Federal Reports

The Office of the Inspector General audited TVA’s internal controls in place to prevent, detect, and report unauthorized access and disclosure of human resource (HR) system Personally Identifiable Information (PII). We found TVA has weaknesses in its internal controls to prevent and detect unauthorized access and disclosure of HR system PII. TVA management agreed with our recommendations for improving the internal controls.

U.S. Immigration and Customs Enforcement (ICE) contracts with 106 detention facilities to detain removable aliens. In FY 2017, these 106 facilities held an average daily population of more than 25,000 detainees. Since the beginning of FY 2016, ICE has paid more than $3 billion to the contractors operating these 106 facilities. Despite documentation of thousands of deficiencies and instances of serious harm to detainees that occurred at these detention facilities, ICE rarely imposed financial penalties. ICE should ensure that detention contracts include terms that permit ICE to hold contractors to performance standards and impose penalties when those standards are not maintained.

The OIG investigated allegations of misuse of funds by an Alaska Native organization after the single audit found approximately $108,561 in questioned costs. The organization is funded through a cooperative agreement with the U.S. Fish and Wildlife Service. We investigated to identify any criminal misuse of funds.We confirmed the single audit findings, but we did not find criminal misuse of funds.

The VA Office of Inspector General (OIG) conducted a focused evaluation of the Washington DC VA Medical Center. The review covered key processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value (QSV); Credentialing and Privileging; Environment of Care (EOC); Medication Management: Controlled Substances (CS) Inspection Program; Mental Health: Posttraumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-Up; and High-Risk Processes: Central Line-Associated Bloodstream Infections (CLABSI). The OIG also followed up on the Facility’s progress with action plans established for a recent hotline report. The OIG noted frequent changes with Facility leaders and organizational risks with the lack of evidence of ongoing, coordinated efforts to improve identified deficiencies, employee relations, and patient care. Facility leaders, who were aware of SAIL data, employee/patient survey results, and patient safety indicators, need to take actions that improve care and performance of the Quality of Care and Efficiency metrics that are likely contributing to the current “1-Star” rating. The OIG noted findings in six processes reviewed and had an incidental finding that significantly impacts quality care. The OIG issued 18 recommendations attributable to the Director, Chief of Staff, Associate Director for Patient Care Services, and Associate Director. These are: (1) QSV • Peer review and root cause analysis (RCA) action implementation • Inpatient admissions and continued stay reviews • Interdisciplinary review of utilization management data • RCA results feedback (2) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluations (3) EOC • Construction site infection prevention • Sterile supplies • Environmental cleanliness • Medical equipment inventory and safety inspections • Mental Health seclusion room safety (4) CS Inspection Program • Physical security • CS inventory balance adjustment process • CS Coordinator position description • Reconciliation of CS returns to pharmacy (5) Geriatric Evaluations • Program oversight and evaluation (6) CLABSI • Staff education (7) Timely scanning of patient reports

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