Federal Reports

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the Jonathan M. Wainwright Memorial VA Medical Center in Walla Walla, Washington. 

This evaluation focused on five key content domains:
     •    Culture
     •    Environment of care
     •    Patient safety
     •    Primary care
     •    Veteran-centered safety net

The OIG issued nine recommendations for VA to correct identified deficiencies in two domains:
   1.    Environment of care
     •    Signs and maps
     •    Emergency generator and fire door inspection and testing
     •    Environment of care committee meetings
     •    Mental Health Residential Rehabilitation Treatment Program area cleanliness
     •    Hands-free sanitizer dispensers
     •    Guidance for shelter-in-place supplies
   2.    Patient safety
     •    Service-level workflows for the communication of test results
     •    Process to monitor the communication of test results
     •    Improvement actions from root cause analyses

This report presents the results of our audit of service and operational performance at previously audited mail processing facilities.

Background

The U.S. Postal Service needs effective and productive operations to fulfill its mission of providing prompt, reliable, and affordable mail service. It has a vast transportation network that moves mail and equipment between approximately 315 mail processing facilities. During fiscal years 2023 and 2024, we audited 24 mail processing facilities, assessing transportation and processing operational efficiency.

What We Did

Our objective was to evaluate trends in service and operational performance at previously audited mail processing facilities to determine potential areas for improvement. For this audit, we interviewed regional and mail processing facility management, analyzed pertinent Postal Service system data for 24 previously audited mail processing facilities, and revisited six of these facilities.

What We Found

We identified persistent issues in the areas of delayed mail reporting, late and canceled outbound trips, and safety and security policies. In addition, though scanning compliance improved at some facilities, scanning scores were still generally below the goal. We also found that service performance for First‑Class Mail stayed relatively consistent, but was below target, while service for Priority Mail and Ground Advantage declined. While the lack of oversight by management continues to contribute to most of the issues found, the Postal Service has opportunities to improve information accuracy and enforcement of existing policy. Specifically, facilities continued to have inaccurate reporting of delayed mail in the Mail Condition Visualization system due to a lack of training and out-of-date policy. We found incomplete scanning load and unload data was due to a lack of scanner availability and accountability. Many of these facilities continue to have high late and canceled outbound trip percentages caused by inconsistent reviews of transportation schedules. Finally, we found that facilities did not consistently follow mail safety and security policies and procedures.

The Federal Emergency Management Agency (FEMA) did not ensure the timely rebuilding of Puerto Rico’s electrical grid in the aftermath of Hurricane Maria.  FEMA officials missed opportunities to provide more assistance to Puerto Rico to manage its Hurricane Maria Public Assistance grant funds in accordance with Federal regulations and FEMA guidelines.  Specifically, FEMA did not provide enough technical assistance and guidance to the Puerto Rico Electric Power Authority (PREPA) to generate detailed statements of work and comprehensive work plans.   Despite FEMA granting multi-year extensions to avoid work stoppages, as of February 2025, FEMA reported that: • 92 percent (183 of 198) of approved and obligated       construction projects were incomplete; and • $3.7 billion of available permanent work funding had not      been obligated for construction of projects.  In June 2024, FEMA received a revised work plan focused on three categories of work: generation, transmission and distribution, and water assets.  The plan lacked detailed costs, schedules, and performance goals — all of which are important to monitoring progress. Over seven years after Hurricane Maria, FEMA does not know when Puerto Rico’s electrical grid will be completely rebuilt.  The grid remains unstable, inadequate, and vulnerable to interruptions, as evidenced by another complete loss of power on December 31, 2024.  

The OIG conducted a national review to evaluate the alignment of information related to mental health, substance use disorder (SUD), and suicide risk treatment needs within the Veterans Health Administration’s (VHA’s) Homeless Operations Management and Evaluation System (HOMES) data collection system and electronic health record (EHR). The OIG also assessed homeless program staff’s adherence to suicide risk screening procedures and care coordination.

Homeless program staff did not document the HOMES Assessment in 42 percent of patient EHRs, which limited access to important clinical information among clinicians outside of VA homeless programs.

The OIG found that 85 percent of patient EHRs included a suicide risk screening at the time of the HOMES Assessment or in the 30 days prior, as required. However, VHA has not implemented processes to ensure that staff complete the required suicide risk procedures, including risk mitigation, in response to HOMES-identified risk of self-harm. 

Homeless program staff did not document care coordination as outlined in VA homeless program policy. The OIG found that 35 percent of patients with HOMES-identified treatment needs, who were interested in participating in treatment, had EHR documentation of care coordination related to those treatment needs. VHA homeless program strategic goals include coordinating care to address veterans’ mental health and SUD needs; however, VHA has not delineated responsibility for ensuring care coordination, resulting in a lack of oversight and risk of patients not receiving needed mental health and SUD treatment.

The OIG made four recommendations to the Under Secretary for Health related to consistent EHR documentation of HOMES clinical information, suicide risk screening at intake, suicide risk screening in response to danger of self-harm identified in the HOMES Assessment, and documentation of mental health and SUD care coordination.