This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the W.G. (Bill) Hefner VA Medical Center in Salisbury, North Carolina.This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued four recommendations for improvement in the mental health area of review:• Comprehensive Suicide Risk Evaluationo Completion following positive suicide screeno Suicide prevention team notified of suicidal or self-directed violent behaviors in previous 12 months• Full-time suicide prevention coordinator appointed for community-based outpatient clinics that serve 10,000 veterans annually• Suicide-related events reported monthly to mental health leaders and quality management staff
Report Date | Agency Reviewed / Investigated | Report Title | Type | Location | |
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Department of Veterans Affairs | Comprehensive Healthcare Inspection of the W.G. (Bill) Hefner VA Medical Center in Salisbury, North Carolina | Inspection / Evaluation |
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National Aeronautics and Space Administration | NASA’s Privacy Program | Audit | Agency-Wide | View Report | |
Peace Corps | Management Advisory Report: Cybersecurity Breaches Highlight a Need for Improvement in Peace Corps’ Incident Response (IG-24-01-SR) | Other | Agency-Wide | View Report | |
Department of the Interior | Review of the U.S. Department of the Interior’s Actions Related to January 6, 2021 | Review | Agency-Wide | View Report | |
International Trade Commission | Management Letter Fiscal Year 2023 Financial Statement Audit | Audit | Agency-Wide | View Report | |
Department of Defense | Report of Investigation: Mr. William K. Lietzau former Director, Defense Counterintelligence and Security Agency | Investigation | Agency-Wide | View Report | |
Internal Revenue Service | The Internal Revenue Service Is Not Fully Complying With the No TikTok on Government Devices Implementation Guidance | Inspection / Evaluation | Agency-Wide | View Report | |
Internal Revenue Service | The Internal Revenue Service Is Developing a Digital Asset Monitoring and Compliance Strategy | Inspection / Evaluation | Agency-Wide | View Report | |
Internal Revenue Service | Improvements Are Needed to Ensure the Health and Safety of Employees at the C-site | Inspection / Evaluation | Agency-Wide | View Report | |
Amtrak (National Railroad Passenger Corporation) | Supervisor Demoted After Using Amtrak-Leased Vehicle for Personal Use | Investigation |
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