Federal Reports

The audit objectives were to determine whether program funds were managed in accordance with the ARC and Federal grant requirements.

The OIG evaluated allegations related to (1) the crisis management of a client at the Everett Vet Center; (2) documentation added to the client’s clinical record by district 5, zone 1 (district) and Everett Vet Center leaders to justify lack of action; and (3) altered notes. The OIG reviewed concerns regarding clinical documentation, safety planning, and the Vet Center Director’s (VCD’s) clinical consultation to staff.

The OIG substantiated that Everett Vet Center staff and leaders inadequately managed the client’s crisis because the VCD advised a counselor to allow the client to leave the clinic without notifying law enforcement authorities. The OIG also substantiated that the VCD and counselor failed to seek consultation from the support facility’s external consultant or follow up with the support facility’s suicide prevention team. The counselor did not update the client’s safety plan when the client presented to the appointment with increased risk.

The OIG found that the VCD backdated a progress note due to lack of awareness of documentation requirements and a district leader deleted progress notes; however, at the time, staff and leaders had the capability to delete notes and did so under certain circumstances. The counselor delayed crisis reporting due to uncertainty about whether the client’s circumstances met the criteria for reporting the event. 

The OIG found that conflicting information regarding the scope of the VCD’s clinical responsibilities may have contributed to the VCD’s failure to consult immediately with a district leader on the day of the client’s visit.

The OIG made four Readjustment Counseling Service-level recommendations on crisis reporting and monitoring, clinical record and risk assessment documentation, and VCD position descriptions; and five district-level recommendations related to  reviews of care; duty-to-warn obligations; consultation with external consultants and suicide prevention coordinators; and safety planning.

The OIG examines individual pharmaceutical proposals submitted by commercial contractors for Federal Supply Schedule contracts that have an anticipated annual value of $5 million or more or that VA has asked the OIG to review. The OIG’s oversight work helps VA contracting officers negotiate fair and reasonable prices for the government and taxpayers. The OIG’s reports on individual proposals are not published because they contain sensitive commercial information protected from release under federal law. To promote transparency, this report summarizes the 14 preaward reports provided to VA contracting officers in FY 2024. The 14 pharmaceutical proposals had a cumulative estimated contract value of approximately $34.4 billion and included 1,361 offered items. 

The OIG found that commercial sales practice disclosures were accurate, complete, and current for six proposals. The remaining eight proposals could not be reliably used by VA for negotiations until noted deficiencies were corrected. The OIG also determined that proposed tracking customers for all 97 sampled items were suitable for the purpose of the price reductions clause. Tracking customers are customers that serve as a benchmark for potential price reductions during the life of the contract; if tracking customers receive a price reduction, the government’s price should also be reduced. Contract negotiations for 10 proposals had been completed as of May 6, 2025, and the OIG recommended lower prices than offered for five of the proposals, assisting contracting officers in obtaining approximately $36.8 million in savings for VA over the life of the contracts.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess the impact of additional staffing on patient access to care in the community through the VA Maryland Health Care System (system) in Baltimore.

The OIG found that high consult volume contributed to system staff’s inability to schedule and complete community care consults timely and consistently coordinate community care, despite staff and system leaders taking some corrective actions to address deficiencies. The OIG also found that Care in the Community nurse care coordinators did not use care coordination plan notes for every consult or routinely document note addendums as required by the Veterans Health Administration. 

The OIG concluded that Veterans Integrated System Network leaders were aware of challenges in Care in the Community, but did not help system leaders improve and sustain consult management performance beyond providing temporary administrative staff assistance.

The OIG learned that, due to insufficient staffing, system leaders only implemented the Referral Coordination Implementation in one specialty, despite the Veterans Health Administration requirement of implementation in 34 specialty medicine areas by February 2021. The OIG concluded that, consistent with other facilities, the system struggled with Referral Coordination Initiative implementation. 

The OIG found that Patient Advocate Tracking System data was collected and trended but the Deputy Chief of Staff did not ensure the data was analyzed or staff directly implemented action plans for quality or process improvements. 

The OIG made 7 recommendations related to assessment of the Care in the Community 7-day appointment scheduling requirement, completion of performance action plans, education to address incomplete consults, consult completion, care coordination documentation, Referral Coordination Initiative implementation, and Patient Advocate Tracker System data analysis. 

Why We Did This Report

The U.S. Environmental Protection Agency Office of Inspector General conducted this evaluation to determine whether the EPA verifies that EPA-authorized state lead-based paint programs continue to meet regulatory requirements after initial authorization. We initiated this evaluation in response to an anonymous OIG Hotline complaint.
 

Summary of Findings

The EPA is not verifying that authorized state lead-based paint programs remain at least as protective of human health and the environment as the federal programs and that the programs provide adequate enforcement after initial program authorization. Without changes to the EPA’s oversight procedures, authorized state lead-based paint programs may not adequately protect public health, and children may suffer adverse and irreversible health effects.