Federal Reports

The OIG conducted a national review to evaluate the alignment of information related to mental health, substance use disorder (SUD), and suicide risk treatment needs within the Veterans Health Administration’s (VHA’s) Homeless Operations Management and Evaluation System (HOMES) data collection system and electronic health record (EHR). The OIG also assessed homeless program staff’s adherence to suicide risk screening procedures and care coordination.

Homeless program staff did not document the HOMES Assessment in 42 percent of patient EHRs, which limited access to important clinical information among clinicians outside of VA homeless programs.

The OIG found that 85 percent of patient EHRs included a suicide risk screening at the time of the HOMES Assessment or in the 30 days prior, as required. However, VHA has not implemented processes to ensure that staff complete the required suicide risk procedures, including risk mitigation, in response to HOMES-identified risk of self-harm. 

Homeless program staff did not document care coordination as outlined in VA homeless program policy. The OIG found that 35 percent of patients with HOMES-identified treatment needs, who were interested in participating in treatment, had EHR documentation of care coordination related to those treatment needs. VHA homeless program strategic goals include coordinating care to address veterans’ mental health and SUD needs; however, VHA has not delineated responsibility for ensuring care coordination, resulting in a lack of oversight and risk of patients not receiving needed mental health and SUD treatment.

The OIG made four recommendations to the Under Secretary for Health related to consistent EHR documentation of HOMES clinical information, suicide risk screening at intake, suicide risk screening in response to danger of self-harm identified in the HOMES Assessment, and documentation of mental health and SUD care coordination.  

On April 26, 2024, the Office of Inspector General received a complaint alleging that Mission Support and Test Services, LLC (MSTS) management at the Remote Sensing Laboratory (RSL) approved the transport of a supplemental pilot from Tennessee to RSL-Joint Base Andrews (RSL-Andrews) using a National Nuclear Security Administration (NNSA)-owned aircraft. Additionally, during a subsequent discussion, the complainant also alleged that MSTS did not list the supplemental pilot on the flight manifest.

We initiated this inspection to determine the facts and circumstances regarding the alleged flight concerns at the RSL.

We substantiated the allegation that MSTS management approved the transport of a supplemental pilot from Tennessee to RSL-Andrews using an NNSA-owned aircraft. An NNSA Nevada Field Office official verbally authorized the flight to address a pilot availability issue. However, we questioned whether the supplemental pilot’s role on the flight was needed. In addition, there were differences in understanding by MSTS aviation personnel about how readiness (availability of assets to rapidly respond to incidents) was tracked in the system. Contributing factors for the issues we identified included the lack of: (1) a documented policy on readiness scores and aircraft availability requirements; (2) documented communication between the Nevada Field Office and MSTS officials; and (3) guidance pertaining to NNSA public aircraft operations.

We also substantiated the allegation that the supplemental pilot was not added to the flight manifest. This occurred because of the lack of a formal written RSL policy to verify personnel on flights.

Improving transparency and access to information helps ensure Government aircraft are used solely for official purposes. Accurate flight manifests are also critical for timely responses in aviation emergencies.  

We have made five recommendations that, if fully implemented, should help ensure that NNSA-owned aircraft are used for Government purposes and that manifest information is accurate.

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Alexandria Healthcare System in Pineville, Louisiana. 

This evaluation focused on five key content domains:
     •    Culture
     •    Environment of care
     •    Patient safety
     •    Primary care
     •    Veteran-centered safety net

The OIG issued one recommendation for VA to correct an identified deficiency in one domain:
   1.    Patient safety
     •    Providers communicate test results to patients in a timely manner

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the Jonathan M. Wainwright Memorial VA Medical Center in Walla Walla, Washington. 

This evaluation focused on five key content domains:
     •    Culture
     •    Environment of care
     •    Patient safety
     •    Primary care
     •    Veteran-centered safety net

The OIG issued nine recommendations for VA to correct identified deficiencies in two domains:
   1.    Environment of care
     •    Signs and maps
     •    Emergency generator and fire door inspection and testing
     •    Environment of care committee meetings
     •    Mental Health Residential Rehabilitation Treatment Program area cleanliness
     •    Hands-free sanitizer dispensers
     •    Guidance for shelter-in-place supplies
   2.    Patient safety
     •    Service-level workflows for the communication of test results
     •    Process to monitor the communication of test results
     •    Improvement actions from root cause analyses