Federal Reports

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 Lebanon VA Medical Center and associated outpatient clinics in Pennsylvania. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (focusing on emergency department and urgent care center suicide prevention initiatives)The OIG issued one recommendation in the Leadership and Organizational Risks area of review regarding conducting institutional disclosures for sentinel events.

We found that a USBR employee wrongfully obtained $28,524 in combined Unemployment Insurance and Pandemic Unemployment Assistance.

The EPA Office of Water issued a policy memorandum in September 2021 that incorrectly advised states that they do not have to review single audits of nonfederal entities that borrow money from state revolving funds.

An Amtrak senior manager based in Philadelphia, Pennsylvania, signed a civil settlement agreement with the U.S. Attorney’s Office, Middle District of Florida, on August 15, 2023, and agreed to pay $25,441 in restitution. Our investigation found that the employee submitted applications that contained false information to the Small Business Administration to qualify for a Coronavirus Aid, Relief, and Economic Security Act Economic Injury Disaster Loan Advance.

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 San Francisco VA Health Care System, which includes the San Francisco VA Medical Center and multiple outpatient clinics in California. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (focusing on emergency department and urgent care center suicide prevention initiatives)The OIG issued five recommendations for improvement in four areas:1. Leadership and Organizational Risks• Institutional disclosures for sentinel events2. Quality, Safety, and Value• Improvement actions for peer reviews• Root cause analysis for patient safety events3. Medical Staff Privileging• Ongoing Professional Practice Evaluation results and privileging decisions4. Environment of Care• Expired supplies in supply rooms

The VA Office of Inspector General (OIG) conducted an inspection to assess concerns with access to mental health care at the Charles George VA Medical Center’s (facility) outpatient Mental Health clinic in Asheville, North Carolina. Complainants alleged concerns regarding delays in Behavioral Health Interdisciplinary Program (BHIP) assessment and psychotherapy consults; prescriber turnover; prescribers’ scope of practice; community care consults; and the role of the suicide prevention team.The OIG substantiated BHIP and psychotherapy consults were not completed within the Veterans Health Administration’s required time frame. Leaders attributed delays to staff vacancies and inefficient BHIP teams. Prescribers incorrectly believed that “permission” from the BHIP team was required before placing psychotherapy consults. Leaders did not clearly communicate with each other or fully address misperceptions about the psychotherapy consult process.The facility did not have processes to ascertain why staff leave so as to inform retention strategies that are necessary to maintain staffing levels.The OIG did not substantiate prescribers were providing care outside of their scope of practice or privileges, as applicable.Facility leaders discouraged, but did not prohibit, clinic providers from entering community care consults. Nearly all the prescribers, as well as additional non-prescribing clinic providers, submitted consults during the period of review.The OIG did not substantiate that the suicide prevention team failed to support prescribers with clinical duties, including patients with a high risk for suicide patient record flag; however, there was a general misunderstanding by some prescribers about the role of the suicide prevention team. Leaders failed to communicate to staff about the suicide prevention team’s role.The OIG made seven recommendations regarding mental health consult scheduling, community care referrals, BHIP implementation, staff retention, leaders’ communication, the role of the suicide prevention team, and follow-up care for patients with high risk for suicide patient record flags.

We reviewed Agricultural Marketing Service's (AMS) controls over the Food Purchase and Distribution Program (FPDP) and determined whether AMS purchased the type and quantity of commodities necessary to mitigate the impact from retaliatory tariffs.

In our final report, we assessed the controls Agricultural Marketing Service developed and implemented to ensure awardees fulfilled the obligations of their contracts.