Federal Reports

The VA Office of Inspector General (OIG) Vet Center Inspection Program evaluated aspects of the quality of care delivered at six randomly selected vet centers throughout Southeast district 2 zone 1: Augusta, Marietta, and Savannah in Georgia; Johnson City, Tennessee; Charleston, South Carolina; and Bay County, Florida.This inspection focused on four review areas: suicide prevention; consultation, supervision, and training; outreach; and environment of care. For the suicide prevention review, the OIG evaluated vet center staff participation on VA medical facility mental health executive councils and High Risk Suicide Flag SharePoint Site client dispositions, which resulted in one recommendation across three of the six vet centers inspected. In the consultation, supervision, and training review, the OIG identified concerns with external clinical consultation and completion of select trainings, which resulted in two recommendations across all six vet centers inspected. The OIG’s outreach review evaluated outreach plan completion, inclusion of strategic components, and tailoring of outreach activities to cultural background information, which resulted in three recommendations across all six vet centers inspected. During the environment of care review, the OIG evaluated vet centers’ physical environment and general safety, which resulted in seven recommendations across four of the six vet centers inspected.The OIG issued 13 recommendations for improvement.

The VA Office of Inspector General (OIG) Vet Center Inspection Program evaluated aspects of the quality of care delivered throughout Readjustment Counseling Service (RCS).This inspection evaluated four review areas within Southeast District 2 including leadership stability, morbidity and mortality reviews, high risk suicide flag (HRSF) SharePoint site, and consultation and safety plans.There were no findings in leadership stability. For the morbidity and mortality review, the OIG identified that district leaders did not complete reviews timely for clients who died by suicide based on the active policy at the time of the inspection. Leaders also did not follow established tracking methods and had different processes, as well as unclear criteria, when evaluating the need for morbidity and mortality reviews for clients who had serious suicide attempts. In the HRSF SharePoint Site review, the OIG identified noncompliance with timely documentation by vet center staff in RCSNet and highlighted concerns with the accuracy of information in, and utilization of, the HRSF SharePoint site. Additionally, the OIG found care coordination practices in violation of RCS client confidentiality requirements. In the consultation and safety plan review, the OIG found vet center staff noncompliant with seeking consultation and completing and providing safety plans to clients.The OIG issued six recommendations to the District Director and one to the RCS Chief Officer for improvement.

EAC OIG requested that the Department of Interior OIG investigation allegations that the Executive Director of the EAC improperly obtained a pay increase, failed to report annual leave on his time and attendance records, and expensed unapproved training courses.

The Tennessee Valley Authority’s (TVA) Executive Policy 37.000, Real Property, states that a strategic guiding principle for management of TVA’s real-property portfolio is to “manage real property from an enterprise perspective and invest in core assets to improve condition, safety, and utilization.” TVA’s real property database lists 3,247 active buildings. Additionally, TVA has 75 bridges that it inspects on a routine basis. Due to the importance of proper maintenance to the safe, efficient, and effective operation of assets, we performed an evaluation to determine if TVA has (1) assessed its facilities for safety risks and (2) developed plans or completed actions to address the identified risks.We found all buildings and infrastructure have not been formally assessed to identify safety risks. Specifically for fiscal years 2022–2023, we found only 111 of 3,247 (approximately 3 percent) active buildings had condition assessments and 376 (approximately 12 percent) had roof inspections. All 75 bridges had required inspections. Additionally, actions were not taken or planned for all identified risks. Building and infrastructure safety risks could go unidentified without performing formal assessments at all facilities and risks could increase if actions are not taken to address assets in poor and failed condition.