Federal Reports

We evaluated the process TVA uses to verify the accuracy of payments made to the Department of Labor (DOL) for workers compensation benefits. We determined TVA did not have a formal process to verify the accuracy of payments made for schedule awards. Although TVA’s Sarbanes-Oxley Act (SOX) controls verified certain aspects of the DOL billings, the SOX controls did not include steps to verify the accuracy of the elements in award of compensation letters and, as a result, some errors were not identified. Additionally, we found TVA was not performing a SOX control related to providing a summary of workers' compensation charges to the applicable organizations for review.

The OIG investigated allegations that a Bureau of Land Management (BLM) Office of Law Enforcement and Security supervisor misused U.S. Government equipment and employee time in support of his personal business. It was also alleged that the supervisor made a wasteful purchase of a $3,250 mountain bike, misused a Government-owned vehicle and other Government-owned equipment for personal use, and inappropriately assigned himself to fire assignments where he earned overtime.We determined that the supervisor violated U.S. Department of the Interior policy on the use of Government property and 5 C.F.R. 2635.704, “Use of Government Property,” when he used Government equipment and employee time to support his personal business. We also found that the mountain bike purchase, although authorized, was wasteful. We determined that the supervisor had not misused a Government-owned vehicle for personal use, nor had he inappropriately assigned himself fire assignments.

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The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate concerns related to the care provided to a patient who was mistakenly treated with phototherapy for bed bugs and developed complications. Two days after receiving the phototherapy treatment, the patient was hospitalized for first degree (outer layer of the skin) and second degree (deeper layers of the skin) burns. Phototherapy is ordered by a dermatologist after diagnosis of a skin condition that would be responsive to treatment. Phototherapy is not indicated for the treatment of patients with bed bugs. A dermatology clinic registered nurse (RN) provided phototherapy to the patient for the treatment of bedbugs without a provider assessment and order, even though a dermatologist was available for assessment the day of treatment. Facility staff improperly attributed the need for action to its Integrated Pest Management policy that guides environmental actions. Despite an appendix to the policy that stated, “there is no specific medical treatment for bed bugs,” facility staff pursued a clinical treatment, phototherapy, for the patient. Facility leaders initiated a fact-finding review. The review’s charge letter was unclear regarding its confidential or non-confidential status. Confidential reviews may not be used as a basis for administrative action. The OIG made two recommendations to the Veterans Integrated Service Network 16 Director related to fact finding reviews conducted at the Gulf Coast Veterans Health Care System. The OIG made five recommendations to the Gulf Coast Veterans Health Care System Director related to dermatology clinic nurse practice requirements, training, and competencies; a review of the Gulf Coast Veterans Health Care System’s policy related to environmental actions following identification of bed bugs; necessary training related to the policy; and completion of Gulf Coast Veterans Health Care System’s actions recommended by an internal review.

We have performed reviews in several States in response to a congressional request concerning the number of deaths and cases of abuse of residents with developmental disabilities in group homes.Federal waivers permit States to furnish an array of home and community-based services to Medicaid beneficiaries with developmental disabilities so that they may live in community settings and avoid institutionalization. The Centers for Medicare & Medicaid Services (CMS) requires States to implement a critical incident reporting system to protect the health and welfare of Medicaid beneficiaries receiving waiver services.