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 evaluates four review areas within Continental District 4 including leadership stability, morbidity and mortality reviews, the high risk suicide flag (HRSF) SharePoint site, and safety plans.There were no findings in stability of leadership. Based on active policy at the time of the inspection, the OIG identified that district leaders did not complete timely morbidity and mortality reviews for clients who died by suicide. Inconsistent with requirements at the time, leaders also implemented a peer review process for all suicide attempts instead of the morbidity and mortality reviews. The OIG did not conduct the HRSF SharePoint site review due to concerns with data accuracy. In April 2024, the OIG made a recommendation to the RCS Chief Officer related to HRSF SharePoint site functionality. The recommendation remained open at the time of the inspection; therefore, the OIG will continue to monitor progress to closure and did not make a new recommendation. Vet center staff were noncompliant with completing and providing safety plans to clients.The OIG issued three recommendations for improvement to the District Director.
Report Date | Agency Reviewed / Investigated | Report Title | Type | Location | |
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Department of Veterans Affairs | Inspection of Continental District 4 Vet Center Operations | Inspection / Evaluation |
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Department of Health & Human Services | New Mexico Did Not Ensure Attendants Were Qualified To Provide Personal Care Services, Putting Medicaid Enrollees at Risk | Audit | Agency-Wide | View Report | |
Environmental Protection Agency | Report of Investigation: Joseph Goffman, Assistant Administrator, Office of Air and Radiation | Other | Agency-Wide | View Report | |
Department of Health & Human Services | Utah Generally Completed Medicaid Eligibility Actions During the Unwinding Period in Accordance With Federal and State Requirements | Audit | Agency-Wide | View Report | |
U.S. Agency for International Development | Financial Audit of USAID Resources Managed by Lilongwe Diocese Catholic Health Commission in Malawi Under Multiple Awards, October 1, 2022, to September 30, 2023 | Other |
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U.S. Agency for International Development | Financial Audit of USAID Resources Managed by Center for Clinical Care and Clinical Research in Nigeria Under Multiple Awards, October 1, 2022, to September 30, 2023 | Other |
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Internal Revenue Service | The IRS Faces Challenges to Address Tax Avoidance Strategies of Large Multinational Corporations | Audit | Agency-Wide | View Report | |
Internal Revenue Service | The IRS Has Made Limited Progress Developing the Methodology to Comply With the Treasury Directive to Not Increase the Audit Rate for Taxpayers With Incomes Below $400,000 Due to Planning and Implementation Challenges | Audit | Agency-Wide | View Report | |
Securities and Exchange Commission | The SEC Missed Opportunities to Lower Contract Risk and More Effectively Manage Time-and-Materials Contracts, Report No. 582 | Audit | Agency-Wide | View Report | |
U.S. Postal Service | Service Performance During the Fiscal Year 2024 Peak Mailing Season | Audit | Agency-Wide | View Report | |