximately half being of reproductive age.2 Maternity benefits are included in the VA medical benefits package for patients enrolled in VA's health care system, as mandated by federal regulation and required by VHA policy.3 VHA provides most pregnancy-related care through community care.4 Review Results
The OIG found that VHA providers largely complied with requirements to refer patients to prenatal providers as early as possible after pregnancy was diagnosed. Seventyseven percent of patients diagnosed in the first trimester attended their first prenatal appointment with a community maternity care provider during their first trimester, indicating that VHA providers and community care coordination of maternity care referrals generally aligned with the American Academy of Pediatrics and American College of Obstetricians and Gynecologists Guidelines for Perinatal Care.
The OIG found that during the prenatal period, 88 percent of pregnant patients had contact attempts documented in the electronic health record by the maternity care coordinator at all required contact points with 73 percent being successfully contacted. However, during the postpartum period, the OIG found that only 51 percent of the patients had contact attempts documented in the electronic health record, and 24 percent were successfully contacted by the maternity care coordinator at all required contact points the year following delivery. The OIG also found that required screenings for depression, relationship health and safety, housing and food security, and alcohol use were not consistently offered to patients successfully contacted by the maternity care coordinator during the postpartum period.
To ensure timely transition of care back to VHA, maternity care coordinators are required to ensure that a postpartum appointment is scheduled within three months of delivery. The OIG found that 35 percent of patients had a VHA primary care provider visit within three months of delivery as required. Given concerns for increased maternal mortality risk during the year following delivery, coordinating timely transition of ongoing care back to the patient's VHA primary care provider is important to promote overall health and ensure any needs are addressed timely during the postpartum period.
During postpartum contacts, maternity care coordinators documented patient reports of billing concerns for 25 percent of patients, and during the OIG's limited survey of women veterans, more than 1 in 3 patients reported billing and payment concerns. This highlights VHA's need to assess processes to resolve billing issues for patients receiving VA maternity care.
The OIG made four recommendations to the Under Secretary for Health related to maternity care coordinator compliance with requirements for postpartum care patient contacts and screenings, community care billing and billing resolution processes for patients, and the scheduling and completion of postpartum primary care appointments.
The OIG will monitor implementation and focus its oversight efforts on the effectiveness and efficiencies of programs and services that improve the health and welfare of veterans and their families.
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The report is posted at: https://www.vaoig.gov/sites/default/files/reports/2026-08/vaoig-24-00818-208_final_0.pdf
VA IG: Review of Timeliness of Mental Health Community Care Appointments
WASHINGTON, Aug. 17 (TNSLrpt) -- The Veterans Affairs Inspector General issued the following report (No. 25-03623-147) entitled "Review of Timeliness of Mental Health Community Care Appointments."
Here are excerpts:
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Executive Summary
VA is authorized under the MISSION Act of 2018 to approve and pay for veterans to receive care from community healthcare providers when eligibility criteria are met.1 One type of service VA often sends to community care is mental health. Using data from mental health appointments that occurred between October 1, 2024, and September 30, 2025, the VA Office
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WASHINGTON, Aug. 17 (TNSLrpt) -- The Veterans Affairs Inspector General issued the following report (No. 25-03623-147) entitled "Review of Timeliness of Mental Health Community Care Appointments."
Here are excerpts:
* * *
Executive Summary
VA is authorized under the MISSION Act of 2018 to approve and pay for veterans to receive care from community healthcare providers when eligibility criteria are met.1 One type of service VA often sends to community care is mental health. Using data from mental health appointments that occurred between October 1, 2024, and September 30, 2025, the VA Officeof Inspector General (OIG) conducted this review to determine to what extent community care outpatient mental health appointments met the Veterans Health Administration's (VHA) timeliness standards for scheduling consults and the timeliness metrics for appointments to occur as established in VHA's Community Care Network contracts.
In December 2025, VHA announced plans to reorganize the structure of its management and operations. As of May 2026, VHA released a planned revised organization structure that includes a "Community Care Hub," a veteran-centric community care system designed to deliver timely access, accurate payments, and consistent, standardized processes for community care consults.
However, at this time, there have been no changes to the scheduling or appointment timeliness standards for community care appointments. The OIG team briefed VHA leaders responsible for overseeing community care throughout the review. These leaders did not raise concerns with the OIG's approach, conclusion, or proposed recommendations. In addition, they informed the OIG that they did not anticipate significant changes to consult processing requirements because of VHA's reorganization.
The OIG made six recommendations to the under secretary for health to improve mental health appointment timeliness. As of March 2026, VHA provided sufficient evidence that it had addressed recommendation 6; therefore, the OIG considers that recommendation closed. In June 2026, the under secretary for health concurred with four of the remaining recommendations and concurred in principle with one. Based on additional evidence provided, the OIG also closed recommendation 1. The under secretary's full response is in appendix B.
What the Review Found
Before an appointment can be made for a veteran to receive care, a VHA provider must make a request on the veteran's behalf by submitting a referral, which VHA calls a consult. Once a consult is created, VHA staff use the eligibility criteria from the MISSION Act to determine whether the veteran is eligible for community care and if so, then schedule an appointment with a community care provider. VHA has an appointment scheduling standard of seven days for community care consults, which starts with the consult creation and ends when the appointment attendance is confirmed. This standard is established in VHA Directive 1230, VHA Directive 1232, and related standard operating procedure.2 Additionally, VHA has timeliness expectations of 30 days for appointment availability established in its Community Care Network contracts with third-party administrators. These two measures--consult scheduling and appointment timeliness--apply to mental health consults and together determine the total time veterans wait for care.
The review found that persistent challenges kept VHA healthcare systems from meeting the timeliness standards for consult scheduling, while most mental health consults for community care met the appointment timeliness metrics.3 The review team evaluated consults at 133 healthcare systems and found that 128 medical centers averaged above the seven-day standard, while five medical centers met the seven-day standard in fiscal year (FY) 2025.
Meanwhile, in FY 2025, about 80 percent of mental health consults for care in the community met the metrics for the appointment to occur within 30 days. However, when the appointment dates did not meet contract metrics, veterans waited an average of 56 days to receive care. The OIG found that, when the appointment metric was not met, scheduling delays consumed much of the 30-day window. Scheduling delays were also a key driver in the 20 percent of consults whose appointments occurred after 30 days. The delays occurred in part because VHA schedulers often had to rely on telephone calls and postal mail to contact veterans; community providers did not always offer appointment types--for example, in person instead of virtual--that met veterans' preferences; and VHA schedulers sometimes had trouble contacting providers.
Improvements are needed in VHA's process for scheduling appointments for mental health consults to enable the VA to meet timeliness standards. This is especially important because veterans who receive community care services for mental health consults represent a vulnerable group who may pose a risk to themselves or others if the care they receive is not timely.
Next Steps
The OIG will monitor VHA's corrective actions and will close the remaining recommendations once VHA provides sufficient evidence that it has addressed the risks identified in this report.
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The report is posted at: https://www.vaoig.gov/sites/default/files/reports/2026-08/vaoig-25-03623-147-final_0.pdf
VA IG: Healthcare Facility Inspection of the VA Kansas City Healthcare System in Missouri
WASHINGTON, Aug. 17 (TNSLrpt) -- The Veterans Affairs Inspector General issued the following report (No. 25-00204-215) entitled "Healthcare Facility Inspection of the VA Kansas City Healthcare System in Missouri."
Here are excerpts:
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The VA Office of Inspector General (OIG) established the Healthcare Facility Inspection program to review Veterans Health Administration (VHA) medical facilities on an approximately three-year cycle. The OIG inspected the VA Kansas City Healthcare System (the facility) from April 1 through 3, 2025. Facility leaders and staff provided updated information in
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WASHINGTON, Aug. 17 (TNSLrpt) -- The Veterans Affairs Inspector General issued the following report (No. 25-00204-215) entitled "Healthcare Facility Inspection of the VA Kansas City Healthcare System in Missouri."
Here are excerpts:
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The VA Office of Inspector General (OIG) established the Healthcare Facility Inspection program to review Veterans Health Administration (VHA) medical facilities on an approximately three-year cycle. The OIG inspected the VA Kansas City Healthcare System (the facility) from April 1 through 3, 2025. Facility leaders and staff provided updated information inDecember 2025 and June 2026. The facility is rated as high complexity and in fiscal year 2025, provided direct care to 56,067 unique patients.1 The inspection team examined aspects of care delivery and patient safety within the facility using five domains.2
What the OIG Examined
Overall, the OIG inspection did not reveal issues that warranted recommendations for corrective actions in any of the five domains.
* Culture. The inspection focused on system shocks (events that disrupt healthcare operations) and both employees' and veterans' experiences.
* Environment of Care. Inspectors examined the main entrance and patient care areas for safety, cleanliness, infection prevention, accessibility, and privacy.
* Patient Safety. The team ascertained whether the facility had processes to communicate test results, respond to oversight recommendations, and identify opportunities for improvement.
* Primary Care. The OIG assessed whether primary care teams were staffed according to VHA Directive 1406(3), Patient Centered Management Module (PCMM) for Primary Care and Handbook 1101.10(2), Patient Aligned Care Team (PACT) Handbook.
* Veteran-Centered Safety Net. The inspection also evaluated facility programs that offer support services to vulnerable veterans who are experiencing or at risk of homelessness, or recently incarcerated.
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The report is posted at: https://www.vaoig.gov/sites/default/files/reports/2026-08/vaoig_-_25-00204-215_final.pdf
VA IG: Desk Review of the U.S. VETS Single Audit Reporting Package for the Year Ended June 30, 2025
WASHINGTON, Aug. 17 (TNSLrpt) -- The Veterans Affairs Inspector General issued the following report (No. 26-02642-227) entitled "Desk Review of the U.S. VETS Single Audit Reporting Package for the Year Ended June 30, 2025."
Here are excerpts:
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The VA Office of Inspector General (OIG) completed a desk review of the single audit reporting package for the United States Veterans Initiative and Subsidiaries (U.S. VETS) for the year that ended June 30, 2025. U.S. VETS is a nonprofit corporation that provides supportive services and housing for veterans of the US Armed Forces and their families.2
A
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WASHINGTON, Aug. 17 (TNSLrpt) -- The Veterans Affairs Inspector General issued the following report (No. 26-02642-227) entitled "Desk Review of the U.S. VETS Single Audit Reporting Package for the Year Ended June 30, 2025."
Here are excerpts:
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The VA Office of Inspector General (OIG) completed a desk review of the single audit reporting package for the United States Veterans Initiative and Subsidiaries (U.S. VETS) for the year that ended June 30, 2025. U.S. VETS is a nonprofit corporation that provides supportive services and housing for veterans of the US Armed Forces and their families.2
Asingle audit includes an audit of a nonfederal entity's financial statements and its federal award expenditures under the requirements of 2 C.F.R. Part 200, "Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards" (Uniform Guidance). A single audit reporting package includes the entity's financial statements and schedule of expenditures of federal awards, a summary schedule of prior audit findings, the auditor's report(s), and a corrective action plan. The single audit reporting package for U.S. VETS was accepted by the Federal Audit Clearinghouse on January 28, 2026.3
Armanino LLP is the independent auditing firm that conducted the single audit as required by 2 C.F.R. Part 200, subpart F. The OIG was delegated the authority to conduct this desk review by VA and did so consistent with its duties and responsibilities under the Inspector General Act of 1978, as amended, 5 U.S.C. Sec. 404.4
The objective of the OIG's desk review was to determine whether the single audit reporting package complied with the reporting requirements of the Uniform Guidance. To achieve the objective, the OIG team conducted the desk review in accordance with the Council of Inspectors General on Integrity and Efficiency's Guide for Desk Reviews of Single Audit Reports, 2021 edition (the review guide). The scope of the desk review consisted of performing procedures on only the reporting package, such as verifying the inclusion of certain required elements. As such, the team did not evaluate the audit work performed or review other documentation supporting the reporting package. Accordingly, the OIG does not express an opinion on the quality of the audit work performed or on the accuracy of the single audit reporting package. In conducting its work, the OIG team complied with internal policies and procedures for quality assurance and independence.
Overall Rating
Based on the OIG team's review, the rating for the reporting package is "pass with deficiencies." As defined by the review guide, this rating means the reporting package contains quality deficiencies that should be brought to the attention of the auditor (and auditee, when appropriate) for correction in future audits. The OIG team found that the Schedule of Expenditures of Federal and Non-Federal Awards included in the reporting package did not fully comply with reporting requirements as stated in the Uniform Guidance.
According to 2 C.F.R. Sec. 200.510(b)(3), the schedule must "provide total Federal awards expended for each individual Federal program and the Assistance Listings number or other identifying number when the Assistance Listings information is unavailable." An assistance listings number is a unique number used to identify federal programs. The schedule listed federal award expenditures with their assistance listings numbers but did not consistently provide totals by individual federal programs and the associated assistance listings numbers, as required.
Additionally, 2 C.F.R. Sec. 200.510(b)(1) states, "[T]he Schedule of Expenditures of Federal Awards must list individual federal programs by federal agency." Instead, the section of the schedule labeled "Pass Through Others" grouped multiple federal programs together on a single line using only acronyms, without clearly identifying each federal agency and individual program. This presentation does not meet the Uniform Guidance requirement for listing individual federal programs.
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The report is posted at: https://www.vaoig.gov/sites/default/files/reports/2026-08/vaoig-26-02642-227_final.pdf
State Department IG: Special Inspector General for Operation Atlantic Resolve | Quarterly Report to the United States Congress | April 1, 2026 - June 30, 2026
WASHINGTON, Aug. 17 (TNSLrpt) -- The State Department Inspector General issued the following audit report entitled "Special Inspector General for Operation Atlantic Resolve | Quarterly Report to the United States Congress | April 1, 2026 - June 30, 2026."
Here are excerpts:
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We are pleased to present this Special Inspector General report to Congress on Operation Atlantic Resolve (OAR). This report discharges our quarterly reporting responsibilities pursuant to Section 1250B of the National Defense Authorization Act for 2024 and Lead IG reporting responsibilities under 5 U.S.C. 419. Section
... Show Full Article
WASHINGTON, Aug. 17 (TNSLrpt) -- The State Department Inspector General issued the following audit report entitled "Special Inspector General for Operation Atlantic Resolve | Quarterly Report to the United States Congress | April 1, 2026 - June 30, 2026."
Here are excerpts:
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We are pleased to present this Special Inspector General report to Congress on Operation Atlantic Resolve (OAR). This report discharges our quarterly reporting responsibilities pursuant to Section 1250B of the National Defense Authorization Act for 2024 and Lead IG reporting responsibilities under 5 U.S.C. 419. Section1250B states that no later than 45 days after the end of each fiscal quarter, the Special Inspector General for OAR shall submit to Congress a report summarizing U.S. funding, programs, and operations for Ukraine with respect to that quarter.
This report covers the period April 1 to June 30, 2026. This report also discusses the planned, ongoing, and completed oversight work conducted by the DoW, State, and USAID Offices of Inspector General and other U.S. oversight agencies that coordinate their activities through the Ukraine Oversight Interagency Working Group.
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View full audit report at: https://www.stateoig.gov/uploads/report/report_pdf_file/oar_q3_jun2026_final_508-secure.pdf
Interior IG: DOI Has Opportunities To Improve Its Financial Assistance Risk Assessments
WASHINGTON, Aug. 17 (TNSLrpt) -- The Interior Inspector General issued the following report (No. 2026-ISP-001) on August 10, 2026, entitled "DOI Has Opportunities To Improve Its Financial Assistance Risk Assessments."
Here are excerpts:
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Objective
To analyze our prior work related to financial assistance risk assessments to identify areas for continued policy improvement, and to research potential best practices from other Federal agencies.
Recommendations
We make four recommendations that, if implemented, will help the U.S. Department of the Interior (DOI) improve its pre-award processes
... Show Full Article
WASHINGTON, Aug. 17 (TNSLrpt) -- The Interior Inspector General issued the following report (No. 2026-ISP-001) on August 10, 2026, entitled "DOI Has Opportunities To Improve Its Financial Assistance Risk Assessments."
Here are excerpts:
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Objective
To analyze our prior work related to financial assistance risk assessments to identify areas for continued policy improvement, and to research potential best practices from other Federal agencies.
Recommendations
We make four recommendations that, if implemented, will help the U.S. Department of the Interior (DOI) improve its pre-award processesand management of Federal financial assistance.
Four recommendations are resolved, and we identified one recommendation as significant.
Findings
Risk assessments assist DOI in identifying and mitigating risks that could affect financial assistance applicants' ability to manage and execute grants as required in Federal regulations. Over the last 10 years, our work has repeatedly found that bureaus did not always conduct comprehensive risk assessments of these applicants before awarding funds. For example, bureaus did not always identify and analyze single audit findings that were relevant to the applicant. These findings can provide insight into an entity's management of Federal awards, internal controls, compliance with laws and regulations, financial capability, and past performance.
Additionally, we have identified bureau risk assessment policies and procedures that were inconsistent with DOI policies. For example, the Bureau of Reclamation, Office of Surface Mining Reclamation and Enforcement, and U.S. Geological Survey risk assessment checklists do not include consideration of independent audits under any circumstances-- including when a single audit does not exist--which is contrary to DOI policy.
In our past reports, we attributed this lack of comprehensive risk assessments to an ineffective checklist and unclear policies. Additionally, staff responsible for performing the risk assessments did not always have the requisite knowledge to perform an adequate review of single audits to identify significant findings and risks that could affect the applicants' ability to successfully manage funds and implement activities under the financial assistance awards.
Due to these longstanding weaknesses in DOI's use of risk assessments, we reviewed risk assessment procedures from DOI bureaus and those at other Federal agencies to identify potential best practices for DOI to consider implementing.
Impact
Completing effective pre-award risk assessments and identifying appropriate mitigation before providing funding can help prevent fraud or reduce mismanagement of financial assistance. In a resource-constrained environment, these practices can help prioritize staff time and post-award oversight work while also protecting taxpayer dollars.
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The report is posted at: https://www.doioig.gov/sites/default/files/2021-migration/Final-Inspection-Report_DOI-has-Opportunities-to-Improve-its-Financial-Assistance-Risk-Assessments.pdf
HHS IG: Medicare Home Health Agency Provider Compliance Audit: Deistic Home Health Care, Inc.
WASHINGTON, Aug. 17 (TNSLrpt) -- The Health and Human Services Inspector General issued the following report (No. A-05-24-00007) entitled "Medicare Home Health Agency Provider Compliance Audit: Deistic Home Health Care, Inc." filed under the CMS:
Here are excerpts:
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Why OIG Did This Audit
* In calendar year 2023, Medicare paid home health agencies (HHAs) about $16 billion for home health services provided to about 2.8 million people enrolled in traditional fee for service Medicare. In that year, nearly 10,000 HHAs participated in Medicare.
* CMS determined through its Comprehensive Error
... Show Full Article
WASHINGTON, Aug. 17 (TNSLrpt) -- The Health and Human Services Inspector General issued the following report (No. A-05-24-00007) entitled "Medicare Home Health Agency Provider Compliance Audit: Deistic Home Health Care, Inc." filed under the CMS:
Here are excerpts:
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Why OIG Did This Audit
* In calendar year 2023, Medicare paid home health agencies (HHAs) about $16 billion for home health services provided to about 2.8 million people enrolled in traditional fee for service Medicare. In that year, nearly 10,000 HHAs participated in Medicare.
* CMS determined through its Comprehensive ErrorRate Testing program that the 2023 improper payment error rate for home health claims was 7.7 percent, or about $1.2 billion.
* This audit report, part of a nationwide series of home health audits, examined whether Deistic Home Health Care, Inc. (Deistic), complied with Medicare requirements.
What OIG Found
For the audit period (January 1, 2021, through December 31, 2022), Deistic complied with Medicare billing requirements for 63 of the 100 sampled home health claims we reviewed. For the remaining 37 claims, Deistic incorrectly billed Medicare $8,332 in net overpayments. Specifically:
* Thirty-six claims did not meet billing and coding requirements.
* Five claims did not meet face-to-face encounter requirements.
The total number of errors exceeds 37 because 4 claims had errors in both error categories.
We determined that these errors occurred because Deistic did not always review medical record documentation to prevent the incorrect billing of Medicare claims.
Based on our sample results, we estimated that, of the $15,301,644 in Medicare payments covered by our audit, Deistic received net overpayments of at least $43,074 for the audit period. Deistic's provider agreement with the Medicare program was voluntarily terminated on August 1, 2025.
What OIG Recommends
We recommended that Deistic refund to the Federal Government $43,074 in estimated net overpayments. Deistic elected not to provide comments on the draft report.
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The report is posted at: https://oig.hhs.gov/documents/audit/11837/A-05-24-00007.pdf
