Federal Reports

The Office of Inspector General (OIG) performed an inspection of the Farm Service Agency (FSA) to determine the likely level of sophistication an attacker would need to compromise selected USDA systems or data.

The OIG reviewed concerns that Veterans Crisis Line (VCL) staff mismanaged a patient’s contact prior to the patient’s death by suicide within the hour after VCL text contact. The OIG also evaluated Audie L. Murphy Memorial Veterans Hospital (facility) leaders’ and staff’s administrative actions following notification of the patient’s death.The OIG found that a VCL responder completed an inadequate assessment of the patient’s suicidal preparatory behavior and alcohol use and failed to establish an effective safety plan, confirm reduced access to lethal means, involve a family member in safety planning, consider a telephone transfer, and complete accurate documentation. It was also determined that VCL leaders provided inadequate oversight and quality assurance by failing to ensure sufficient silent monitor contacts and text message retention.The OIG further found inadequate and problematic leader and staff actions following the patient’s death. VCL leaders and staff failed to complete a root cause analysis and consider disclosure, potentially interfered in the OIG inspection, failed to alert facility staff of the patient’s death and address a family member’s complaint, and delayed discontinuation of caring letters. Facility leaders and staff failed to update the patient’s electronic health record and complete a behavioral health autopsy.The OIG made eleven recommendations to the VCL Director related to review of staff’s management of the patient’s contacts, suicide risk assessment classification guideline alignment, quality management oversight, text retention, issue brief accuracy, review of customers’ deaths by suicide and accidental overdose, institutional disclosure, notification of a customer’s death, review of leader and staff interactions during OIG inspection preparation, complaint submission, and caring letters discontinuation.The OIG made three recommendations to the Facility Director related to timely death notification processes, standard operating procedure adherence for actions following a death by suicide, and Behavioral Health Autopsy Program implementation.

The VA Office of Inspector General (OIG) conducted this audit to determine whether the Veterans Benefits Administration’s Veteran Readiness and Employment Service (VR&E) properly approved and monitored participants’ use of Chapter 31–only programs, which assist veterans who have service-connected disabilities that limit employment opportunities. By law, these programs may only be used when approved GI Bill programs are insufficient to meet a veteran’s unique training needs.The OIG found that VR&E did not properly implement a December 2016 law that required individual waivers from the VR&E executive director each time a Chapter 31–only program was selected for a participant. This was because VR&E did not correctly interpret the law. Consequently, VR&E did not issue these veteran-specific waivers and did not implement controls to provide the necessary oversight to limit these programs to veterans with the requisite needs. Further, VR&E did not complete compliance surveys for Chapter 31–only programs, though the law and VR&E’s manual require them. The OIG determined that VA paid over $13 million in questioned costs for these programs that likely would not have received those funds had VR&E limited use of the programs.After the OIG presented its findings, VR&E took steps to remedy these issues, such as issuing new guidance to require approved GI Bill programs to the maximum extent possible or approve each participant individually, ensure proper documentation of decisions, develop training, and update the manual to clarify when these programs may be used.VA concurred with the OIG’s five recommendations to ensure VR&E understands the laws and regulations that govern Chapter 31–only programs, trains all staff on waivers and compliance surveys, reviews and updates the manual as needed, and develops a monitoring process. Two recommendations have been closed as implemented based on VA-submitted documentation.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the VA Sierra Nevada Health Care System, which includes the Ioannis A. Lougaris VA Medical Center and multiple outpatient clinics in California and Nevada. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (emergency department and urgent care center suicide prevention initiatives)The OIG issued six recommendations for improvement in three areas:1. Quality, Safety, and Value• Peer review aspects of care• Peer Review Committee improvement actions2. Environment of Care• Panic alarm testing documentation• Patient safety cameras• Minimizing risk of self-harm3. Mental Health• Patient follow-up

Our objective was to evaluate the USPS Loyalty Program’s performance, customer experience, and management. We reviewed related regulatory filings and business rules, interviewed Postal Service officials, and analyzed user feedback.

Interim Report: Audit of the Effectsthe Main Street Lending Program’sLoan Losses Have on Treasury’sInvestment in the Program