Federal Reports

The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of care delivered at vet centers. This report focused on North Atlantic district 1 zone 4 and four selected vet centers: Baltimore and Dundalk in Maryland, Raleigh in North Carolina, and Richmond in Virginia. The OIG inspection focused on five review areas: leadership and organizational risks; quality reviews; suicide prevention; consultation, supervision, and training; and environment of care.Generally, district leaders had a good understanding of quality improvement principles and implemented district-wide quality improvement programs in response to VA All Employee Survey results. District 1 zone 4 Vet Center Service Customer Feedback survey results were below the national average in all areas except one regarding vet center location. High turnover and use of technology instead of face-to-face visits were noted as reasons.The OIG conducted an analysis of vet center quality reviews required to ensure compliance with policies and procedures. The OIG made five recommendations for clinical and administrative quality reviews and issued one finding for morbidity and mortality reviews.The suicide prevention review included a zone-wide evaluation of electronic client records, and a focused review of the four selected vet centers. The OIG issued ten recommendations—six related to the review of electronic client records and four specific to the selected vet centers’ suicide prevention and intervention processes.The consultation, supervision, and training review evaluated the four selected vet centers. The OIG identified concerns with external clinical consultation, supervision, chart audits and training, and issued four recommendations.The environment of care review evaluated the four selected vet centers. The OIG made three recommendations.The OIG issued a total of 22 recommendations for improvement to the District Director.

NASA is adapting heritage hardware from the Space Shuttle era, including solid rocket boosters and RS-25 rocket engines, to power the Artemis campaign’s Space Launch System rocket that will launch the Orion crew capsule to the Moon. This report examines whether NASA is meeting cost, schedule, and performance goals for its Booster and RS-25 Engine contracts and examines efforts to reduce the Agency’s financial risk and promote affordability.

The Semiannual Report to Congress summarizes the results of VA OIG oversight, provides statistical information, and lists all 103 work products issued from October 1, 2022, to March 31, 2023. During this reporting period, VA OIG audits, evaluations, investigations, inspections, and other reviews identified more than $401 million in monetary impact for a return on investment of $4 for every dollar spent. The OIG hotline received and triaged over 15,500 contacts in the past six months—to help identify wrongdoing and address concerns with VA activities. Also during the past six months, special agents opened 222 investigations and closed 217, with efforts leading to 122 arrests. Collectively, the OIG’s work also resulted in 595 administrative sanctions and corrective actions during the six-month reporting period.

I am pleased to submit the Amtrak Office of Inspector General (OIG) Semiannual Report to the United States Congress for the six months ending March 31, 2023, which summarizes our independent and objective reviews and investigations related to Amtrak’s programs and operations.The following report provides an overview of our oversight work during the reporting period, which underscores the dedication, experience, and value of our staff and the importance of our oversight mission. In the next six months, we will continue to focus our efforts on high-impact areas important to the company, the Board of Directors, Congress, and the public.

This Office of Inspector General Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the VA Loma Linda Healthcare System, which includes the Jerry L. Pettis Memorial Veterans’ Hospital 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 (emergency department and urgent care center suicide prevention initiatives)The OIG issued five recommendations for improvement in three areas:1. Leadership and organizational risks• Sentinel events and institutional disclosures2. Quality, safety, and value• Adverse events3. Medical staff privileging• Focused Professional Practice Evaluation processes• Reprivileging reviews