Federal Reports

Objective: to evaluate the effectiveness of the Social Security Administration’s controls over the recording of death information on the Numident database for deceased beneficiaries.

At the request of the Tennessee Valley Authority's (TVA) Supply Chain, we examined the cost proposal submitted by a company for transmission construction services. Our examination objective was to determine if the cost proposal was fairly stated for a planned 5-year, $50 million contract.In our opinion, the company's cost proposal was overstated. Specifically, we found the proposed general liability insurance markup rate was overstated compared to recent actual costs. We estimated TVA could avoid about $118,000 over the planned $50 million contract by negotiating a reduction to the general liability insurance markup rates to more accurately reflect the company's recent actual costs. (Summary Only)

EAC OIG performed this review to determine whether EAC complied with the Payment Integrity Information Act of 2019 reporting requirements for fiscal year 2021.

Our objective was to determine whether DHS followed its standard process when it drafted, edited, and disseminated an I&A intelligence product.

A Crew Management Representative based in Wilmington, Delaware, was terminated from the company on May 3, 2022, after a disciplinary hearing. Our investigation found that the employee violated company policies by engaging in outside employment while on a medical leave of absence and receiving short-term disability benefits. The employee is not eligible for rehire.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate OIG identified concerns related to the assessment and documentation practices of a behavioral health certified registered nurse practitioner (BHNP) and leaders’ completion of BHNPs’ ongoing professional practice evaluations (OPPEs) at the VA Pittsburgh Healthcare System (facility) in Pennsylvania. During the inspection, the OIG found that the BHNP did not perform thorough suicide risk assessments for a patient who died by suicide.The OIG identified multiple deficiencies in a BHNP’s assessment and documentation practices including absence of comprehensive suicide risk assessments, failure to complete abnormal involuntary movement and metabolic assessments for patients prescribed certain antipsychotic medication, missing informed consent or a risk-benefit discussion when prescribing off-label medications, failure to resolve rule-out diagnoses, and substantial copy and paste use. The OIG found adverse clinical outcomes for one of eight patients for whom the BHNP did not document a comprehensive suicide risk assessment, as required by The Joint Commission.The OIG concluded that the Nurse Manager evaluated BHNPs as satisfactory in the OPPE elements of copy and paste use for fiscal year 2018 through the first half of fiscal year 2021, and safety plan completion for high risk for suicide patients for February 2020 through the first half of fiscal year 2021, without these elements being evaluated.The OIG made five recommendations to the Facility Director related to a comprehensive review of the BHNP’s assessment practices regarding the patient who died by suicide, a review of the BHNP’s overall assessment and documentation practices, alignment of facility policy and leaders’ expectations related to the assessment and documentation of abnormal involuntary movements and metabolic problems for patients prescribed antipsychotic medications, Behavioral Health managers’ verification of BHNPs’ OPPEs review, and a review of managers’ oversight of BHNPs’ OPPEs.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate leaders’ response to the knowledge of inappropriate provider-patient relationships (inappropriate relationships) in the Mental Health Service Line at the VA Illiana Health Care System (facility) in Danville, Illinois.The OIG determined that while facility leaders took initial actions to address three inappropriate relationships between mental health providers (Providers A, B, and C) and mental health patients (Patients A, B, and C), multiple factors affected the effectiveness of those actions. The OIG found that effective facility leader actions to investigate and address the inappropriate relationships of Provider A and Provider B occurred only after an Office of Accountability and Whistleblower Protection complaint. Facility leaders ineffectively addressed Provider C’s inappropriate relationship before Patient C died by overdose.Facility leaders implemented action plans to prevent future occurrences of inappropriate relationships. Given the egregious nature of the providers’ behaviors, facility leaders failed to report Providers B and C to their state licensing boards in a timely manner and failed to report Provider A to the appropriate professional certification board.The OIG also determined that facility leaders did not take actions to address the circumstances that contributed to the death of Patient C who was involved in an inappropriate romantic relationship with Provider C.The OIG made one recommendation to the Veterans Integrated Service Network 12 Director related to evaluating processes that affected facility supervisors’ identification and actions to address inappropriate relationships. The OIG made two recommendations to the Facility Director related to timely reporting of providers to state licensing or certification boards, and reviewing Patient C’s care to determine if there was an adverse event and if so, whether institutional disclosure is warranted.