Federal Reports

The VA Office of Inspector General (OIG) reviewed allegations referred by Chairman Mark Takano, House Committee on Veterans’ Affairs, regarding deficiencies in the mental health care provided at the Ralph H. Johnson VA Medical Center (facility) to a high risk for suicide patient who died by suicide.The OIG did not substantiate that service agreement procedures resulted in inadequate psychiatric monitoring or delayed psychiatric care or that facility staff delayed placement of the patient’s high risk for suicide patient record flag.The OIG found that staff did not adequately evaluate the patient’s condition when reviewing the patient’s high-risk status. Facility staff did not assign a Mental Health Treatment Coordinator (MHTC) prior to discharge or establish a facility MHTC policy, as required. The Recovery Engagement and Coordination for Health – Veterans Enhanced Treatment (REACH VET) provider did not outreach the patient, as required.Facility staff did not comply with Veterans Health Administration suicide risk assessment procedures and did not notify facility leaders or suicide prevention staff of the patient’s death by suicide.The OIG made five recommendations to the Facility Director related to high risk for suicide patient record flag reviews, MHTC assignment, REACH VET program requirements, suicide risk assessment, and staff notification of patients’ death by suicide.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate concerns related to Ralph H. Johnson VA Medical Center (facility) staff’s management of a patient’s reported perpetration of intimate partner violence (IPV). The OIG also evaluated concerns related to the IPV Assistance Program (IPVAP) implementation at the facility.The OIG found that despite the patient’s and spouse’s IPV reports, inpatient mental health unit staff did not consult with the IPVAP point of contact or ensure the spouse felt safe with the patient returning home upon discharge. The inpatient psychiatry resident did not timely complete a progress note addendum, which resulted in other clinicians not having access to critical IPV related information for 34 days. Facility staff failed to consider consultation with the Office of Chief Counsel although the Veterans Health Administration (VHA) advises employees to “work with your Office of Chief Counsel” regarding state reporting requirements for victims of IPV. Outpatient mental health staff did not consult with the IPVAP point of contact or document discussion of IPV resources or treatment options, as the OIG would have expected. The Facility Director did not ensure development of an IPVAP protocol, as required, and although a licensed independent provider was appointed as the IPVAP coordinator, facility staff and leaders did not identify the assigned IPVAP coordinator as a resource at the time of the patient’s care in 2019. The OIG also found that VHA guidance about IPV training responsibilities was unclear.The OIG made one recommendation to the Under Secretary for Health related to IPV training guidance and three recommendations to the Facility Director related to staff consultation with the IPVAP coordinator, timely clinical documentation, and consultation with the Office of General Counsel to determine reporting requirements.

We found that NPS employees did not follow compliance and protection requirements for archeological resources in Virgin Islands National Park.

Every Postal Service-owned vehicle is assigned a Voyager credit card to pay for its commercially purchased fuel, oil, and routine maintenance. OIG data analytics identified offices with potentially fraudulent Voyager card activity. The Wilmington, NC, Magnolia Station had 1,713 transactions at risk from October 1, 2020, through March 31, 2021, totaling $41,211. This included 282 Voyager card fuel purchases conducted with one employee’s PIN and valued at $6,084 and 60 transactions flagged as high-risk in FAMS. The objective of this audit was to determine whether Voyager card PINs were properly managed, and Voyager card transactions were properly reconciled at the Wilmington, NC, Magnolia Station.

Final Management Letter: Review of the SEC's Compliance With CISA ED 21-01 and Initial Response to the SolarWinds Compromise

John Pangelinan, a medical marketer based in Los Angeles was sentenced on August 2, 2021, to time served and two years’ probation for conspiracy to commit honest services mail fraud and health care fraud. Pangelinan brokered kickbacks and bribe payments to doctors in exchange for their referrals of compounded medications, durable medical equipment, and other health care goods to certain providers.Our investigation found that Pharmacy Acquisition LLC provided medically unnecessary compounded drug prescriptions to Precise Compounding Pharmacy that were reimbursed by health care benefit programs, including Amtrak’s plan. As a result of the scheme, Amtrak’s insurance providers were fraudulently charged approximately $22,000.