Federal Reports

An Amtrak Sheetmetal Worker Mechanic based in Beech Grove, Indiana, resigned from the company on September 14, 2021, following the release of our investigative report. Our investigation found that the former employee violated company policies by engaging in self-employment that interfered with his job duties and responsibilities. On some occasions, he used a personal leave of absence and leave granted under the Americans with Disabilities Act to operate his lawn care service.

As part of our annual audit plan, we audited costs billed to the Tennessee Valley Authority (TVA) by Mesa Associates, Inc. (Mesa) under Contract No. 13191 for engineering, design, and construction support services in support of TVA's dam safety, generation, and transmission work. The contract provided for TVA to compensate Mesa for these services on either a cost-reimbursable or fixed price basis. Our audit objectives were to determine if (1) costs were billed in accordance with the terms and conditions of the contract and <br> (2) tasks were issued using the most cost efficient pricing methodology. Our audit scope included about $57.5 million in costs billed to TVA from March 12, 2018, through August 31, 2020. This included $25.8 million for cost-reimbursable projects and $31.7 million for fixed price projects.In summary, we determined:Mesa overbilled TVA $213,545 on cost-reimbursable projects, including (1) $147,045 in temporary living allowances and travel costs, (2) $34,298 in subcontractor costs, <br> (3) $18,576 in labor costs, (4) a net $7,195 in performance fee payments, and (5) $6,431 in volume discounts not provided to TVA.The use of fixed price payment terms on projects caused TVA to pay at least $1.52 million more than it would have if cost-reimbursable payment terms had been used for those projects. Additionally, if TVA utilized cost-reimbursable pricing for the remaining spend on its current contract with Mesa (i.e., Contract No. 15396), we estimated TVA could potentially avoid up to $8.69 million in future costs.(Summary Only)

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 Central Western Massachusetts Healthcare System in Leeds, which includes multiple outpatient clinics in Massachusetts. The inspection covered key clinical and administrative processes that are associated with promoting quality care. It focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.The executive leadership team had worked together for seven months at the time of the OIG virtual review. Survey data revealed opportunities for the Director to reduce employee feelings of moral distress and improve workgroup respect and sharing of concerns. The healthcare system’s patient experience scores were generally higher than VHA averages, except for female patients’ access to timely outpatient appointments. The OIG’s review of the hospital’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Executive leaders were knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance.The OIG issued five recommendations for improvement in two areas:(1) Care Coordination• Patient transfer monitoring and evaluation(2) High-Risk Processes• Disruptive behavior committee meeting attendance• Order of Behavioral Restriction and patient notification documentation• Completion of training

The VA Office of Inspector General (OIG) evaluated an August 2019 hotline complaint alleging mismanagement of supplies, equipment, and operating rooms while activating the New Orleans VA Medical Center in Louisiana.The OIG substantiated that the medical center purchased about $1.85 million in excess surgical supplies. Employees also violated VA supply chain management policies by not properly accounting for nor advertising the excess supplies to other facilities. Employees violated Federal Acquisition Regulations and VA financial policy when they used purchase cards instead of contracts to obtain supplies.The OIG did not substantiate that the facility purchased unnecessary equipment, nor that funds were wasted on purchasing surgical equipment and related service contracts. The OIG was unable to determine if operating rooms were underused because sufficient data on percentage of surgeries being outsourced were not available. However, the OIG substantiated that two operating rooms were not being used two years after the surgical department opened and the department’s activation was delayed. Employees provided evidence supporting the decisions to not yet open all the operating rooms. COVID-19 also affected delays in surgical department activation.The OIG recommended the Southeast Louisiana Veterans Health Care System director account for undocumented excess supplies and determine if any administrative action should be taken on some $675,000 in missing supplies listed in a report of survey. The director should also ensure identified FAR violations are reported to the Financial Services Center, appropriate remedies or penalties are imposed, and all unauthorized commitments are ratified per policy. The director should ensure employees coordinate with and obtain guidance from National Purchase Card Program staff when they are uncertain about proper use of government purchase cards. Leased equipment should be returned to the contractor for any operating rooms that will not be used for at least one year.