Federal Reports

The VA Office of Inspector General (OIG) assessed allegations that a patient died by suicide the day of discharge from the Inpatient Mental Health Unit, and that facility leaders failed to complete an institutional disclosure.The patient, who was over 70 years old at the time of death, had diagnoses that included posttraumatic stress disorder and major depression. After approximately 15 years of care at a California VA facility, the patient transferred care to the facility in summer 2019.The OIG substantiated that the patient died by suicide the day of discharge. In summer 2019, outpatient providers did not complete required comprehensive evaluations with the patient. The emergency department social worker documented an incomplete comprehensive evaluation.The suicide prevention team did not assign the patient a high risk for suicide patient record flag in spite of the patient’s stressors and history of suicide behaviors.Staff did not adequately assess the patient’s substance use, incorporate relevant history into the treatment plan, or address the patient’s change in demeanor and concerning statements. The discharge safety plan had not been modified for approximately eight months in spite of significant life changes.Leaders had not established a mental health treatment coordinator (MHTC) policy. Staff assigned the patient an MHTC at the patient’s tenth visit and four MHTCs over nine months.Staff did not coordinate care with a geropsychologist, with whom the patient had nine appointments. Leaders did not effectively address the patient’s expressed complaints.The OIG substantiated that leaders did not conduct an institutional disclosure.The OIG made 10 recommendations related to evaluation of suicide risk and substance use disorder, incorporation of critical information into treatment and discharge planning, MHTC policy, discharge coordination, patient complaint response, identification of sentinel events, and an institutional disclosure for the patient’s care.

What We Looked AtThe Payment Integrity Information Act of 2019 (PIIA) requires agencies to identify, report, and reduce improper payments in their programs. For fiscal year 2020, the Department of Transportation reported one program, the Federal Highway Administration’s (FHWA) Highway Planning and Construction (HPC) Program, as susceptible to significant improper payments and subject to PIIA reporting requirements. HPC reported total expenditures of over $46 billion and DOT estimated that about $172 million of those payments were improper. PIIA also requires inspectors general to annually report on their agencies’ compliance. Our audit objective was to determine whether DOT complied with PIIA’s requirements as prescribed by the Office of Management and Budget (OMB). We reviewed the improper payment testing results published in DOT’s fiscal year 2020 Annual Financial Report (AFR) and posted to the Federal Government’s Payment Accuracy website and used statistical sampling to test transactions. What We FoundDOT is in compliance with PIIA. For fiscal year 2020, DOT reported improper payment estimates for FHWA’s HPC. The payment integrity information in DOT’s 2020 AFR and data posted to the Payment Accuracy website was accurate and complete. DOT also conducted risk assessments of programs as the Office of Management and Budget requires. The Department published its planned and completed corrective actions in its supplemental data call posted to the Payment Accuracy website. DOT’s corrective action plans appear adequately designed, focused on true root causes, and effectively implemented and prioritized with an emphasis on reducing improper payments. Furthermore, for fiscal year 2020, FHWA’s HPC Program surpassed its fiscal year 2020 improper payment reduction target of 0.85 percent, reporting estimated improper payments of 0.37 percent or about $172 million—a decrease of $224 million from 2019. Lastly, DOT continues to take steps to reduce and recapture improper payments through its risk assessments, annual improper payment testing, and payment recapture audits. RecommendationsWe made no recommendations.

The City Carrier Cost System (CCCS) is a statistical study of mail delivered on city carrier routes. For each selected route, a data collection technician selects a sample of mail to be delivered on the scheduled test date. The technician records the mail class, product type, and other characteristics of each manually sampled mailpiece directly into a portable microcomputer using the Computerized On-Site Data Entry System (CODES) data collection software. The Postal Service conducted 9,257 and 8,694 CCCS tests in fiscal years (FY) 2019 and 2020, respectively. Our objective was to assess the reliability of CCCS data and evaluate CCCS sampling methodologies to identify opportunities for improved efficiencies.