Federal Reports

Our objective was to determine whether the Postal Inspection Service, Washington Division, implemented effective controls for case management, accountable property, and training.

Deficiencies in the EPA’s information technology internal controls could be used to exploit weaknesses in Agency applications and hinder the EPA’s ability to prevent, detect, and respond to emerging cyberthreats.

The EPA did not achieve its mission when senior leaders issued instructions to Region 5 that impacted the region’s ability to address ethylene oxide emissions and when the EPA delayed communicating health risks regarding ethylene oxide.

The VA Office of Inspector General (OIG) evaluated allegations regarding Veterans Crisis Line (VCL) responses to a caller (caller 1) with homicidal ideation and a second caller (caller 2) with suicidal and homicidal ideation. The OIG also evaluated concerns regarding caller 1’s care at the Montana VA Health Care System (facility).The OIG substantiated a VCL responder failed to assess caller 1’s homicidal risk factors, address lethal means restriction, complete an adequate risk mitigation plan, communicate critical information to a supervisor, and take actions to prevent a family member’s death. VCL leaders did not consider an administrative investigation board to review the responder’s potential misconduct.The OIG substantiated that two social service assistants (SSAs) failed to dispatch local emergency services for caller 2 following a responder’s rescue request. The OIG identified deficiencies in SSA oversight.VCL leaders did not fully adhere to Veterans Health Administration (VHA) policies related to reporting and disclosure of adverse events.A facility primary care provider failed to include caller 1’s mental health diagnosis in the assessment and plan of care. Also, the primary care provider did not submit caller 1’s non-VA medical records for scanning into the electronic health record or document a review of the records, as expected by VHA policy.The OIG made two recommendations to the Executive Director, Office of Mental Health and Suicide Prevention, related to the establishment of quality management and disclosure processes.The OIG made seven recommendations to the VCL Director related to a review of the callers’ contacts, administrative investigation board procedures, quality management processes, responders’ communication, and SSA oversight.The OIG made two recommendations to the Facility Director related to providers’ assessment and care plans and documentation of patients’ non-VA health records.

A TVA manager was accused of improperly providing employees with gifts. While no federal ethics standards were implicated, it was determined TVA Standard Programs and Processes 11.418, Employee Recognition and Acknowledgment (TVA SPP-11.418), was not followed.