Federal Reports

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In response to a request from Representative Tim Walz, the VA Office of Inspector General (OIG) reviewed the care of a patient who died from a self-inflicted gunshot wound less than 24 hours after discharge from the inpatient mental health unit of the Minneapolis VA Health Care System. The OIG determined that an inpatient interdisciplinary treatment team failed to include the outpatient treatment team in discharge planning, did not manage medication follow-up, and did not educate the patient on limiting access to firearms. The inspection also revealed inadequate documentation of clinicians’ assessments of the patient’s access to unsecured firearms, as well as efforts to contact the family to secure weapons, engage in treatment or discharge planning, or to confirm the discharge plan that included release to the parents’ home. The System Suicide Prevention Coordinator did not collaborate with the inpatient interdisciplinary treatment team during admission, determine the need for a Patient Record Flag indicating a high risk for suicide before discharge, or provide required Suicide Behavior Report training to System clinical staff. Beyond the case findings, the OIG found the Suicide Prevention Coordinator failed to complete 22 percent of a sample of 2017 and 2018 Behavioral Health Autopsies within the required timeframe. System staff also failed to follow policy for conducting a root cause analysis. The OIG was unable to determine that identified deficits, alone or in combination, were a causal factor in the patient’s death. However, the OIG made seven recommendations related to interdisciplinary team collaboration, determination of Patient Record Flag status, accuracy of mental health clinical documentation, Suicide Behavior Report training, timely completion of Behavioral Health Autopsies, documentation of Suicide Prevention Awareness Committee activities, and the root cause analysis process.

The Postal Service implemented use of Intelligent Mail barcodes (IMb) in September 2006, to sort and track individual letters, cards, and flats. The technology offers greater versatility by allowing many services to be requested and embedded in one barcode. The Postal Service obtains reports related to IMb data from various systems, including its data analytics platform, the Informed Visibility (IV) system. Our objective was to assess whether the Postal Service can leverage IMb data in the IV system to enhance the accuracy and reliability of mail processing costs for First-Class Mail letters.

Due to the importance of the clearance procedure to plant personnel safety, and in response to recent fatalities resulting from clearance violations, we initiated a review of TVA’s coal operations’ clearance procedure. We determined the clearance procedure was being performed for work requiring clearances. However, the effectiveness of the clearance process is limited because (1) some clearances were not in compliance with the clearance procedure, (2) required training had not been completed by all personnel holding or working on clearances, and (3) audits performed were not in compliance with the procedure. We also identified opportunities for improvement related to procedure clarification and training.