Federal Reports

The VA Office of Inspector General (OIG) conducted a national review to evaluate the Veterans Health Administration’s (VHA’s) suicide risk screening and evaluation training, adherence, and oversight procedures. VHA’s standardized Suicide Risk Identification Strategy (Risk ID) process requires annual screening using the Columbia-Suicide Severity Rating Scale (screening) and comprehensive suicide risk evaluation (evaluation) in response to a positive screening. VHA also recognized the need for screening beyond annual screening and implemented setting-specific Risk ID requirements in 10 clinical settings.

The OIG found that VHA’s required suicide prevention training does not include Risk ID processes or requirements. Training related to Risk ID responsibilities is available. However, the training is optional and not monitored.

VHA has not established annual or setting-specific Risk ID performance benchmarks and has conveyed inconsistent expectations to facility leaders and staff. In fiscal year 2023, annual screening and evaluation adherence was 55 and 82 percent, respectively. In a November 2020 memorandum, VHA expected 100 percent adherence, while other VHA documents reference expectations ranging from 81 to 95 percent. Furthermore, except for emergency department and urgent care settings, VHA does not monitor setting-specific Risk ID adherence.

The OIG determined that staff encountered barriers to completing Risk ID screening and evaluation, which included (1) limited engagement of facility clinical staff, (2) lack of facility leaders’ support, (3) limitations of performance data, and (4) unclear delineation of responsibilities.

The OIG made six recommendations to the Under Secretary for Health related to suicide risk and intervention training, suicide screening and evaluation performance benchmarks, setting-specific Risk ID monitoring, effectively addressing barriers to Risk ID non-adherence, non-mental health clinical specialty leaders’ awareness of Risk ID requirements, and clear identification of Risk ID monitoring and oversight responsibilities.

In accordance with the Government Performance and Results Modernization Act of 2010, this report presents the results of the OIG's work over fiscal year 2024 in meeting its performance goals.

This report presents the results of our audit of Network Changes: Local Transportation Optimization.

In June 2019, the Tennessee Valley Authority (TVA) completed an Integrated Resource Plan and recommended the expansion of solar generating capacity by up to 14,000 megawatts (MW) by 2038. According to TVA’s fiscal year 2020 Sustainability Report, TVA set a sustainability aspiration to achieve 10,000 MW of solar generation by 2035. To help achieve this goal, TVA purchased 3,000 acres to construct an estimated 200 MW solar facility in Lawrence County, Alabama. TVA purchased 139,750 solar panels, totaling $30 million, in December 2019 for installation at the Lawrence County Solar (LCS) project. TVA began receiving these solar panels in late January 2020 and received the final shipment on March 30, 2020. The project was originally estimated to be in service by December 2023. Due to delays in the LCS project, the solar panels purchased in 2019 were transferred to another TVA project. TVA subsequently purchased an additional 581,250 solar panels for $92.7 million in May 2023 for installation at the LCS project.

TVA’s Standard Programs and Processes 34.000, Project Management, states risk assessments should be performed as early as possible in a project to identify critical technical, performance, schedule, and cost risks. Due to the length of time the solar panels purchased in 2019 for the LCS project have been in inventory, we performed an audit of TVA’s assessment of risks associated with solar panel purchases for the LCS project. Our audit objective was to determine if TVA assessed risks in accordance with applicable policies and procedures prior to the purchase of solar panels for the LCS project. Our audit scope included the solar panels purchased in calendar years 2019 and 2023.

We determined TVA (1) did not perform a risk assessment prior to purchasing solar panels in 2019 and (2) only performed a partial risk assessment prior to the purchase of the 2023 solar panels. Additionally, the solar panels purchased in 2023 were procured after the project had been placed on hold by TVA.