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 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.

What We Looked AtWe queried and downloaded 93 single audit reports prepared by non-Federal auditors and submitted to the Federal Audit Clearinghouse between April 1, 2023, and June 30, 2023, to identify significant findings related to programs directly funded by the Department of Transportation (DOT).What We FoundWe found that reports contained a range of findings that impacted DOT programs. The auditors reported 26 incidents of significant noncompliance with Federal guidelines related to 18 grantees that require prompt action from DOT’s Operating Administrations (OA). Of the 26 significant findings, 13 were repeat findings related to 8 grantees. The auditors also identified questioned costs totaling $2,892,004 for five grantees. Of this amount, $2,550,676 was related to the Confederated Tribes of the Colville Reservation, Nespelem, WA. Additionally, we identified nonmonetary repeat findings that caused a qualified opinion for the Hydaburg Cooperative Association, Hydaburg, AK, the City of Fairburn, Fairburn, GA, and the Yankton Sioux Tribe, Wagner, SD.RecommendationsWe recommend that DOT coordinate with the impacted OAs to develop a corrective action plan to resolve and close the findings identified in this report. We also recommend that DOT determine the allowability of the questioned transactions and recover $2,892,004, if applicable. 

We substantiated allegations that a marina owner submitted false receipts for an FWS grant and violated the terms and conditions of the grant.

The U.S. Environmental Protection Agency Office of Inspector General conducted this evaluation to determine whether the EPA has verified that its own laboratories are complying with Resource Conservation and Recovery Act requirements for the management of hazardous waste.

Objectives: To determine whether the Social Security Administration’s (SSA) completed counts for program integrity and hearings workloads in Fiscal Years 2017 through 2021 were complete and accurate. In addition, we determined whether SSA’s spending exceeded dedicated funding amounts for program integrity and hearings backlog workloads.

The report provides information for administrative law judge trends for Fiscal Years 2018 through 2022.