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 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.

The AmeriCorps Office of Inspector General (AmeriCorps OIG) investigated allegations that a contractor submitted invoices under its Blanket Purchase Agreement (BPA) with AmeriCorps that included unallowable and/or unsupported costs. AmeriCorps OIG’s investigation foundevidence that the contractor billed AmeriCorps $167,714.42 in unallowable charges in violation of acquisition regulations and policies, including, Federal Acquisition Regulation (FAR) 31.201-2(d) Determining allowability, FAR 5.503(c) Proof of advertising, and AmeriCorps Acquisition Policy5.1304(c) Invoice Certification, and the contractor lacked supporting documentation required by the BPA. In addition, the investigation found that the contractor both overbilled and underbilled AmeriCorps, the net of which favored the contractor.

The AmeriCorps Office of Inspector General (AmeriCorps OIG) investigated allegations that the former Executive Director (ED) of the Volunteer and Community Service Commission of Puerto Rico (Commission) attempted to use AmeriCorps funds to award a sole-source contract to a close friend, required prayers before AmeriCorps events, and requested subgrantees allow AmeriCorps members to perform service outside the scope of their grant. AmeriCorps OIG’s investigation confirmed the allegations regarding the sole-source contract and that the former ED required a prayer before the start of multiple AmeriCorps events. The investigation also found that the Commission was not reimbursing its subgrantees in a timely manner and that a former Commission Program Coordinator was improperly paid $2,825.

The Office of Inspector General (OIG) is issuing this inspection report to present the results of our assessment of the U.S. Small Business Administration’s (SBA) initial response to Hurricanes Fiona and Ian, including staffing adequacy, loan application volume, and timeliness of disaster loan approvals.We found SBA’s initial response to Hurricanes Fiona and Ian was timely and effective. The agency established a field presence within 3 business days and opened a Business Recovery Center within 10 business days for both hurricanes, meeting its strategic goal. Additionally, SBA successfully addressed initial staffing concerns and maintained adequate staffing levels throughout its response to both hurricanes.The agency reacted to anticipated resource needs by implementing a hiring initiative and providing advanced specialty training. These actions addressed a projected staffing shortfall, including the need for bilingual staff who were brought in to assist from other SBA offices.

The Veterans Community Care Program allows the Veterans Health Administration (VHA) to purchase care for veterans through Community Care Network (CCN) contracts or veterans care agreements. While the CCN groups VA medical facilities into regions managed by third-party administrators (TPAs), the Office of Integrated Veteran Care (IVC) is responsible for overseeing execution of CCN contracts.The VA Office of Inspector General (OIG) conducted this audit to determine whether VHA provided effective oversight of its TPAs and VA medical facilities. The review team evaluated IVC’s oversight of the TPAs’ adherence to four contract requirements designed to ensure facilities have enough community providers to administer care within the timeliness and drive-time standards established in the contracts. The OIG found that IVC did not hold TPAs accountable for implementing these contract requirements, causing staff to struggle to convince TPAs to add community providers to their networks at the eight facilities the audit team visited.While IVC provided proof of TPA discussing community care needs with three facilities, similar evidence for other facilities was not provided. Furthermore, IVC did not conduct any analyses of facilities’ network adequacy needs to help TPAs build provider networks and did not ensure TPAs maintained provider networks that were accepting VA patients. IVC also did not position itself to defend facilities’ needs for additional community care providers.The OIG recommended to the undersecretary for health that the IVC holds future TPAs accountable for operational readiness and provider network adequacy; develop processes to update and maintain CCN data, challenges, and needs; conduct Advanced Medical Cost Management Solution training on evaluating network adequacy through the tool for community care staff; and not only develop its own network adequacy performance reports but also evaluate TPAs’ reports, holding them accountable for resolving identified issues.

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 Syracuse VA Medical Center, which includes multiple outpatient clinics in New York. 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 12 recommendations for improvement in four areas:1. Quality, safety, and value• Peer review committee • Peer review level reassignments • Review of data by medical executive committee2. Medical staff privileging• Ongoing Professional Practice Evaluation completion• Specialty-specific criteria for professional practice evaluations3. Environment of care• Environment of care inspections• Safe and clean patient care areas• Mental health inpatient unit: • Panic and over-the-door alarm testing • Maintaining a safe environment • Ceiling tiles checked semiannually• Biomedical staff inspection and testing of medical equipment• VISN oversight of biomedical program4. Mental health• Comprehensive Suicide Risk Evaluation completion