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Brought to you by the Council of the Inspectors General on Integrity and Efficiency
Federal Reports
Report Date
Agency Reviewed / Investigated
Report Title
Type
Location
National Endowment for the Arts
Performance Audit of the Western States Arts Federation Denver, CO
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.
This report summarizes the results of CLA’s independent evaluation and contains two recommendations that will assist the agency in improving the effectiveness of its information security and its privacy programs and practices. NCUA management concurred with and has identified corrective actions to address the recommendations.
On March 18, 2022, the Peace Corps notified the United States Congress that Peace Corps/Morocco (hereafter referred to as “the post”) intended to resume operations in September 2022. The first intake of 51 Volunteers arrived in September 2022. On November 21, 2022, the Office of Inspector General (OIG) announced this review to assess the post’s compliance with specific agency policies and procedures related to Volunteer and trainee health and safety, and the re-entry process.
A Patient’s Suicide Following Veterans Crisis Line Mismanagement and Deficient Follow-Up Actions by the Veterans Crisis Line and Audie L. Murphy Memorial Veterans Hospital in San Antonio, Texas
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.
Financial Audit of the Schedule of Expenditures Incurred by People In Need in Multiple Countries Under Multiple USAID Awards for the Fiscal Year Ended December 31, 2020