Federal Reports

Williams, Adley & Company – DC, LLP (Williams Adley), under contract with the Department of Homeland Security Office of Inspector General, issued an Independent Accountant’s Report on the U.S. Customs and Border Protection’s (CBP) Detailed Accounting Report. CBP management prepared the Table of FY 2022 Drug Control Obligations and related assertions to comply with the requirements of the ONDCP Circular, National Drug Control Program Agency Compliance Reviews, dated September 9, 2021.

The VA Office of Inspector General (OIG) evaluated allegations that a patient presented unscheduled to the Chico Community-Based Outpatient Clinic in California (Chico CBOC) and later was involved in a violent incident with family members, and facility leaders did not address employee concerns related to the adverse clinical outcome and mental health staffing. The OIG also identified concerns related to facility staff’s failure to provide same-day access, adequate mental health assessment, mental health triage, medication management, and facility leaders’ failure to consider completing an institutional disclosure and address concerns about the Chico CBOC building design.The OIG substantiated that the patient presented to the Chico CBOC Mental Health Clinic “highly agitated,” “was sent home,” and later had a violent altercation. The OIG did not substantiate that facility leaders failed to address employee concerns regarding staff well-being and inadequate mental health staffing levels.The OIG found that a nurse practitioner did not have same-day availability to evaluate the patient the day of the unscheduled visit. When the patient was unable to engage in a risk assessment, the OIG found that a triage social worker did not document the patient’s risk and protective factors, reasons for the patient’s inability to complete the assessment, or attempt to ask the patient’s family member about risk and protective factors.The OIG found that the nurse practitioner did not align medication management with treatment guidelines, document a comprehensive rationale for medication choices, document medication instructions accurately, or schedule a follow-up appointment within the expected time frame. Following the patient’s adverse clinical outcome, the OIG found that facility leaders did not complete an institutional disclosure.The OIG made five recommendations to the Facility Director related to same-day mental health access, risk assessment documentation, medication management continuity of care, institutional disclosure, and environmental changes to the Chico CBOC.

As part of our annual audit plan, we performed an audit of costs billed to the Tennessee Valley Authority (TVA) by Baker's Construction Services, Inc. (BCS) for field labor support services provided for TVA's civil construction organization under Contract No. 14743. Our audit objective was to determine if costs were billed in compliance with the contract's terms. Our audit scope included about $19.26 million in costs billed to TVA from January 1, 2020, through August 31, 2021.In summary, we determined BCS billed TVA:From $116,763 to $421,683 in unapproved temporary living allowance (TLA) costs. In addition, we identified other areas where the administration of TLA and TLA certifications could be improved.$44,941 in other ineligible and unsupported costs, including (1) $21,582 for ineligible and unapproved subcontractor costs, (2) $11,269 for ineligible equipment costs, <br> (3) $8,845 for duplicate and ineligible material costs, and (4) $3,245 for unsupported noncraft labor costs. We also noted opportunities to improve contract administration by TVA. Specifically, (1) the contract contained inconsistent language related to compensating noncraft labor, and <br> (2) several invoice and payment errors resulted in incorrect payments by TVA, which could have been identified with a proper invoice review.(Summary Only)

The VA Office of Inspector General (OIG) evaluated allegations that a primary care provider did not timely identify a liver abnormality nor inform a patient about a terminal cancer diagnosis at Overton Brooks VA Medical Center (facility) in Shreveport, Louisiana. The OIG identified additional concerns related to care coordination, resident supervision, communication of abnormal results, surrogate provider coverage, and patient safety event reporting.In early 2019, a primary care provider referred the patient to the facility’s Emergency Department for evaluation of leg pain. The patient was admitted and had imaging tests that showed a liver lesion with further testing recommended. The inpatient medicine provider (resident) included the imaging results in the patient’s progress note; however, the resident did not document findings or follow-up needs in the patient’s discharge summary. During four subsequent visits, the primary care provider’s notes lacked documentation of the lesion and recommended follow-up. In summer 2019, the patient reported having imaging at a community hospital that identified a liver tumor, and the primary care provider ordered a liver scan. The scan showed a liver mass and lesion. The primary care provider was on leave during the time the scan was conducted and an Emergency Department physician assistant was assigned as a surrogate for coverage. The OIG found no documentation that the primary care provider or the surrogate informed the patient of the abnormal findings.The patient died in fall 2019, after a confirmed liver cancer diagnosis.Facility leaders and staff did not take timely administrative action in response to the patient’s adverse event. Staff did not initiate a patient safety report and review the episode of care and the issues related to coordination of care.The OIG made four recommendations related to communication of abnormal test results, resident supervision, provider surrogate assignments, and patient safety reporting.