Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess the quality of care provided during a patient’s hospitalization, which ended with the patient’s death at the Lt. Col. Luke Weathers, Jr. VA Medical Center (facility) in Memphis, Tennessee. The OIG also evaluated facility leaders’ response to the patient’s care.A telemetry technician’s failure to follow a series of communications within the time frame established in the facility’s cardiac telemetry monitoring policy delayed initiating a blue alert, which may have affected the patient’s outcome. A charge nurse’s failure to assign a nurse to care for the patient or provide accurate nursing assignments to the telemetry technician may have also contributed to the delay. Additionally, an intensive care unit fellow did not document a response to a critical care consult and did not recall the patient, rendering the OIG unable to determine the clinical decision-making rationale.Facility leaders’ factfinding and root cause analysis reviews of the patient’s care were not thorough, which hindered identification of systemic and causal factors. Contributing factors included a nursing leader who did not issue an authorization letter to provide the factfinding investigator guidance on the focus of the review, and the root cause analysis team who did not interview some staff directly involved with the patient event, as required.The OIG made five recommendations to the Facility Director related to compliance with the cardiac telemetry monitoring policy, making and communicating nursing assignments, documenting critical care consults, conducting factfindings and root cause analyses, and consideration of another root cause analysis.

The Cybersecurity and Infrastructure Security Agency (CISA) had extensive products and services to manage risks and mitigate cybersecurity threats to critical water and wastewater infrastructure and increase its resiliency. However, CISA did not consistently collaborate with the Environmental Protection Agency and the Water and Wastewater Systems Sector to leverage and integrate its cybersecurity expertise with stakeholders’ water expertise.

During fiscal years 2018 through 2022, we issued 61 reports and 178 recommendations for improving conditions at the Southwest border. As of August 17, 2023, 144 recommendations were closed, 31 recommendations were resolved and open, and 3 recommendations remained unresolved.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the Tomah VA Medical Center in Wisconsin. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued five recommendations for improvement in three areas:1. Medical staff privileging• Ongoing Professional Practice Evaluations2. Environment of care• Environment of care inspections• VA police response times to panic alarm testing in the inpatient mental health unit3. Mental health• Monthly outreach activities• Monthly suicide-related data reporting to local mental health and quality management leaders

This report contains information about recommendations from the OIG's audits, evaluations, reviews, and other reports that the OIG had not closed as of the specified date because it had not determined that the Department of Justice (DOJ) or a non-DOJ federal agency had fully implemented them. The list omits information that DOJ determined to be limited official use or classified, and therefore unsuitable for public release.The status of each recommendation was accurate as of the specified date and is subject to change. Specifically, a recommendation identified as not closed as of the specified date may subsequently have been closed.

The Office of the Inspector General conducted an evaluation to determine if the Tennessee Valley Authority (TVA) is performing preemployment suitability and onboarding steps necessary for access in a timely manner. We found TVA was allowing access to TVA facilities while not always performing preemployment suitability and onboarding steps in a timely manner. Specifically, we determined that the Form I-9, for 381 of 1,571 personnel (24 percent) hired between October 1, 2021, and June 30, 2023, was either not completed in a timely manner or never completed in accordance with the Immigration Reform and Control Act of 1986 and 8 Code of Federal Regulations §§ 274a.1-274a.14. However, according to TVA Police and Emergency Management personnel, physical access should have been revoked but was not because Human Resources and Administration does not notify them when the I-9 threshold is exceeded. Additionally we identified opportunities to strengthen TVA Standard Programs and Processes to better align with federal requirements.