Federal Reports

The VA Office of Inspector General (OIG) evaluated the oncology service staff’s adherence to the facility’s psychosocial distress screening standard operating procedure in the care of two patients who died by suicide, and facility leaders’ response to the root cause analyses following the two patients’ deaths. Facility oncology service staff demonstrated compliance with psychosocial distress screening standard operating procedures. However, the OIG was unable to determine if a mental health evaluation completed prior to one of the patients leaving the clinic would have changed the patient’s outcome. Completion of a mental health evaluation may have identified additional risk factors and provided opportunity for suicide prevention interventions prior to the patient leaving the clinic. The National Comprehensive Cancer Network standards of care state a patient should be screened at the initial visit and ideally at every visit. Facility oncology service nursing staff were unclear about when to administer the psychosocial distress thermometer, a self-report tool that evaluates a patient’s distress level, and therefore, administered the tool at every visit. Thus, nursing practice in the facility oncology service exceeded the facility standard operating procedure requirements and provided the National Comprehensive Cancer Network ideal standard of care. The alignment of the standard operating procedure with the ideal standard and current practice is critical to ensure clear guidance to staff regarding the completion of the psychosocial Distress Thermometer. The facility’s Patient Safety Manager did not monitor progress toward root cause analysis action item completion. Following the OIG team’s expressed concern about this deficiency, the Patient Safety Manager implemented a tracking tool that same month. The OIG identified one additional concern. After a patient’s death by suicide in 2017, the Acting Suicide Prevention Coordinator did not complete a Suicide Behavior Report or Behavioral Health Autopsy, as required by Veterans Health Administration.

We reviewed FSIS’ compliance with CIS program requirements for the interstate shipment of certain State-inspected meat and poultry products.

In accordance with our annual plan, the Office of Inspector General (OIG) assessed the United States Capitol Police (USCP or Department) Pre-screener Program to determine whether (1) the organizational structure and training for the program was the most efficient and effective, and (2) the Department complied with applicable policies and procedures as well as applicable laws, regulations, and best practices. Our scope included the Pre-screener Program organizational structure, training, and compliance with policies and procedures.

We investigated an allegation that Secretary of the Interior David Bernhardt, when he was the Deputy Secretary, interfered with the U.S. Fish and Wildlife Service’s (FWS’) scientific process during an assessment of the effects of pesticides on endangered species. We investigated whether Secretary Bernhardt exceeded or abused his authority by influencing consultations between the FWS and the U.S. Environmental Protection Agency on the proposed registration or re-registration of three pesticides, and whether his involvement in the consultations violated his ethics pledge or Federal ethics regulations.We found that Secretary Bernhardt reviewed a draft FWS opinion on the potential biological effects one of the three pesticides could have on endangered species, and he instructed the FWS team developing the opinion to change its method for determining the potential effects. This change has delayed the completion of the opinion, but we found no evidence that Secretary Bernhardt exceeded or abused his authority or that his actions influenced or altered the findings of career FWS scientists. We also found no evidence that Secretary Bernhardt’s involvement in this matter violated his ethics pledge or Federal ethics regulations.On January 7, 2021, this report was corrected to remove an inaccurate footnote. This correction did not affect our findings.

We investigated an allegation that Douglas Domenech, Assistant Secretary for Insular and International Affairs, U.S. Department of the Interior (DOI), violated his Federal ethics pledge under Executive Order No. 13770 by meeting with an official from his former employer, the Texas Public Policy Foundation (TPPF), during the required 2-year recusal period following Domenech’s resignation from the TPPF.Although we did not find that Domenech violated his ethics pledge as alleged, we found that he did violate Federal ethics regulations that prohibit Federal employees for 1 year from participating with their former employers in particular matters involving specific parties. Domenech, who began working for the DOI in January 2017 as a special Government employee (SGE), arranged and held two meetings with a TPPF attorney in April 2017 about issues in litigation between DOI bureaus and the TPPF. Domenech had a duty to consider whether his involvement in these meetings would cause a reasonable person to question his impartiality, and his failure to make that determination violated the regulation.Domenech did not violate his ethics pledge, however, because he was an SGE when the meetings took place and thus was not required to sign the pledge at the time. He signed the pledge in September 2017, after he became a permanent DOI employee.