This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the VA NY Harbor Healthcare System. The system includes three medical centers located in Brooklyn, Manhattan, and Queens and two outpatient clinics in New York. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (focusing on suicide prevention initiatives)The OIG issued 12 recommendations for improvement in four areas:1. Quality, safety, and value• Peer review aspects of care• Peer Review Committee recommendations• Communication and implementation of recommendations2. Medical staff privileging• Service-specific criteria in professional practice evaluations3. Environment of care• Inspections• Deficiency monitoring until resolution• Over-the-door alarm testing• Hazard warning signs• Safety and cleanliness4. Mental health• Suicide-related events reporting• Comprehensive Suicide Risk Evaluations• Notification of suicidal behaviors
| Report Date | Agency Reviewed / Investigated | Report Title | Type | Location | |
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| Department of Veterans Affairs | Comprehensive Healthcare Inspection of the VA NY Harbor Healthcare System in New York | Inspection / Evaluation |
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| Department of the Treasury | SIGPR 13th Quarterly Report to Congress | Semiannual Report | Agency-Wide | View Report | |
| U.S. Agency for International Development | Financial Audit of Action Contre La Faim Under Multiple Awards, for the Fiscal Year Ended December 31, 2020 | Other |
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| U.S. Agency for International Development | Performance Audit of Visionary Consulting Partners, LLC for Fiscal Year 2019 | Other |
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| Federal Maritime Commission | Audit of the FMC’s Compliance with the Federal Information Security Modernization Act FY 2023 | Audit | Agency-Wide | View Report | |
| Internal Revenue Service | Actions Are Needed to Address Inaccurate, Incomplete, and Inconsistent Taxpayer Assistance Center Information Provided to Taxpayers | Inspection / Evaluation | Agency-Wide | View Report | |
| Social Security Administration | Numberholders Age 100 or Older Who Did Not Have Death Information on the Numident | Audit | Agency-Wide | View Report | |
| Board of Governors of the Federal Reserve System | The Board’s Approach to Climate Risk Supervision at Financial Institutions | Other | Agency-Wide | View Report | |
| Department of Homeland Security | Results of an Unannounced Inspection of ICE’s Stewart Detention Center in Lumpkin, Georgia | Inspection / Evaluation | Agency-Wide | View Report | |
| Department of Defense | Evaluation of Controls over the Application of Analytic Standards by the Service Intelligence Centers and U.S. Cyber Command | Inspection / Evaluation | Agency-Wide | View Report | |