Federal Reports

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Poplar Bluff Health Care System in Missouri. 

This evaluation focused on five key content domains:
   •    Culture
   •    Environment of care
   •    Patient safety
   •    Primary care
   •    Veteran-centered safety net

The OIG issued four recommendations for improvement in three domains:
   1.    Culture
   •    Key leadership turnover
   •    Interactions with local union leaders
   2.    Environment of care
   •    Nonoperational security camaras
   3.    Primary care
   •    Primary care team staffing

To learn how communities across the nation responded to the pandemic, we initiated a multi-part review of six communities—two cities, two rural counties, and two Tribal reservations. This report is the fourth community-specific report and focuses on our work in Marion County, Georgia, where we previously identified that recipients, including city government, small businesses, and individuals, received almost $39 million from 27 pandemic relief programs and subprograms. This report provides a closer look at six pandemic programs and subprograms provided to Marion County by six federal departments.

The Tennessee Valley Authority (TVA) currently operates 29 power-generating hydro plants and one pumped-storage plant.  Between June 1, 2022, and May 31, 2024, employees at TVA’s hydro plants were paid a total of $71.7 million.  Of this $71.7 million, $15.1 million (21 percent) was paid for 187,579 hours of overtime to 243 employees. 

To help manage the effects of fatigue, TVA Safety Procedure 18.018, Fatigue Management, establishes “. . . a process to provide reasonable assurance that the effects of fatigue and degraded alertness do not impact an individual’s ability to safely and competently perform their duties.” Due to the high number of overtime hours worked at some of TVA’s hydro plants, we performed an evaluation to assess TVA’s management of overtime at hydro plants.

We determined significant amounts of overtime were worked at some hydro plants.  Specifically, we determined 58 percent (108,796 hours) of the 187,579 hours of overtime was worked at 5 of the 30 hydro plants.  The overtime worked was the equivalent of 24 full-time employees.  We also determined some employees worked significant amounts of overtime.  There were 30 instances where employees worked over 1,000 hours of overtime in a single year and 2 employees worked approximately 2,000 hours of overtime in a single year.  Additionally, we determined that TVA may not be accurately capturing the effects of fatigue because (1) fatigue evaluations are not being performed and (2) fatigue data is not being trended as required by the Fatigue Management procedure.

The Tennessee Valley Authority (TVA) currently operates 101 natural gas- and fuel oil-fired generators at 18 sites.  During 2020, we performed an evaluation of overtime worked at TVA gas plants and found a significant amount of overtime was being worked by employees at some plants.  In response to that evaluation, TVA hired additional full-time employees at some gas plants.  However, overtime worked at gas plants has continued to increase since our previous evaluation.  Specifically, between June 1, 2022, and May 31, 2024, employees at TVA’s gas plants were paid a total of $119.75 million.  Of this $119.75 million, $33.6 million (28 percent) was paid for 369,218 hours of overtime to 360 employees.

To help manage the effects of fatigue, TVA Safety Procedure 18.018, Fatigue Management, establishes “. . . a process to provide reasonable assurance that the effects of fatigue and degraded alertness do not impact an individual’s ability to safely and competently perform their duties.”  Due to the high number of overtime hours worked at some gas plants and the potential impact on fatigue management, we performed an evaluation to assess TVA’s management of overtime at gas plants.

We determined significant amounts of overtime were worked by employees at some gas plants.  Specifically, we determined 73 percent (269,586 hours) of the 369,218 hours of overtime was performed at 7 of 18 plants between June 1, 2022, and May 31, 2024.  The overtime worked was the equivalent of 61 full-time employees.  We also determined some employees worked significant amounts of overtime.  There were 109 instances where employees worked over 1,000 hours of overtime in a single year, including three with over 1,800 hours. Additionally, we determined that TVA may not be accurately capturing the effects of fatigue because (1) fatigue evaluations are not being performed and (2) fatigue data is not being trended as required by the Fatigue Management procedure.