Federal Reports

The VA Office of Inspector General (OIG) evaluated allegations about the care of a patient at the Marion VA Health Care System (facility) who died by suicide. The OIG reviewed concerns that the patient’s traumatic brain injury (TBI), pain, and mental health needs were not addressed. The OIG identified additional concerns regarding the management of the patient’s repeated falls, TBI care coordination, suicide prevention efforts, and the absence of an institutional disclosure.

The OIG substantiated that the neurologist did not provide TBI treatment following the patient’s TBI diagnosis and the primary care provider (PCP) did not facilitate recommended follow-up care. Further, facility staff did not ensure timely coordination of community care records highlighting the patient’s TBI treatment needs. The OIG also found the PCP did not coordinate with community providers regarding the patient’s pain management. The OIG did not substantiate that facility staff failed to provide the patient with appropriate mental health treatment. 

Facility staff did not address the patient’s multiple reports of falls with strikes to the head. Suicide prevention staff did not notify the patient of high-risk flag activation status, routinely complete safety plan reviews, or accommodate the patient’s communication preferences. Facility leaders also did not consider an institutional disclosure related to the patient’s care due to the lack of identifying any concerns. 

Inadequate management of the patient’s TBI and pain care needs, repeated falls, and insufficient suicide prevention efforts may have limited the treatment options available to the patient. 

In response to the OIG’s findings and recommendations, the Facility Director shared plans to update procedures on fall prevention, care coordination, and management of high risk for suicide flags. The Facility Director also planned to ensure compliance with community care coordination and scheduling practices. 
 

The report summarizes the FTC OIG’s activities and accomplishments during the second half of the FY 2025 reporting period.

The audit objectives were to determine whether program funds were managed in accordance with the ARC and Federal grant requirements.

Why We Did This Report

Our objective for this audit was to describe the status of funds, top recipients, and potential risks and impacts of the Solar for All program. However, the EPA terminated the program in August 2025.
 

Summary of Findings

We described the status of Solar for All recipients, top recipients, risks, and impacts. We identified four risk areas that the EPA should consider, plan for, and address in its implementation of new grant programs. The risks relate to resources for oversight and controls in the form of subrecipient monitoring, standard operating procedures, and quality assurance plans.

USDSA OIG identified all programs in which the Farm Service Agency (FSA) processes payments with self-certification and determined what percentage of these payments resulted in an improper payment during FSA spot check reviews.