Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations related to deficiencies in the communication with and care coordination for a post-stroke patient who died by suicide at the VA Maine Healthcare System (facility) outpatient clinic in Augusta, Maine. Although the OIG identified deficiencies in the quality of care and completion of quality reviews, the OIG was unable to determine whether a change in care would have resulted in a different outcome for the patient.After the patient had a stroke, facility staff communicated with the patient and scheduled a primary care appointment. However, following the patient’s suicidal statements, facility staff were unable to engage the patient to complete a formal suicide risk screening and did not document the inability to complete the screening per Veterans Health Administration policy or ensure a safety plan was in place. Furthermore, a staff member did not follow the facility policy of notifying suicide prevention staff to garner support for the patient.A primary care provider failed to assess the patient for post-stroke depression, conduct a neurological assessment to determine cognitive or neurological impairments, or consider all options for rehabilitation services and transportation to outpatient therapy.The OIG identified deficiencies with facility quality management reviews. The root cause analysis team did not follow the required process for facility leaders’ nonconcurrence with root cause analysis findings. Additionally, facility leaders did not recognize the need to conduct a peer review of the primary care provider as required by VHA policy.The OIG made seven recommendations to the Facility Director related to suicide screening, safety plans, suicide prevention staff engagement, root cause analyses, peer reviews, and quality management reviews.

We included an audit of the Tennessee Valley Authority’s (TVA) management of early payment discounts on vendor invoices in our annual audit plan as a follow up to audit 2017-15500, Early Payment Discounts on Vendor Invoices, dated May 30, 2018, where we reported TVA missed 19 percent of all early payment discount opportunities. Our audit objective was to determine if early payment discounts are appropriately managed by TVA. Our audit scope included invoices from Supply Chain contracts and purchase orders with greater than $1 million in spend in any one fiscal year from October 1, 2020, through September 30, 2023.We found TVA’s management of early payment discounts could be improved as 18 percent of all available discounts, totaling $826,252, were not taken during the audit period. Based on our analysis and interviews with relevant personnel, we determined some personnel were often unaware of important aspects of how to manage (1) early payment discount terms, (2) invoices sent by vendors after the discount period expired, and (3) invoices sent by vendors before materials are received. Additionally, we noted TVA Supply Chain maintains dashboards that could be used to help management identify training needs.

The audit objectives were to determine whether program funds were managed in accordance with the ARC and Federal grant requirements.

The audit objectives were to determine whether program funds were managed in accordance with the ARC and Federal grant requirements.

An Amtrak secretary based in Pennsylvania violated company policies by regularly logging into work remotely, then not showing up to her worksite or arriving late, leaving early, or both. Our investigation found that the employee logged in remotely 30 times on 18 days during a one-month period, when her supervisor only approved her to work remotely on only four of the 18 days. Therefore, the employee was absent from her worksite without her supervisor’s knowledge or approval on 22 of 30 instances. She was terminated on March 12, 2024, after her corporate hearing. The former employee is not eligible for rehire.