Federal Reports

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Clement J. Zablocki VA Medical Center and multiple outpatient clinics in Wisconsin. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. The medical center’s executive leadership team had been working together for over two years. Employee satisfaction survey results revealed opportunities for the Deputy Director and Assistant Director to decrease employee feelings of moral distress at work. Patient experience survey data noted satisfaction with care. Survey results for males and females were generally more favorable than VHA results nationally. The review of accreditation findings did not identify any substantial organizational risk factors. The OIG identified significant concerns with sentinel events identification. Executive leaders were generally able to speak knowledgeably about actions taken during the previous 12 months to maintain or improve performance, and were knowledgeable within their scopes of responsibilities about Strategic Analytics for Improvement and Learning data. The OIG issued 28 recommendations for improvement in seven areas:(1) Quality, Safety, and Value • Committee processes • Utilization management processes (2) Medical Staff Privileging • Professional practice evaluations • Provider exit reviews (3) Environment of Care • Safety and cleanliness • Information security (4) Medication Management • Behavior risk assessment • Urine drug testing • Informed consent • Patient follow-up (5) Mental Health • Patient follow-up (6) Women’s Health • Gynecologic care coverage • Committee membership • Quality data • Women veteran program manager position (7) High-Risk Processes • Annual risk analysis • Environmental cleanliness • Equipment storage

o Since 2017, DHS has continued to make progress in meeting its Digital Accountability and Transparency Act of 2014 (DATA Act) reporting requirements, but challenges remain. To enable more effective tracking of Federal spending, DHS must continue to take action to accurately align its budgetary data with the President’s budget, reduce award misalignments across DATA Act files, improve the timeliness of financial assistance reporting, implement and use government-wide data standards, and address risks to data quality. Without these actions, DHS will continue to experience challenges in meeting its goal of achieving the highest possible data quality for submission to USAspending.gov. We made five recommendations to help strengthen DHS’ controls for ensuring complete, accurate, and timely spending data. The Department concurred with all five recommendations.

As part of our annual audit plan, we performed an audit of costs billed to the Tennessee Valley Authority (TVA) by Thalle Construction Company, Inc. (Thalle) for construction and modification services for civil projects and coal combustion product management under Contract No. 10061. The contract provided for TVA to compensate Thalle for work on either a cost reimbursable, target cost estimate (TCE), or fixed price basis. Our audit objectives were to determine if (1) costs were billed in compliance with the terms and conditions of the contract and (2) tasks were issued using the most cost efficient pricing methodology. Our scope included about $16.2 million in costs billed to TVA from May 20, 2015, through December 20, 2018. This included about $14.7 million for fixed price projects, $1.3 million for TCE projects, and $186,000 for cost reimbursable projects. In summary, we determined:Thalle overbilled TVA $78,414 on a TCE project, including (1) $24,716 for ineligible costs billed and (2) $53,698 in overstated TCE cost savings.Thalle overbilled TVA $70,751 in equipment costs on cost reimbursable projects, including (1) $54,755 in overbilled TVA Equipment Support Services equipment rental costs and (2) $15,996 in overbilled costs for Thalle owned equipment.The use of fixed price or unit rate payment terms on projects caused TVA to pay at least $2.1 million more than it would have if cost reimbursable payment terms had been used for those projects. Additionally, we determined the unit rate payment terms used by TVA to compensate Thalle were not provided for in the contract's terms and conditions.We also noted several opportunities to improve contract administration by TVA.(Summary Only)