Federal Reports

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Bedford Healthcare System, which includes the Edith Nourse Rogers Memorial Veterans’ Hospital in Bedford and three outpatient clinics in Massachusetts. 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 four areas:1. Leadership and organizational risks• Institutional disclosures for applicable sentinel events2. Quality, safety, and value• Root cause analysis for patient safety events3. Environment of care• Patient care areas clean and free from undue wear• Inpatient mental health unit over-the-door alarm testing4. Mental health• Comprehensive Suicide Risk Evaluation completion

Our objective for this alert was to determine facility opening procedures and mail conditions at the South Houston Local Processing Center.Each year, increased mail volume during the Postal Service’s peak mailing season — Thanksgiving through New Year’s Eve1 — significantly strains the Postal Service’s processing and distribution network. The Postal Service opens peak season annexes to temporarily help with increased package volume at select processing facilities. As part of our peak season audit, we assessed the Postal Service’s acquisition and use of these peak season annexes. One such annex we identified was the South Houston Local Processing Center (LPC), which opened on November 18, 2023, and was associated with the North Houston Processing and Distribution Center (P&DC).

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Salt Lake City Health Care System, which includes the George E. Wahlen VA Medical Center in Salt Lake City and multiple outpatient clinics in Idaho, Nevada, and Utah. 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 six recommendations for improvement in three areas:1. Medical staff privileging• Focused Professional Practice Evaluation results2. Environment of care• Environment of care inspections• Inpatient Psychiatry Unit: • Panic and over-the-door alarm testing • Maintaining a safe environment3. Mental health• Comprehensive Suicide Risk Evaluation completion

The Office of the Inspector General performed an audit to determine the effectiveness of the Tennessee Valley Authority’s (TVA) business application retirement process. Our scope included application retirement requests in TVA’s ticketing system as of December 6, 2023. We determined TVA's business application retirement process was ineffective. Specifically, the application retirement process did not (1) have clear ownership and accountability, (2) have effective controls to prevent duplicate requests and incomplete data, and (3) align with best practices. As a result of the ineffective process, only one application had been retired since September 28, 2022, and 631 business application retirement requests were between 1 and 434 days outstanding. TVA management agreed with our recommendations.