Federal Reports

The OIG’s Mental Health Inspection Program (MHIP) evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on care delivered on the inpatient mental health unit at the VA Salem Healthcare System in Virginia. 

The inpatient unit had some aspects of a recovery-oriented physical environment, including artwork, natural lighting, and secure outdoor spaces. The local recovery coordinator was integrated into recovery-oriented activities and staff provided the required interdisciplinary programming on weekdays but not on weekends. 

The facility had an established local Mental Health Executive Council; however, the OIG could not verify that all required participants attended meetings. The facility had an admission procedure that addressed involuntary hospitalization but lacked a written process to monitor and track compliance with involuntary commitment state laws. 

Staff involved veterans in treatment planning, but did not comply with requirements to document medication risks and benefits discussions. Staff also did not consistently complete suicide screening within 24 hours before discharge, complete or review safety plans, or consistently address ways to make veterans’ environments safer from lethal means beyond access to firearms and opioids. Many staff did not have evidence of completed lethal means safety and suicide risk trainings. Additionally, most discharge instructions included abbreviations that could be difficult for veterans to understand.

The OIG was unable to determine whether Interdisciplinary Safety Inspection Team members completed the required environment of care training. Staff reported using a restraint chair; while the facility had a local policy on the use of restraints, it did not include the use of restraint chairs. 

As a result of its findings, the OIG issued 15 recommendations to facility leaders. These recommendations, once addressed, may improve the quality and delivery of veteran-centered, recovery-oriented care on the inpatient mental health unit.

The OIG’s Mental Health Inspection Program (MHIP) evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on inpatient care delivered at the VA Philadelphia Healthcare System (facility) in Pennsylvania.

The facility met some VHA requirements for the inpatient mental health unit, such as completion of twice-yearly environment of care inspections, and had some aspects of a recovery-oriented environment. However, not all areas met VHA standards for a safe, hopeful, and healing setting. Facility leaders did not establish written processes for staff to accompany veterans on outdoor breaks.

The facility did not have an established mental health executive committee for local oversight or a plan for continued transformation to recovery-oriented services. Additionally, inpatient staff did not offer the required daily hours of interdisciplinary programming. Facility leaders did not have formal written guidance to monitor and ensure compliance with state involuntary commitment laws. 

Not all electronic health records (EHRs) reviewed included documentation of a treatment plan. Most EHRs did not have evidence of required discussions with veterans on the risks and benefits of prescribed medications. Some EHRs did not have evidence of timely suicide risk screenings. Most reviewed safety plans did not address ways to make the environment safer from potentially lethal means beyond access to firearms and opioids. 

Inpatient unit clinical staff were compliant with suicide prevention trainings, but nonclinical staff did not consistently complete the required training.

The Interdisciplinary Safety Inspection Team did not adhere to VHA requirements, including staff’s completion of annual environmental safety hazards training, and did not address safety hazards, including ligature risks.

The OIG issued 20 recommendations to the Facility Director, Chief of Staff, and Associate Chief of Staff for Behavioral Health. These recommendations, once addressed, may improve the quality and delivery of veteran-centered, recovery-oriented care on the inpatient mental health.

The Postal Regulatory Commission (PRC) is an independent establishment of the executive branch that exercises regulatory oversight of the U.S. Postal Service. The PRC offers a range of benefits to its employees including, but not limited to, transit benefits, bonuses, time-off-awards, telework, remote work, flexible work schedules, recruitment and retention incentives, and paid leave. By providing these options, the PRC seeks to attract and retain a high-performing, varied workforce with workplace flexibility.

In August 2023, the Office of Inspector General received an allegation that a contractor had not provided any deliverables supporting the National Nuclear Security Administration’s (NNSA) $90 million Safety, Analytics, Forecasting, Evaluation, and Reporting (SAFER) system. The allegation claimed that the project was halfway through its 5-year contract period, but it had been “staggeringly unproductive given the money spent.” 

We initiated this inspection to determine the facts and circumstances regarding alleged productivity weaknesses and lack of deliverables from the contractor supporting NNSA’s SAFER system.

We did not substantiate the allegation that a contractor had productivity weaknesses and had not provided any deliverables on its project with NNSA. However, we identified inadequate project planning and management of the SAFER system by NNSA. For instance, key performance indicators were not developed to measure project success. In addition, user acceptance criteria was not established to measure the success of the development process and ensure that delivered functionality aligned with user requirements. Further, a required Contractor Performance Assessment Report was not completed for the base year of the contract but was completed in subsequent years.   

Based on feedback provided by SAFER users and a lack of acceptance criteria to measure the success of the development process for the safety programs, we question whether SAFER is meeting user needs. Although not fully implemented, we were unable to obtain evidence that SAFER had produced widespread benefits and improved oversight across the NNSA enterprise.

As a result of the weaknesses identified, NNSA may be unable to determine the overall health of its safety programs and potential improvements needed to those programs. The lack of progress in completing actions outlined in the Federal Data Strategy may also have hindered effective data-driven decision making. Without improvements, NNSA may continue to encounter weaknesses related to managing the SAFER project, which could delay project progress.

We made three recommendations related to establishing quantifiable metrics to measure the performance of NNSA’s investments and ensuring that data management practices and project management requirements are followed. These recommendations should improve the management of the SAFER project and help inform future technology projects.