Federal Reports

We performed an audit of the Tennessee Valley Authority’s (TVA) Contract No. 15387 with a company to provide a broad range of engineering, design, and construction management support when and as requested by TVA.  The objective of our audit was to determine if the costs billed to TVA were in accordance with the contract’s terms.  Our audit scope included approximately $33.2 million in costs billed to TVA between January 1, 2024, and March 31, 2025. 

In summary, we determined the company overbilled TVA an estimated $33,595, including (1) 14,079 in unsupported and overbilled travel and temporary living allowance costs, (2) $13,764 in invoice and payment errors, (3) a net $3,632 in performance fee credits, and (4) $2,120 in labor costs.  In addition, we identified opportunities for TVA to improve the administration of the contract.  Specifically, (1) the contract was unclear on how the company was to bill temporary employees it received from staffing agencies and (2) TVA did not evaluate fee for all tasks greater than $50,000, as required by the contract.   

This report contains the results of our assessment of the effectiveness of the Consumer Product Safety Commission’s (CPSC) internal control over the pre-dissemination review (PDR) of scientific information, and the CPSC’s compliance with relevant laws and regulations regarding the PDR of scientific information.  We determined that the CPSC had inadequate policies and procedures for identifying the type of influential information that might require peer review and inadequate internal controls over the PDR process in general.  Current agency management generally concurred with our findings and recommendations and have reported that they have already taken initial corrective action regarding some of the issues raised in our report.

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Western North Carolina VA Health Care System (system) to assess concerns brought forward in October 2025 by an OIG Healthcare Facility Inspection team regarding issue briefs related to sentinel events and falls at the North Carolina State Veterans Home (SVH) in Black Mountain, North Carolina (Black Mountain SVH). The OIG initiated the inspection on January 5, 2026, conducted a virtual site visit from January 20 through 22, 2026, and continued inspection activities through early February 2026.

The OIG determined facility, Veterans Integrated Service Network (VISN), and Veterans Health Administration (VHA) leaders were aware of patient safety events, including sentinel events, at the Black Mountain SVH as reported by SVH staff. From August 2024 through December 2025, facility staff completed 13 issue briefs in response to the reported patient safety events to alert VISN and VHA Geriatrics and Extended Care (GEC) leaders. Eleven of the issue briefs were related to resident falls, while two involved resident injuries unrelated to falls. The Black Mountain SVH determined 2 of the 13 events were sentinel events—resident falls resulting in injury and subsequent death—and were reported timely to the VA medical facility representative. Further, the OIG determined facility, VISN, and GEC leaders responded to SVH sentinel events as required by VHA—both sentinel event issue briefs, and associated updates, were provided to the VISN liaison for review, approval, and submission to the GEC SVH National Program Manager.

The OIG made no recommendations.