An official website of the United States government
Here's how you know
Official websites use .gov
A .gov website belongs to an official government organization in the United States.
Secure .gov websites use HTTPS
A lock (
) or https:// means you’ve safely connected to the .gov website. Share sensitive information only on official, secure websites.
Brought to you by the Council of the Inspectors General on Integrity and Efficiency
Federal Reports
Report Date
Agency Reviewed / Investigated
Report Title
Type
Location
U.S. Agency for International Development
Single Audit of The Carter Center, Inc., for the Year Ended August 31, 2023
Financial Audit of USAID Resources Managed by Children in Distress Network in South Africa Under Cooperative Agreement 72067418CA00030, April 1, 2023, to March 31, 2024
Financial Audit of USAID Resources Managed by Institut Pasteur de Madagascar Under Cooperative Agreement 72068719CA00001, January 1 to December 31, 2024
PEPFAR in Ukraine: USAID/Ukraine Achieved Mixed Results When Implementing Programs Due to Wartime Challenges and Did Not Conduct Independent Performance Monitoring
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.
