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 inpatient care delivered at the VA Philadelphia Healthcare System (facility) in Pennsylvania.

The facility met some VHA requirements for the inpatient mental health unit, such as completion of twice-yearly environment of care inspections, and had some aspects of a recovery-oriented environment. However, not all areas met VHA standards for a safe, hopeful, and healing setting. Facility leaders did not establish written processes for staff to accompany veterans on outdoor breaks.

The facility did not have an established mental health executive committee for local oversight or a plan for continued transformation to recovery-oriented services. Additionally, inpatient staff did not offer the required daily hours of interdisciplinary programming. Facility leaders did not have formal written guidance to monitor and ensure compliance with state involuntary commitment laws. 

Not all electronic health records (EHRs) reviewed included documentation of a treatment plan. Most EHRs did not have evidence of required discussions with veterans on the risks and benefits of prescribed medications. Some EHRs did not have evidence of timely suicide risk screenings. Most reviewed safety plans did not address ways to make the environment safer from potentially lethal means beyond access to firearms and opioids. 

Inpatient unit clinical staff were compliant with suicide prevention trainings, but nonclinical staff did not consistently complete the required training.

The Interdisciplinary Safety Inspection Team did not adhere to VHA requirements, including staff’s completion of annual environmental safety hazards training, and did not address safety hazards, including ligature risks.

The OIG issued 20 recommendations to the Facility Director, Chief of Staff, and Associate Chief of Staff for Behavioral Health. These recommendations, once addressed, may improve the quality and delivery of veteran-centered, recovery-oriented care on the inpatient mental health.

The Smithsonian Institution (Smithsonian) relies on funding from external sponsors such as governments, foundations, and corporations to support projects that further its mission to increase and diffuse knowledge.

The Office of Sponsored Projects (OSP) provides centralized support, guidance, and training for Smithsonian units receiving sponsored project funding. Together they manage sponsored projects in compliance with Smithsonian policies and procedures and sponsors’ terms and conditions.

OSP oversaw $189 million in sponsored project funding provided during fiscal years 2022 and 2023. 

This audit determined the extent to which OSP and recipient units complied with: (1) Smithsonian policies and procedures and (2) sponsors’ terms and conditions concerning administering and overseeing sponsored projects.

OIG reviewed a sample of 25 sponsored projects totaling $33.8 million—approximately 18 percent of sponsored project funding provided through OSP in fiscal years 2022 and 2023. OIG also analyzed OSP’s sponsored project universe for balances and transactions determined to be of higher risk of noncompliance. 

During the two fiscal years under audit, OSP managed a 65 percent increase in sponsored project funding while maintaining high-quality service reported by Smithsonian units. However, OIG identified opportunities to improve the administration and oversight of projects throughout their lifecycle. 

The Postal Regulatory Commission (PRC) is an independent establishment of the executive branch that exercises regulatory oversight of the U.S. Postal Service. The PRC offers a range of benefits to its employees including, but not limited to, transit benefits, bonuses, time-off-awards, telework, remote work, flexible work schedules, recruitment and retention incentives, and paid leave. By providing these options, the PRC seeks to attract and retain a high-performing, varied workforce with workplace flexibility.

In August 2023, the Office of Inspector General received an allegation that a contractor had not provided any deliverables supporting the National Nuclear Security Administration’s (NNSA) $90 million Safety, Analytics, Forecasting, Evaluation, and Reporting (SAFER) system. The allegation claimed that the project was halfway through its 5-year contract period, but it had been “staggeringly unproductive given the money spent.” 

We initiated this inspection to determine the facts and circumstances regarding alleged productivity weaknesses and lack of deliverables from the contractor supporting NNSA’s SAFER system.

We did not substantiate the allegation that a contractor had productivity weaknesses and had not provided any deliverables on its project with NNSA. However, we identified inadequate project planning and management of the SAFER system by NNSA. For instance, key performance indicators were not developed to measure project success. In addition, user acceptance criteria was not established to measure the success of the development process and ensure that delivered functionality aligned with user requirements. Further, a required Contractor Performance Assessment Report was not completed for the base year of the contract but was completed in subsequent years.   

Based on feedback provided by SAFER users and a lack of acceptance criteria to measure the success of the development process for the safety programs, we question whether SAFER is meeting user needs. Although not fully implemented, we were unable to obtain evidence that SAFER had produced widespread benefits and improved oversight across the NNSA enterprise.

As a result of the weaknesses identified, NNSA may be unable to determine the overall health of its safety programs and potential improvements needed to those programs. The lack of progress in completing actions outlined in the Federal Data Strategy may also have hindered effective data-driven decision making. Without improvements, NNSA may continue to encounter weaknesses related to managing the SAFER project, which could delay project progress.

We made three recommendations related to establishing quantifiable metrics to measure the performance of NNSA’s investments and ensuring that data management practices and project management requirements are followed. These recommendations should improve the management of the SAFER project and help inform future technology projects.