This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Cheyenne VA Medical Center and multiple outpatient clinics in Colorado, Nebraska, and Wyoming. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued five recommendations for improvement in three areas:1. Medical staff privileging• Focused Professional Practice Evaluation results review• Ongoing Professional Practice Evaluation completion2. Environment of care• Environment of care inspections3. Mental health• Suicide-related event reporting• Comprehensive Suicide Risk Evaluation completion
Report Date | Agency Reviewed / Investigated | Report Title | Type | Location | |
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Department of Veterans Affairs | Comprehensive Healthcare Inspection of the Cheyenne VA Medical Center in Wyoming | Inspection / Evaluation |
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Department of State | Inspection of Embassy Lilongwe, Malawi | Inspection / Evaluation | Agency-Wide | View Report | |
U.S. Agency for International Development | New Partnerships Initiative: USAID Provided Technical Assistance to Support Implementation but Faced Challenges with Data Reliability, Partner Inexperience, and Mission Staff Capacity | Audit | Agency-Wide | View Report | |
U.S. Agency for International Development | Single Audit of Internews Network for the Year Ended December 31, 2019 | Other |
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Department of the Interior | The National Park Service Did Not Adequately Oversee the Guard Services Contract at the Statue of Liberty National Monument | Audit |
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Department of the Interior | U.S. Fish and Wildlife Service Grants Awarded to the State of Arizona, Game and Fish Department, From July 1, 2019, Through June 30, 2021, Under the Wildlife and Sport Fish Restoration Program | Audit |
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Department of Veterans Affairs | Comprehensive Healthcare Inspection of the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin | Inspection / Evaluation |
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Denali Commission | Results of the FY 2023 Denali Commission Federal Information Security Modernization Act of 2014 (FISMA) Reporting Metrics | Inspection / Evaluation | Agency-Wide | View Report | |
Nuclear Regulatory Commission | Audit of the U.S. Nuclear Regulatory Commission’s Security Oversight of Category 1 and Category 2 Quantities of Radioactive Material | Audit | Agency-Wide | View Report | |
Export-Import Bank | Management Advisory: Lack of Clarity in EXIM’s Conduct, Performance, and Discipline Policy | Other | Agency-Wide | View Report | |