Federal Reports

The OIG’s Mental Health Inspection Program (MHIP) evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on the inpatient care delivered at the Edward P. Boland VA Medical Center, part of the VA Central Western Massachusetts Healthcare System (facility) in Leeds.

The facility met some VHA requirements for inpatient mental health units, including providing the required amount of interdisciplinary programming for veterans and the completion of twice-yearly environment of care inspections. The inpatient unit included some aspects of a recovery-oriented physical environment, such as soft night lighting in the nurses’ station and veterans’ rooms.

Electronic health record reviews indicated most veterans were involved with the interdisciplinary treatment team in treatment planning, and veterans had documented safety plans. However, some records did not include evidence of timely suicide risk screenings, and discharge instructions were difficult to understand, lacking important details for appointment follow-up and medication management.

The facility did not have an established local mental health executive council or an interdisciplinary safety inspection team during the review period. The facility’s admission policy did not include processes for the admission of veterans on an involuntary hold. The facility leaders lacked formal processes to monitor and track compliance with involuntary commitment state laws.

The OIG identified environment of care deficiencies such as the unit’s sally port entrance doors were not synchronized; the inpatient unit had unweighted, unsecured chairs in a group room; and facility staff did not have a policy that addressed the use of a restraint chair. Additionally, many staff did not have evidence of completed environment of care or suicide prevention trainings. 

The OIG issued 16 recommendations to facility leaders. These recommendations, once addressed, may improve the quality and delivery of veteran-centered, recovery-oriented care on the inpatient mental health unit and beyond.

We have reviewed the system of quality control for the audit organization of the National Railroad Passenger Corporation (Amtrak) Office of Inspector General (OIG) in effect for the year ended September 30, 2024. A system of quality control encompasses Amtrak OIG’s organizational structure, and the policies adopted, and procedures established to provide it with reasonable assurance of conforming in all material respects with Government Auditing Standards1 and applicable legal and regulatory requirements. The elements of quality control are described in Government Auditing Standards. 

In our opinion, the system of quality control for the audit organization of Amtrak OIG in effect for the year ended September 30, 2024, has been suitably designed and complied with to provide Amtrak OIG with reasonable assurance of performing and reporting in conformity with applicable professional standards and applicable legal and regulatory requirements in all material respects. 

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Central Western Massachusetts Healthcare System in Leeds. 

This evaluation focused on five key content domains:
   •    Culture
   •    Environment of care
   •    Patient safety
   •    Primary care
   •    Veteran-centered safety net

The OIG issued one recommendation for improvement in one domain:
1.    Environment of care
   •    Leaders assess storage locations outside of standard supply rooms and implement a process to ensure staff remove expired supplies

We audited loanDepot.com to evaluate its quality control (QC) program for originating and underwriting Single Family Federal Housing Administration (FHA)-insured loans.  We selected loanDepot for review based on its loan volume and delinquency rate and because its rate of self-reporting loans to HUD when it identified fraud, material misrepresentations, and other material findings that it could not mitigate was below average for more than a 5-year period.

 We found that loanDepot’s QC program for originating and underwriting FHA-insured loans was not sufficient.  Specifically, loanDepot (1) did not select the proper number of loans for review and maintain complete and accurate data to document its loan selection process; (2) missed material deficiencies; and (3) did not adequately assess, mitigate, and report loan review findings, which included self-reporting loans to HUD when required.  These issues occurred because loanDepot had insufficient controls over its QC program.  As a result, HUD did not have assurance that loanDepot’s QC program fully achieved its intended purposes, which include, among other things, protecting the FHA insurance fund and lender from unacceptable risk, guarding against fraud, and ensuring timely and appropriate corrective action. 

 We recommended that HUD require loanDepot to (1) update its QC plan and related procedures to align with HUD requirements; (2) provide training to its staff and management on HUD requirements for lender QC programs; (3) review the loans that it had not selected and take appropriate actions when applicable; and (4) evaluate its QC files for the loans in which it identified material findings to confirm whether it self-reported to HUD all findings of fraud or material misrepresentation, along with any other material findings that it did not acceptably mitigate.