Federal Reports

The VA Office of Inspector General (OIG) conducted an inspection at the Washington DC VA Medical Center (facility) to assess care provided to a patient six days prior to death by suicide and an allegation that an Emergency Department physician made a statement to the effect of “[the patient] can go shoot [themself]. I do not care.” The OIG substantiated that the patient died by suicide six days after presenting to the Emergency Department with suicidal ideation and staff failed to complete required suicide prevention planning. During the 12-hour episode of care, the patient navigated two transitions between the Emergency Department and outpatient Mental Health Clinic and saw seven providers. Lack of collaboration between providers, hand-off process deficiencies, and providers’ failure to read the outpatient psychiatrist’s notes led to a compromised understanding of the patient’s medical needs and a failure to enact the outpatient psychiatrist’s recommended treatment plan. The OIG substantiated that an Emergency Department physician made a statement to the effect of “[the patient] can go shoot [themself]. I do not care,” which could be considered misconduct and patient abuse. Facility and contracted staff failed to report the behavior and did not receive required annual abuse and neglect policy education. The Emergency Department physician had a history of verbal misconduct. Despite facility leaders’ awareness by late spring 2019 of physician 2’s inappropriate statement regarding the patient and physician 2’s prior pattern of misconduct, facility leaders did not conduct a formal fact-finding or administrative investigation as required by VA. The Suicide Prevention Coordinator failed to complete the required suicide behavior report and the Emergency Department did not meet Veteran Health Administration’s requirements for a safe and secure mental health evaluation area. The OIG made one recommendation to the Veterans Integrated Service Network Director and 10 recommendations to the Facility Director.

On March 27, 2020, the President signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). To date, the CARES Act has provided the U.S. Department of the Interior (DOI) with $909.7 million, which includes direct apportionments of $756 million to support the needs of DOI programs, bureaus, Indian Country, and the Insular Areas and a $153.7 million transfer from the U.S. Department of Education to the Bureau of Indian Education in June.This report presents the DOI’s progress as of June 30, 2020, in spending CARES Act appropriations. Specifically, the DOI’s expenditures to date total $393,538,262 and its obligations total $534,545,127.We are also monitoring the DOI’s progress on reporting milestones established by the CARES Act and the Office of Management and Budget.We anticipate issuing updated status reports monthly.

The Puerto Rico Electric Power Authority (PREPA) complied with Federal procurement requirements for its noncompetitive procurement of the Whitefish contract. However, the contract costs may not have complied with Federal cost principles that costs must be reasonable to be eligible for Federal awards. PREPA’s oversight of the Cobra contract did not comply with PA program guidelines. Finally, FEMA’s Public Assistance grant to PREPA for the Cobra contract did not fully comply with PA program guidelines. We made two recommendations for FEMA to provide technical assistance to Puerto Rico to ensure compliance with Federal regulations and PA program guidelines. We made two other recommendations for FEMA to develop guidance to verify its subrecipients’ oversight of time and material contracts and determine the reasonableness and eligibility of time and material contract costs. FEMA concurred with three of the recommendations and did not concur with one recommendation.