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Brought to you by the Council of the Inspectors General on Integrity and Efficiency
Federal Reports
Report Date
Agency Reviewed / Investigated
Report Title
Type
Location
General Services Administration
Alert Memorandum: Uncleared Contractors Worked on PBS’s San Luis I Land Port of Entry Expansion and Modernization Project in San Luis, Arizona
Management Advisory Report on Post Medical Inventory: Promising Practices in Peace Corps/The Gambia Can Inform Needed Improvements in Peace Corps/Namibia
The OIG evaluated allegations related to (1) the crisis management of a client at the Everett Vet Center; (2) documentation added to the client’s clinical record by district 5, zone 1 (district) and Everett Vet Center leaders to justify lack of action; and (3) altered notes. The OIG reviewed concerns regarding clinical documentation, safety planning, and the Vet Center Director’s (VCD’s) clinical consultation to staff.
The OIG substantiated that Everett Vet Center staff and leaders inadequately managed the client’s crisis because the VCD advised a counselor to allow the client to leave the clinic without notifying law enforcement authorities. The OIG also substantiated that the VCD and counselor failed to seek consultation from the support facility’s external consultant or follow up with the support facility’s suicide prevention team. The counselor did not update the client’s safety plan when the client presented to the appointment with increased risk.
The OIG found that the VCD backdated a progress note due to lack of awareness of documentation requirements and a district leader deleted progress notes; however, at the time, staff and leaders had the capability to delete notes and did so under certain circumstances. The counselor delayed crisis reporting due to uncertainty about whether the client’s circumstances met the criteria for reporting the event.
The OIG found that conflicting information regarding the scope of the VCD’s clinical responsibilities may have contributed to the VCD’s failure to consult immediately with a district leader on the day of the client’s visit.
The OIG made four Readjustment Counseling Service-level recommendations on crisis reporting and monitoring, clinical record and risk assessment documentation, and VCD position descriptions; and five district-level recommendations related to reviews of care; duty-to-warn obligations; consultation with external consultants and suicide prevention coordinators; and safety planning.
The OIG examines individual pharmaceutical proposals submitted by commercial contractors for Federal Supply Schedule contracts that have an anticipated annual value of $5 million or more or that VA has asked the OIG to review. The OIG’s oversight work helps VA contracting officers negotiate fair and reasonable prices for the government and taxpayers. The OIG’s reports on individual proposals are not published because they contain sensitive commercial information protected from release under federal law. To promote transparency, this report summarizes the 14 preaward reports provided to VA contracting officers in FY 2024. The 14 pharmaceutical proposals had a cumulative estimated contract value of approximately $34.4 billion and included 1,361 offered items.
The OIG found that commercial sales practice disclosures were accurate, complete, and current for six proposals. The remaining eight proposals could not be reliably used by VA for negotiations until noted deficiencies were corrected. The OIG also determined that proposed tracking customers for all 97 sampled items were suitable for the purpose of the price reductions clause. Tracking customers are customers that serve as a benchmark for potential price reductions during the life of the contract; if tracking customers receive a price reduction, the government’s price should also be reduced. Contract negotiations for 10 proposals had been completed as of May 6, 2025, and the OIG recommended lower prices than offered for five of the proposals, assisting contracting officers in obtaining approximately $36.8 million in savings for VA over the life of the contracts.