Federal Reports

The OIG’s Mental Health Inspection Program (MHIP) evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on care delivered on the inpatient mental health unit at the VA Salem Healthcare System in Virginia. 

The inpatient unit had some aspects of a recovery-oriented physical environment, including artwork, natural lighting, and secure outdoor spaces. The local recovery coordinator was integrated into recovery-oriented activities and staff provided the required interdisciplinary programming on weekdays but not on weekends. 

The facility had an established local Mental Health Executive Council; however, the OIG could not verify that all required participants attended meetings. The facility had an admission procedure that addressed involuntary hospitalization but lacked a written process to monitor and track compliance with involuntary commitment state laws. 

Staff involved veterans in treatment planning, but did not comply with requirements to document medication risks and benefits discussions. Staff also did not consistently complete suicide screening within 24 hours before discharge, complete or review safety plans, or consistently address ways to make veterans’ environments safer from lethal means beyond access to firearms and opioids. Many staff did not have evidence of completed lethal means safety and suicide risk trainings. Additionally, most discharge instructions included abbreviations that could be difficult for veterans to understand.

The OIG was unable to determine whether Interdisciplinary Safety Inspection Team members completed the required environment of care training. Staff reported using a restraint chair; while the facility had a local policy on the use of restraints, it did not include the use of restraint chairs. 

As a result of its findings, the OIG issued 15 recommendations to facility leaders. These recommendations, once addressed, may improve the quality and delivery of veteran-centered, recovery-oriented care on the inpatient mental health unit.

The Pandemic Response Accountability Committee’s (PRAC) Semiannual Report to Congress, covering the period from October 1, 2024 through March 31, 2025.

This report presents the results of our self-initiated audit of the Postal Regulatory Commission (PRC) Compensation and Benefits (Project Number 25-033). Our objective was to determine whether the PRC followed all applicable laws, regulations, and policies around employee compensation and benefits.

The PRC is an independent agency of the executive branch that has exercised regulatory oversight over the U.S. Postal Service since its creation by the Postal Reorganization Act of 1970. As of the end of calendar year (CY) 2024, the PRC was comprised of about 93 full-time employees. While the PRC maintains its own Human Resources department, the agency uses several Postal Service systems to administer benefits, such as pay and leave.

The PRC did not always carry out policy consistently regarding the disbursement of benefits, and we identified opportunities for the PRC to realign processes with agency policy and improve internal controls to verify benefits are provided in line with policy. Specifically, we found instances of the PRC not following its policy related to remote work. Additionally, the PRC used inconsistent processes regarding hiring incentives and locality pay. Further, we identified an internal control issue related to leave requests.

In August 2023, the Office of Inspector General received an allegation that a contractor had not provided any deliverables supporting the National Nuclear Security Administration’s (NNSA) $90 million Safety, Analytics, Forecasting, Evaluation, and Reporting (SAFER) system. The allegation claimed that the project was halfway through its 5-year contract period, but it had been “staggeringly unproductive given the money spent.” 

We initiated this inspection to determine the facts and circumstances regarding alleged productivity weaknesses and lack of deliverables from the contractor supporting NNSA’s SAFER system.

We did not substantiate the allegation that a contractor had productivity weaknesses and had not provided any deliverables on its project with NNSA. However, we identified inadequate project planning and management of the SAFER system by NNSA. For instance, key performance indicators were not developed to measure project success. In addition, user acceptance criteria was not established to measure the success of the development process and ensure that delivered functionality aligned with user requirements. Further, a required Contractor Performance Assessment Report was not completed for the base year of the contract but was completed in subsequent years.   

Based on feedback provided by SAFER users and a lack of acceptance criteria to measure the success of the development process for the safety programs, we question whether SAFER is meeting user needs. Although not fully implemented, we were unable to obtain evidence that SAFER had produced widespread benefits and improved oversight across the NNSA enterprise.

As a result of the weaknesses identified, NNSA may be unable to determine the overall health of its safety programs and potential improvements needed to those programs. The lack of progress in completing actions outlined in the Federal Data Strategy may also have hindered effective data-driven decision making. Without improvements, NNSA may continue to encounter weaknesses related to managing the SAFER project, which could delay project progress.

We made three recommendations related to establishing quantifiable metrics to measure the performance of NNSA’s investments and ensuring that data management practices and project management requirements are followed. These recommendations should improve the management of the SAFER project and help inform future technology projects.