Federal Reports

VA provides tax-free monthly compensation payments to veterans for service-connected disabilities, including special monthly compensation for certain serious disabilities or combinations of disabilities. As part of its Veterans Benefits Administration (VBA) oversight, the VA Office of Inspector General (OIG) identified instances where VBA did not properly implement annual disability compensation cost-of-living adjustments (COLA). First, the OIG team found that certain special monthly compensation amounts had been calculated incorrectly for each annual COLA since December 1, 2016. This resulted in some monthly payments to veterans being slightly higher or lower than they should have been.Second, the OIG team found that the increased amounts for disability compensation, additional compensation for dependents, and clothing allowance for the COLA effective December 1, 2022, were not published in the Federal Register, as required by law. VBA received the Federal Register notice signed by the VA Secretary containing the increased amounts; however, VBA did not forward the notice to the next office for publication. Although the increased amounts were available on VA’s website, including them in the Federal Register is important because it is the official publication for notices of federal agencies and organizations.In November 2023, the OIG team notified VBA representatives of the improper implementation of these compensation COLAs. The VA OIG issued the management advisory memorandum to formally and transparently convey this information so that VBA can determine if additional actions are warranted. The OIG requested that VBA inform the OIG of what action, if any, VBA takes regarding the incorrect special monthly compensation amounts identified in this memorandum and the increased disability compensation amounts effective December 1, 2022, that were not published in the Federal Register.

As required by FISMA, OIG reviewed USDA’s ongoing efforts to improve its information technology security program and practices during FY 2024.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess an allegation of inadequate clinical care of a patient who died by suicide on the inpatient medical unit.In summer 2023, a physician admitted the patient to the facility’s medical unit, placed an order for one-to-one observation status (1:1) for suicidal ideation, started a Clinical Institute Withdrawal Assessment of Alcohol Revised (CIWA-Ar) protocol for treatment of alcohol withdrawal symptoms, and entered a consult to the psychiatry service. Four days later, the patient was found in the bathroom hanging from a necklace, having died by suicide.The OIG found that staff did not follow policy requirements to remove the patient’s belongings or reduce environmental risks. Additionally, a nurse failed to conduct a warm handoff as required for the completion of a Comprehensive Suicide Risk Evaluation (CSRE) after completing a positive suicide risk screening. The psychiatrist completed a telemental health evaluation of the patient but did not complete the required CSRE. On the third day of admission, the psychiatrist did not reassess the patient before changing the patient’s 1:1 order to every 15-minute checks and did not sign the evaluation note within the required 24-hour time frame, leaving the assessment unavailable to other providers.Nursing staff documented CIWA-Ar assessments every 1–4 hours and administered lorazepam as ordered except for one error. The medical unit nurse manager reported addressing the error, and the error had no impact on the patient’s outcome.Facility leaders evaluated processes related to the care of the patient through actions that included a root cause analysis in accordance with Veterans Health Administration policy. The resulting action plans addressed concerns identified in this report.The OIG made four recommendations to the Facility Director related to clinical screenings and evaluations, timely documentation, and removing environmental risks.