Federal Reports

We are pleased to present our report for the period April 1, 2022, to September 30, 2022. The information in this report shows firsthand the dedication and professionalism of the TVA OIG team and our understanding of the importance of providing independent oversight of TVA. We will continue to focus on making TVA better by identifying potential risks to TVA’s ability to achieve its mission of providing reliable power at the lowest feasible rates, environmental stewardship, and economic development to the Tennessee Valley.In this semiannual period, our audit, evaluation, and investigative activities identified more than $145 million in questioned costs; funds put to better use; recoveries; civil and criminal forfeitures; and opportunities for TVA to improve its programs and operations.

The VA Office of Inspector General (OIG) conducted a review of Veterans Health Administration’s lethal means safety (LMS) training, firearms access and safe storage discussions within suicide risk assessments and safety plans, and clinicians’ perspectives on lethal means interventions.The OIG examined the electronic health records of 480 patients with firearm-related suicide behavior events. Among 15 patients with fatal firearm-related suicide behavior events, who required a comprehensive suicide risk evaluation (CSRE) prior to the event, three lacked required documentation. Six of the remaining 12 failed to assess firearms access and three of six CSREs that documented firearms access failed to include safe storage discussion. Among patients with a non-fatal firearm suicide behavior event, staff failed to include safe storage discussions in approximately 30 percent of CSREs and 21 percent of safety plans.One-third of Veterans Integrated Service Networks fell below an average of 90 percent compliance with one-time, mandatory LMS training completion. The OIG conducted a national survey of mental health, primary care, and emergency department clinicians. Among respondents who completed LMS training, 75 to 81 percent reported asking most or every patient about firearms access when assessing suicide risk and safety planning. However, only 50 to 56 percent of respondents who did not complete the LMS training reported asking most or every patient about firearms access. The same pattern emerged for safe storage discussions. Additionally, about 60 percent of clinicians who completed LMS training, and about a third of clinicians who did not complete the training, reported documenting firearms access and safe storage discussions. The OIG made seven recommendations to the Under Secretary for Health related to training compliance and oversight, one-time LMS training, CSRE and safety plan completion, and evaluation of staff barriers to conducting and documenting the suicide risk identification strategy, firearms access, and safe storage discussions.