Federal Reports

The Office of Inspector General (OIG) provides oversight to U.S. Department of Agriculture (USDA) programs and operations to help ensure that USDA is able to provide the best possible service to the public and American agriculture. OIG focuses its efforts to advance the value, safety and security, and integrity of USDA programs. In providing such oversight, OIG makes recommendations to address agency programs and core management functions that may be vulnerable to waste, fraud, abuse, and mismanagement. These vulnerabilities can affect USDA’s ability to achieve its mission. Since the Reports Consolidation Act of 2000, OIG has annually reported on the Department’s progress in addressing its most critical management challenges. The COVID-19 pandemic, and USDA’s increased responsibilities for program delivery, have made addressing these challenges even more important.

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The VA Office of Inspector General (OIG) conducted a healthcare inspection after receiving a referral from OIG inspectors regarding facility leaders’ response to a report that a urologist had severe hand tremors and possibly low vision. The OIG identified two adverse clinical outcomes in 121 of the urologist’s surgical patients, neither of which required an increased level of care and did not result in long-term impact. The OIG determined the two complications were appropriately managed by the urologist, reported through the patient safety reporting system, and acted upon. Facility leaders failed to adequately oversee the urologist’s performance by not formally evaluating a report of the urologist’s physical impairments that could have posed a risk to patient safety. The facility conducted management reviews of the urologist, but deficiencies were identified in the processes used. Failures in facility leaders’ privileging processes led to delays in removing the urologist’s privilege to perform open procedures and a failure to inform the urologist of active privileges. Facility leaders were noncompliant with VHA directives that require reporting adverse privileging actions to the National Practitioner Data Bank and reporting patient safety concerns to state licensing boards. Consequently, patient safeguards intended to be achieved through reporting did not occur. Frequent personnel changes in facility-leader positions may have contributed to failures in oversight, privileging, and practitioner reporting processes. The noncompliance with facility and VHA policies likely occurred due to poor communication regarding the urologist’s practice and privileging status, a lack of knowledge of position responsibilities, and inexperienced support staff. The deficiencies found in the focused professional practice evaluation processes and National Practitioner Data Bank reporting were consistent with issues previously identified by the OIG. Duplicative recommendations were not made regarding these issues. The OIG made six recommendations to the Veterans Integrated Service Network 7 and facility directors.

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We audited the Tennessee Valley Authority’s (TVA) business meeting and hospitality expenses to determine if they complied with TVA’s Business Meetings and Hospitality policy and any other applicable TVA guidance. Our audit scope included approximately $6.5 million in business meeting and hospitality expenses occurring from October 1, 2018, through September 30, 2019.Our audit found TVA’s approval process did not ensure expenses complied with the Business Meetings and Hospitality Policy. Specifically, we found expenses were approved for (1) reimbursement and/or payment without the required information and supporting documentation included with the expense voucher, (2) questionable team-building expenditures, and (3) prohibited alcohol expenditures. We also found a lack of guidance for compliance with TVA’s Food Services Policy. Additionally, we found the process for approving large meeting expenses and guidance for the classification of meeting-related expenses could be improved.We made five recommendations to TVA management to strengthen controls around business meetings and hospitality by (1) developing additional guidance to ensure compliance with the Business Meetings and Hospitality Policy and Food Services Policy, and (2) reinforcing the existing Food Services Policy. TVA management provided actions they plan to take to address each of our recommendations.

We included an audit of the Tennessee Valley Authority’s (TVA) plans for an active shooter incident in our annual audit plan due to the potential risk of an active shooter incident occurring. Our audit objective was to determine if TVA has adequate plans in place to prevent, prepare for, and manage active shooter incidents. The audit scope included all program documentation and records that support TVA's plans to prevent, prepare for, and manage active shooter incidents as of May 13, 2020. We compared TVA’s procedures around preventing, preparing for, and managing active shooter incidents to best practices recommended by the Department of Homeland Security (DHS). DHS best practices include four steps (Connect, Plan, Train, and Report) to apply in advance of an incident or attack. We found TVA has plans in place to prevent, prepare for, and manage active shooter incidents that include steps to address the connecting and planning phases of DHS recommendations to prepare for active shooter incidents. However, we found the training and reporting steps need improvement. Specifically, we found TVA’s Active Threat Awareness program training is not mandatory and less than 10 percent of TVA’s employees have taken the training. In addition, portions of best practices related to active threat awareness are included in at least ten TVA Standard Programs and Processes rather than a single document and are not easily accessible by employees. TVA management agreed with our findings and recommendations.