Federal Reports

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the Sheridan VA Health Care System in Wyoming. 

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

The OIG issued three recommendations for improvement in two domains:
  1.    Environment of care
     •    Facility navigation tools for sensory-impaired veterans
  2.    Patient safety
     •    Patient test result communication effectiveness
     •    Service-specific workflows for test result communications

The Tennessee Valley Authority’s (TVA) Supply Chain organization enters into blanket contracts with vendors to support TVA goals and lower total costs to TVA.  Blanket contracts are defined as open-scope contracts under which TVA may place multiple orders for designated products or services over a set timeframe.  Defined scopes of work and TVA’s commitment to buy are established through purchase orders (PO) issued against existing blanket contracts.

Under appropriate circumstances, TVA may group multiple blanket contracts that have the same general scope of work under a master contract.  TVA’s Supply Chain Buyer Guide, which defines best practices for contracting officers, describes this process as the competitive model.  According to the Buyer Guide, competitions between vendors under a competitive model can often be conducted quickly to better support organizational needs.

Due to issues identified in previous audits related to TVA’s lack of competition of fixed price POs, we conducted an audit to assess TVA’s process for evaluating and awarding POs issued under blanket contracts. Our audit scope focused on POs issued under blanket contracts where TVA has multiple blanket contracts for a general scope of work. 

In summary, we determined TVA does not have an overall policy and there are limited procedures and guidance for evaluating and awarding POs issued under blanket contracts where TVA has multiple blanket contracts for a general scope of work.  This has resulted in inconsistencies in how Supply Chain and the organizations have evaluated and awarded POs.  Specifically, we determined there were inconsistencies in the level of (1) competition between prequalified vendors when issuing POs and (2) Supply Chain involvement in the evaluation and selection of vendors.  With limited guidance on evaluating and awarding POs issued under blanket contracts, TVA increases its risk of not achieving best value for TVA.

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 Coatesville Healthcare System in Pennsylvania. 

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

The OIG issued no recommendations.

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 Boston Healthcare System in Massachusetts. 

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

The OIG issued 11 recommendations for improvement in two domains:
  1.    Environment of care
     •    Processes to prevent repeat findings
     •    Biological hazard signs
     •    Safe and clean patient care areas
     •    Medication storage areas
           o    Restricted access
           o    Pharmacy staff inspections
           o    Temperature and humidity
     •    Urgent Care Center operates according to VHA Directive 1101.13
     •    Repeat findings and sustained improvements
     •    Trends, performance improvement plans, and outcome measures
  2.    Patient safety
     •    Test result communication policy complies with VHA directives for critical test results

Follow-Up on the Evaluation of the Federal Labor Relations Authority’s
Compliance with the Privacy Act Mandatory Annual Training Requirement
for Fiscal Year 2023

The U.S. AbilityOne Commission's Office of the Inspector General has issued an OIG Alert to inform Program stakeholders of recent activities of a third party. Specifically, the third party entity has published incorrect and misleading information regarding OIG activities and has insinuated that they have confidential OIG information.