Federal Reports

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Salt Lake City Health Care System, which includes the George E. Wahlen VA Medical Center in Salt Lake City and multiple outpatient clinics in Idaho, Nevada, and Utah. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued six recommendations for improvement in three areas:1. Medical staff privileging• Focused Professional Practice Evaluation results2. Environment of care• Environment of care inspections• Inpatient Psychiatry Unit: • Panic and over-the-door alarm testing • Maintaining a safe environment3. Mental health• Comprehensive Suicide Risk Evaluation completion

The Office of the Inspector General performed an audit to determine the effectiveness of the Tennessee Valley Authority’s (TVA) business application retirement process. Our scope included application retirement requests in TVA’s ticketing system as of December 6, 2023. We determined TVA's business application retirement process was ineffective. Specifically, the application retirement process did not (1) have clear ownership and accountability, (2) have effective controls to prevent duplicate requests and incomplete data, and (3) align with best practices. As a result of the ineffective process, only one application had been retired since September 28, 2022, and 631 business application retirement requests were between 1 and 434 days outstanding. TVA management agreed with our recommendations.

The AmeriCorps Office of Inspector General (AmeriCorps OIG) investigated allegations that a contractor submitted invoices under its Blanket Purchase Agreement (BPA) with AmeriCorps that included unallowable and/or unsupported costs. AmeriCorps OIG’s investigation foundevidence that the contractor billed AmeriCorps $167,714.42 in unallowable charges in violation of acquisition regulations and policies, including, Federal Acquisition Regulation (FAR) 31.201-2(d) Determining allowability, FAR 5.503(c) Proof of advertising, and AmeriCorps Acquisition Policy5.1304(c) Invoice Certification, and the contractor lacked supporting documentation required by the BPA. In addition, the investigation found that the contractor both overbilled and underbilled AmeriCorps, the net of which favored the contractor.

The AmeriCorps Office of Inspector General (AmeriCorps OIG) investigated allegations that the former Executive Director (ED) of the Volunteer and Community Service Commission of Puerto Rico (Commission) attempted to use AmeriCorps funds to award a sole-source contract to a close friend, required prayers before AmeriCorps events, and requested subgrantees allow AmeriCorps members to perform service outside the scope of their grant. AmeriCorps OIG’s investigation confirmed the allegations regarding the sole-source contract and that the former ED required a prayer before the start of multiple AmeriCorps events. The investigation also found that the Commission was not reimbursing its subgrantees in a timely manner and that a former Commission Program Coordinator was improperly paid $2,825.