Federal Reports

This audit was conducted in response to OIG hotline complaints and a congressional request alleging violations of law and VA policy at the Boston VA Research Institute (BVARI), a VA-affiliated nonprofit corporation. Among the allegations was the inappropriate use of agreements allowing VA and BVARI to collaborate on mutually beneficial projects while VA subsidized part or all of the salary and fringe benefits of participating employees. The audit team identified serious lapses in oversight and weak internal controls, which allowed a pattern of inappropriate payments to BVARI. Such payments risk the loss of VA funds and are not in the best interest of veterans as required by law. The OIG found that VA Boston Healthcare System officials authorized about $1.6 million in inappropriate payments to BVARI because they did not follow VA policy. This included $685,000 in administrative fees that BVARI intentionally invoiced for about three years and $576,000 in administrative salaries and benefits for positions prohibited by VA policy. The healthcare system also made $341,000 in duplicate payments for retirement contributions. The OIG also estimated the healthcare system made $22.8 million in improper payments to BVARI because employees did not verify that services were performed before making payments, as VA policy requires. The OIG did not substantiate allegations that officials in Boston attempted to cover up payment of prohibited administrative fees or interfered with audits of VA-affiliated nonprofits or efforts to recoup overpayments to BVARI. The OIG made seven recommendations, including that the under secretary for health confer with the VA Office of General Counsel and human resources officials about whether administrative actions should be taken against officials responsible for inappropriate payments to BVARI for ineligible administrative staff and duplicate retirement contributions.

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the VA Greater Los Angeles Healthcare System, covering leadership, organizational risks, and key processes associated with promoting quality care. Focused areas were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. The facility did not have a stable leadership team. Upon review of the facility’s accreditation findings, sentinel events, and disclosures, the OIG did not identify any substantial organizational risks. However, the OIG had concerns regarding the facility’s 17 percent staff vacancies and the multiple deficiencies in the controlled substances inspections program. The OIG noted that leaders need to improve employee satisfaction and trust and patient experiences. The leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics and should continue to take actions to sustain and improve performance contributing to the facility SAIL “3-star,” Sepulveda’s CLC “5-star,” and West Los Angeles’ CLC “4-star” quality ratings. The OIG issued 25 recommendations for improvement: (1) Quality, Safety, and Value • Peer review and utilization management review processes (2) Environment of Care • Medication and environmental safety • Protection of patient information • Mental health unit panic alarm testing and bathroom faucet safety (3) Controlled Substances Inspections • Controlled substances coordinator’s reports and program oversight • Controlled substances inspectors’ appointments, competencies, and requirements • Monthly controlled substances areas and pharmacy requirements • Pharmacy operations • Override reports review (4) Antidepressant Use among the Elderly • Patient/caregiver education • Medication reconciliation (5) Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee requirements

In accordance with the Reports Consolidation Act of 2000, the Office of Inspector General (OIG) reports on the most serious management and performance challenges facing the U.S. AbilityOne Commission, for inclusion in the Commission’s Performance and Accountability Report (PAR) for fiscal year 2019.

The Harrisburg Processing & Distribution Center is in the Central PA District of the Eastern Area. During fiscal year (FY) 2019, it manually processed 86.9 million letters, 11.4 million flats, and 1.6 million parcels. The Harrisburg P&DC’s FY 2019 manual parcel productivity of 7,898 mailpieces per hour was significantly higher than the national average productivity of 74 mailpieces per hour. Our objective was to assess the manual parcel processing operations.

We performed an audit of craft labor costs billed to the Tennessee Valley Authority (TVA) by Day & Zimmermann NPS, Inc. (DZ) under Contract No. 11515. Under the contract, DZ was to provide the services of qualified craft, noncraft, or staff augmented personnel to perform modification, outage, supplemental maintenance, or technical support at TVA Nuclear Power Group generating sites. Our audit included approximately $19.2 million in craft labor costs billed to TVA for work performed at Watts Bar Nuclear Plant from June 1, 2018, to November 30, 2018. Our audit objective was to determine if craft labor costs billed to TVA at Watts Bar Nuclear Plant were in compliance with Contract No. 11515.In summary, we determined DZ billed TVA in accordance with the contract terms. However, we found craft employees are allowed up to 15 minutes of walkout time before the end of their assigned shift and are paid for the time as if they had worked until the end of the shift. Although this appears to be a standard and accepted practice by TVA and DZ, the practice of allowing walkout time is not documented in the contract, TVA's Project Maintenance and Modification Agreement, or any other TVA Project Labor Agreement. Additionally, it is not clear if DZ's practice (1) meets the intent of TVA's (unwritten) policy on craft end of shift walkout time or (2) is managed effectively. (Summary Only)