Federal Reports

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In keeping with its responsibilities under the Inspector General Act of 1978, as amended, the OIG monitored the audit of TVA's fiscal year 2020 financial statements performed by Ernst and Young LLP (EY) to assure their work complied with Government Auditing Standards. Our review of EY's work disclosed no instance in which the firm did not comply in all material respects with Government Auditing Standards.

The Postal Inspection Service established the Proper Handling of Suspected Marijuana Parcels Mandatory Stand-Up Talk in FY 2019 as guidance for postal employees on how to handle mail suspected of containing illicit drugs (suspected mail). In addition, the Postal Inspection Service’s Administrative Nonmailability Protocol policy describes procedures for recording referred suspected mail by postal employees. This policy was established primarily to remove marijuana from the mailstream. Our objective was to evaluate the U.S. Postal Inspection Service’s controls for handling mail suspected of containing illicit drugs at U.S. Postal Service facilities.

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 Atlanta VA Health Care System and multiple outpatient clinics in Georgia. 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 healthcare system leaders were relatively new to their positions and had been working together as a team for less than two months. Employee and patient survey results were generally worse than the VHA averages, indicating multiple opportunities for leaders to improve employee and patient satisfaction. The OIG noted concerns with the healthcare system’s under-reporting of sentinel events and medication administration processes in the inpatient mental health unit. Although leaders were generally knowledgeable about VHA data and/or system-level factors contributing to specific poorly performing measures, these leaders have opportunities to improve quality of care and efficiency.The OIG issued 23 recommendations for improvement in seven areas:(1) Quality, Safety, and Value • Committee processes• Protected peer reviews• Root cause analysis processes(2) Medical Staff Privileging• Professional practice evaluations• Provider exit reviews(3) Medication Management• Aberrant behavior risk assessments• Urine drug testing• Informed consent(4) Mental Health• Outreach activities• Staff training(5) Women’s Health• Women’s health primary care providers• Women veterans health committee membership(6) High-Risk Processes• Storage area temperature and humidity• Staff training(7) Incidental Finding• Bar code medication administration processes