Federal Reports

At the request of the Tennessee Valley Authority's (TVA) Supply Chain, we examined the cost proposal submitted by a company for engineering, design, and construction support services. Our examination objective was to determine if the company's cost proposal was fairly stated for a planned 5-year, $45 million contract.In our opinion, the company's cost proposal was overstated. Specifically, we found the (1) proposed costs for the request for proposal's (RFP) example projects contained math errors, were not priced in accordance with the RFP requirements, and overstated travel expenses; (2) proposed total labor markup rate, for recovery of the company's indirect costs, was overstated compared to recent actual costs; (3) proposal did not include reduced labor markup rates for employees working in the field and nonbenefited workers; and <br> (4) proposed maximum wage rates were overstated.We estimated TVA could avoid about $3.08 million over the planned $45 million contract by (1) ensuring the company's project estimates and invoices are reviewed for accuracy and comply with contract pricing criteria, (2) negotiating a reduced total labor markup rate based on the company's recent actual costs, (3) including labor markup rates for employees performing work in the field and nonbenefited workers, and (4) requiring the company to revise its wage range maximums.(Summary Only)

The VA Office of Inspector General (OIG) conducted an inspection to evaluate facility oversight and leaders’ response to a pathologist’s practice at the facility. The OIG found the Pathology and Laboratory Medicine Chief (Chief) followed VHA policy and performed a quality review of surgical pathology cases and reported the pathologist’s initial misdiagnosis. Facility leaders ensured the required comprehensive clinical care reviews were conducted, resulting in the discovery of 10 additional misdiagnoses. The pathologist also misdiagnosed a skin biopsy. The Chief followed Veterans Health Administration (VHA) policy for secondary reviews of the misdiagnoses, completed supplemental reports, and documented provider notification. The OIG found no documentation that providers informed three patients of their misdiagnoses. The OIG learned one patient experienced an adverse clinical outcome and did not have any documented disclosures. Also, facility staff and leaders did not report any of the misdiagnoses as adverse events. Facility leaders summarily suspended the pathologist; however, the OIG found no documentation renewing the suspension. The Facility Director then terminated the pathologist. The pathologist appealed the termination through the VHA Disciplinary Appeals Board, which recommended a reinstatement. The pathologist was reinstated, and clinical privileges were restored. Facility leaders did not comply with VHA’s mandated privileging processes and were unaware of who was responsible for state licensing board reporting. Quarterly retrospective reviews of all pathology reports exceeded the 10 percent standard; however, the Chief and staff pathologists did not consistently review 10 percent of each pathologist’s cases. The Chief and staff pathologists reviewed 9.4 percent of the pathologist’s cases, below the 10 percent requirement. The OIG made 10 recommendations related to test results, disclosure and reporting of adverse events, issue briefs, the summary suspension process, the credentialing and privileging process, state licensing board reporting, and quality reviews of the pathologists’ work.

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 VA Illiana Health Care System and multiple outpatient clinics in Illinois. The inspection covers key clinical and administrative processes that are associated with promoting quality care. For this inspection, the areas of focus were 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 executive leadership team positions were filled more than six months prior to the on-site visit. Survey results revealed opportunities for the Associate Director to improve employee satisfaction and for the Chief of Staff and Associate Director Patient Care Services to improve staff feelings of “moral distress” at work. Patient experience survey data indicated that patients appeared satisfied with their care. The OIG’s review of the system’s accreditation findings did not identify any substantial organizational risk factors. Executive leaders were knowledgeable within their scopes of responsibilities about selected Strategic Analytics for Improvement and Learning data and should continue to take action to sustain and improve performance.

This report presents the results of our audit of all stamp and cash inventories at six postal units in Chicago, IL. These offices were located in the Chicago District of the Great Lakes Area. We conducted this audit in response to concerns raised by the U.S. Postal Inspection Service of potentially lost stamps, cash, and money orders due to looting of offices during protests and riots from May 29 through June 1, 2020. The six postal units audited were Englewood, Station K, Wicker Park Retail Store, Wicker Park Carrier Annex, Ogden Park, and Henry W. McGee. All six postal units had thefts of mail and parcels. One unit had theft of stamps and cash. One unit did not have any stamp or cash inventory.

Our objective was to evaluate the performance of the U.S. Postal Service’s Small Package Sorting System (SPSS) machines.The continued growth of eCommerce and the package delivery market provides opportunities for the Postal Service to increase revenue. The Postal Service has directed resources and management attention toward building a world-class package platform to compete and gain business in the package delivery market. Part of this strategy includes purchasing package processing machines such as the SPSS to improve efficiency and meet demand.

Congress has expressed concerns about the safety and well-being of children in foster care. Additionally, in a recent series of audits of State-monitored child care facilities in various States, we found that the majority of child care providers had instances of potentially hazardous conditions and noncompliance with State health and safety requirements, including employee background record check requirements. To determine whether similar vulnerabilities exist in foster care group homes, we performed this audit in Kansas. Allegations of neglect and abuse at some foster care group homes in Kansas were the subject of a number of reports in the media, both before and during our audit.

The OIG investigated allegations that a U.S. Bureau of Reclamation (BOR) project management specialist illegally diverted water from a BOR canal to a private ranch. Our investigation confirmed the project management specialist approved the water diversion, but we did not find evidence the project management specialist received any personal benefit, financial or otherwise, as a result. The project management specialist said they approved the water diversion because they were trying to solve the ranch owner’s concern that construction in the area had blocked flood-water overflow from coming onto the ranch owner’s property. The project management specialist further said they were concerned that the ranch owner would terminate an agreement that allowed the BOR to operate a pump station—which the BOR uses to protect endangered species in the area by pumping water to dry areas—on the ranch owner’s property because the terms of the agreement allowed the ranch owner to terminate the agreement if the ranch owner believed the BOR impeded any of their projects.We further found the project management specialist circumvented engineering and environmental approval by funding the project through an existing operations and maintenance contract instead of a new contract, which would have triggered the BOR’s review and approval process. The project management specialist said they believed the project was within the scope of work of the existing contract and did not seek approval before authorizing the water diversion.