Federal Reports

The VA Office of Inspector General (OIG) conducted a review to assess aspects of the care provided to a patient who was struck and killed by a motor vehicle following elopement from a community living center (CLC).The patient suffered from paranoid schizophrenia and was involuntarily civilly committed to the CLC. The OIG had concerns regarding the appropriateness of CLC admission and elopement prevention.The OIG determined that the patient’s admission to the CLC was inappropriate as indicated by the CLC’s own screening process. The OIG determined that interventions implemented by staff were inadequate to mitigate the patient’s risk for elopement. The patient eloped multiple times and facility staff failed to provide individualized, progressive, mental health-driven interventions to prevent the patient from eloping. The OIG also found that facility staff assigned to care for the patient were inadequately trained in mental health care, and patient safety reports were not completed as required.On the day of the patient’s death, the OIG found that facility staff did not follow missing patient procedures after the patient eloped. Facility staff failed to detect that the patient was missing for nearly three hours and once the patient was noted as missing, facility staff failed to follow policy to locate the patient. In addition, the OIG found that facility leaders did not ensure the facility had a missing patient prevention policy or that staff completed annual missing patient training. The OIG expressed concern that the CLC may not have been utilized as intended, given the lack of mental health standards applicable to CLCs and the complex mental health needs of this patient. The OIG made 12 recommendations to the Veterans Integrated Service Network and Facility Directors regarding reviews of the patient’s care, the use of the CLC, and staff training.

The Office of Inspector General (OIG) is issuing this Evaluation report to notify Small Business Administration (SBA) officials of significant matters regarding its handling of complaints of identity theft in the Coronavirus Disease 2019 (COVID-19) Economic Injury Disaster Loan (EIDL) program.We recommend the Administrator to direct the Associate Administrator for the Office of Disaster Assistance, the Chief Financial Officer for the Office of Performance Management and Chief Financial Officer, and the Associate Administrator for the Office of Capital Access to:1. Develop a process to maintain and track all identity theft complaints.2. Develop a process to provide status updates to each complainant alleging identity theft.3. Complete and formalize a process to restore identity theft victims to their condition prior to the fraud. The process should include steps to stop the loan billing statements, prevent delinquency collections, release them from loan liability and UCC liens.4. Develop a process to remove any fraudulent loans and related UCC filing fees from its financial records.5. Review over 150,000 returned billing statements and resolve any that involve identity theft, then refer fraudulent loans to OIG.While management stated they partially agreed with all of the recommendations, management’s formal comments state they took actions to address each of them.

The EPA should conduct new RTRs for chloroprene- and ethylene oxide-emitting source categories to address elevated individual lifetime cancer risks impacting over 464,000 people, as found in a modeling tool, and to achieve environmental justice.