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Brought to you by the Council of the Inspectors General on Integrity and Efficiency
The Office of the Inspector General performed an audit of the Tennessee Valley Authority’s (TVA) Unmanned Aircraft Systems (UAS) Program due to the increased use of unmanned aircraft in TVA operations. Our audit objectives were to determine if TVA's (1) UAS Program was in compliance with applicable federal requirements and (2) use of unmanned aircraft was in compliance with applicable TVA policies. Our audit scope included TVA's use of unmanned aircraft from January 1, 2024, through December 31, 2024.
In general, we determined TVA's (1) UAS Program complied with applicable federal requirements and (2) use of unmanned aircraft complied with applicable TVA policies. However, we determined 2 of 64 pilots did not have the remote pilot certificate required to operate UAS. We made one recommendation to management to address verification of remote pilot certificates.
This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Louisville Healthcare System in Kentucky. This evaluation focused on five key content domains: • Culture • Environment of care • Patient safety • Primary care • Veteran-centered safety net
The OIG issued 13 recommendations for VA to correct identified deficiencies in four domains: 1. Culture • Telephone system improvements 2. Environment of care • Exit signs • Detectable warning surfaces • Clean and safe patient care areas • Electrical cord management • Biological hazard signs • Biohazardous waste disposal • Liquid nitrogen use and storage • Environment of care trends, improvement plans, and outcome measures 3. Patient safety • Service-level workflows for test result communications • Test result communication policy • Test result communication performance metrics 4. Primary care • Panel sizes
The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess care concerns and inadequate quality reviews related to a patient’s death at the VA Greater Los Angeles Healthcare System (facility). The OIG determined that clinical staff did not timely recognize, address, and investigate changes in the patient’s clinical condition. Although the outcome may not have changed, not recognizing an emerging condition hindered clinical staff considering modifications to the plan of care and discussing the course of action with the patient and family.
The OIG identified several factors that contributed to staff not recognizing the patient’s deterioration and intervening accordingly. The resident physician ordered laboratory tests, but neither the resident nor attending physician reviewed or acted upon the patient’s abnormal laboratory values. The resident ordered stat imaging studies to assess abdominal pain and evaluate for infection; however, the resident, attending, and nursing staff did not ensure imaging completion.
Nurses missed early warning signs of the patient’s deteriorating condition by not conducting National Early Warning Score (NEWS) assessments as required or intervene, as expected, with elevated NEWS scores. Nurses did not complete shift assessments within the required time frames. The OIG identified an 11-hour gap in nursing documentation before the patient’s death. Nurses lacked accurate on-call provider contact information and attempts to reach the on-call provider to address the patient’s pain were unsuccessful.
Facility leaders did not conduct a comprehensive review of the events that occurred prior to the patient’s death and were unsuccessful in their attempts to conduct an institutional disclosure with the patient’s family.
The Facility Director concurred with and submitted action plans to address the OIG’s seven recommendations related to comprehensive reviews of the patient’s care, NEWS assessment training, nursing assessment compliance, patient care escalation processes, and disclosure efforts.
This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Detroit Healthcare System in Michigan. This evaluation focused on five key content domains: • Culture • Environment of care • Patient safety • Primary care • Veteran-centered safety net
The OIG issued six recommendations for VA to correct identified deficiencies in one domain: 1. Environment of care • Damaged furnishings • Maps for navigation • Clean equipment storage • Unobstructed hallways and exits • Defective equipment removal • Computer screen privacy filters
The Postal Service is a self-funded entity that primarily finances its operations through postage sales, with package delivery comprising a major portion of its services. During fiscal year (FY) 2024, the Postal Service shipped 7.3 billion packages, generating $32.3 billion in revenue. The Postal Service offers multiple options to purchase postage, including through third party vendors, its Click-N-Ship online service, and over the retail counter at local post offices. Every USPS package label contains specific information that can be used for multiple reasons, to include detecting and intercepting potentially fraudulent package labels.
