Federal Reports

The OIG evaluated allegations related to the care of a patient who died by suicide six days after a mental health appointment at the VA Tuscaloosa Healthcare System (facility). Concerns regarding appointment scheduling, supervision of a posttraumatic stress disorder (PTSD) clinic social worker (social worker), and leaders’ administrative actions were reviewed.The OIG substantiated that a mental health nurse practitioner failed to inform the patient of a mirtazapine-related suicide risk, complete required suicide screening, and closely monitor the patient after initiating mirtazapine. Administrative staff did not attempt to schedule the patient’s medication management follow-up appointment within two business days, as required.The OIG substantiated that the social worker failed to sufficiently assess suicide risk, conduct lethal means safety counseling, and seek consultation. Facility staff did not arrange the patient’s PTSD treatment and the social worker received inadequate supervision.The OIG substantiated that staff did not submit a consult for required traumatic brain injury evaluation.Staff did not inform leaders about closing an incomplete root cause analysis action item. The peer review committee failed to address two identified system issues. Further, a suicide prevention coordinator failed to complete required Behavioral Health Autopsy Program (BHAP) documentation.VHA leaders did not provide guidance to suicide prevention staff on when not to contact family to offer a BHAP interview, and facility leaders did not conduct an institutional disclosure due to an erroneous understanding of requirements.The OIG made one recommendation to the Under Secretary for Health to consider establishing written guidance regarding the BHAP family interview process, and 13 recommendations to the Facility Director related to reviewing the patient’s care; boxed warning education; suicide risk screenings; appointment scheduling; lethal means safety counseling; PTSD clinic processes; traumatic brain injury evaluation; and root cause analysis, peer review, BHAP, and institutional disclosure processes.

The AmeriCorps Office of Inspector General (AmeriCorps OIG) investigated allegations that AmeriCorps Volunteers in Service to America (VISTA) members at Heal the City Free Clinic (HTC), located in Amarillo, TX, were engaging in prohibited activities. HTC was a VISTA service site for the Lone Star Association of Charitable Clinics, also known as the Texas Association of Charitable Clinics (TXACC).

We performed an audit of costs billed to the Tennessee Valley Authority (TVA) by Barnard Construction Company, Inc., (Barnard) to provide TVA support in connection with its coal combustion residual conversion program, activities or projects, and/or waste-water treatment, dewatering, and landfill projects under Contract No. 13159. The contract provided for TVA to compensate Barnard for work on either a cost-reimbursable, target cost estimate, time and materials, fixed price, or fixed unit rate basis. Our audit objectives were to determine (1) if the costs billed to TVA were in accordance with the contract’s terms and (2) the reasonableness of TVA’s process for evaluating and awarding fixed price or fixed unit rate tasks issued under the contract. Our audit scope included about $140.6 million in costs paid by TVA from January 1, 2021, through July 27, 2023, for purchase orders with initial payments after January 1, 2021. This included approximately $83.7 million for fixed price projects, $23.2 million for fixed unit rate projects, and $33.7 million for cost reimbursable projects.In summary, we determined Barnard generally billed cost-reimbursable projects in accordance with the contract, except (1) Barnard billed salaried personnel at an average rate for each labor category instead of actual salaries, and (2) the fee structure agreed upon in the work releases and paid by TVA did not meet the intent of the fee structure provided for in the contract. In addition, we determined there were opportunities to strengthen TVA’s process for evaluating and awarding fixed price and fixed unit rate tasks that were issued when TVA received limited or no competition.