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 VA Battle Creek Healthcare System in Michigan. 

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

The OIG issued four recommendations for VA to correct identified deficiencies in two domains:
   1.    Environment of care
     •    Clean and safe environment
     •    Medical equipment maintenance
     •    Repeat findings prevention
   2.    Patient safety
     •    Service-level workflows for test result communication

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 Southern Nevada Healthcare System in North Las Vegas. 

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 identified deficiencies in one domain:
   1.    Environment of care
     •    Labels for reusable medical equipment

The Office of Inspector General (OIG) is issuing this inspection report to determine whether the SBDC met financial, programmatic, and performance requirements as prescribed in the terms and conditions of the cooperative agreement. The Small Business Administration (SBA) is authorized to make grants to states, institutions of higher education, and Women’s Business Centers to establish Small Business Development Centers (SBDCs). SBDCs, which generally consist of a lead center that manages a network of service centers, provide free business consulting and low-cost training to small businesses.

For every dollar received from SBA, SBDCs are required to provide an equal amount of funds. For program year (PY) 2023, SBA awarded the Kentucky SBDC $1,756,008 in federal funds and the SBDC contributed $1,756,008 in matching funds, for a total of $3,512,016. The period of performance for PY 2023 was from January 1, 2023, through December 31, 2024.The SBDC generally met financial requirements as prescribed in the agreement for the transactions we reviewed.

We made five recommendations for SBA to enhance and enforce financial and program compliance to strengthen program integrity, and address risks in program performance.

Management agreed with Recommendations 1 through 4 and disagreed with Recommendation 5. Notwithstanding the one disagreement, management’s actions to work with the Kentucky SBDC officials to review questioned costs, update the SBDC’s website to include service center hours and addresses, evaluate the whistleblower policy, and review reported counseling hours and capital infusion transactions resolved all 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 Indiana Healthcare System in Indianapolis. 

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

The OIG issued two recommendations for improvement in two domains:
   1.    Environment of care
     •    Maintain clean environment of care and prevent repeat findings
   2.    Patient safety
     •    Review laboratory scheduling practice change and minimize
           effect on clinic efficiency

The Tennessee Valley Authority (TVA) routinely engages in business meetings and external relationship events to conduct business and develop improved relationships.  TVA Standard Programs and Processes 13.063, Business Meetings & External Relationship Events, requires all employees responsible for planning a business meeting or external relationship event to ensure and document that the (1) business need is justified; (2) expense is reasonable, proper, and an efficient use of TVA resources; and (3) cost is appropriate to the occasion or circumstance.  Approving managers are responsible for ensuring that purchases are reasonable, for official business use, within the organization’s approved budget, and in accordance with policies and procedures.  To add an additional level of oversight for expenditures, TVA management reports these activities annually to the TVA Board of Directors.

Our audit objective was to determine if expenditures reimbursed as business meetings or external relationship events complied with TVA policies and procedures and any other applicable guidance.  Our audit scope included approximately $7.1 million in business meetings and external relationship event expenditures occurring from January 1, 2024, through December 31, 2024.

We reviewed expenditures associated with 180 business meetings and external relationship events.  We determined that while all expenditures for meetings/events were approved by TVA management or their delegates, a substantial number had expenditures that were not in compliance with policies and procedures.  Specifically, these events/meetings included (1) disallowed expenses for team-building events and alcohol and (2) meals that exceeded allowable amounts.  In addition, we identified expense reports for meetings/events that were approved that did not comply with documentation requirements.  These included expense reports approved without (1) evidence of review, (2) itemized receipts, and (3) obtaining waivers required by the Randolph Sheppard Act.

To improve transparency, the TVA Board of Directors, CEO, and Direct Reports annual Fiscal Year Expense Review Summary could be revised to (1) attribute all support staff expenses authorized by an executive to that executive in the report and (2) identify executive expenses that do not comply with policy and document justifications for the expenses.

The noncompliance issues identified were the result of TVA’s system of internal controls, including the key control, management review and approval of expenses, not operating effectively because policies and procedures were not followed or enforced by approvers of expenditures.  This included expenditures made and/or approved by some executives that did not adhere to policies. 

During fiscal year 2024, the Tennessee Valley Authority (TVA) communicated its intent to invest approximately $7 billion over the next 20 years to ensure safe and reliable operations of its three nuclear sites.  This investment is to extend and preserve the life of its nuclear units and will be accomplished through nuclear life extension (NLE) projects. Moisture separator reheaters (MSRs) are a major plant asset that will be included in the NLE focus.  Sequoyah Nuclear Plant’s (SQN) Unit 1 includes six MSRs located at the SQN Turbine Building. These MSRs have been in place since SQN Unit 1 entered commercial operation in 1981.  Because of the operational and financial impact to SQN, we performed an evaluation to determine the reasons for cost increases and schedule delays of the MSR Replacement Project.

We determined the primary reason for the cost increases and schedule delays for the MSR Replacement Project was the initial estimate and schedule did not fully consider the scope of the structural modifications necessary to support the increased size and weight of the new MSRs.  As a result, TVA spent more than three years evaluating options without an identified solution, and the project’s forecasted cost increased from $43.6 million in February 2021 to $93.9 million in September 2024. With the cost estimate increasing and over $55 million spent, TVA deferred the MSR Replacement Project.  To address MSR degradation, TVA planned a partial refurbishment project.  As of December 2025, the partial refurbishment project was complete and in‑service with a spend of approximately $37 million.  TVA continues to evaluate the feasibility of utilizing the six purchased MSRs, which cost $25.4 million, on future projects.  We also identified other cost increases related to storage costs resulting from project delays, the initial installation estimate being understated, and contractor costs that could have potentially been avoided.

In addition, we determined the MSRs were not purchased as quality‑related components in accordance with TVA’s Nuclear Regulatory Commission approved Nuclear Quality Assurance Plan (NQAP).  The NQAP details the steps necessary for properly overseeing the manufacture of quality-related nuclear plant components.  Since the MSRs were not manufactured in accordance with the NQAP, they may require additional evaluation to determine if they can be used at Sequoyah Nuclear Plant or another site in the future.  Additionally, we found that the MSR quality-related identification and purchasing issues were not properly documented in TVA’s Corrective Action Program, as required. 

Lastly, we identified actions that increased risk to TVA, including the (1) original equipment manufacturer (OEM) being absolved of liability related to the study of improvement options for the MSRs, (2) contracting officer not being included in some contract changes, and (3) OEM not being held accountable for procuring components from unapproved sources.