Federal Reports

As part of our annual audit plan, we audited costs billed to the Tennessee Valley Authority (TVA) by Williams Plant Services, LLC (Williams) under Contract No. 10728 for managed task construction and modification work at TVA's nuclear facilities. The contract provided for TVA to compensate Williams for these services on either a time and materials or fixed price basis. Our objective was to determine if costs billed to TVA were in accordance with the contract's terms. Our audit scope included approximately $34.1 million in costs billed to TVA from January 1, 2019, through September 18, 2020.In summary, we determined Williams overbilled TVA $549,911, including (1) $359,753 in unapproved subcontractor costs, (2) $30,802 in excessive and ineligible fee applied to subcontractor costs, (3) $107,080 in ineligible temporary living allowance and travel costs, (4) $29,840 in unsupported and ineligible labor costs, (5) $14,209 in ineligible material costs, and (6) $8,227 in credits not received by TVA (which have since been recovered by TVA).In addition, we noted several opportunities to improve contract administration by TVA. Specifically, (1) TVA approved and implemented a contract rate attachment that contained incorrect craft labor rates, (2) TVA paid invoices under an incorrect contract, and (3) the contract contained inconsistent compensation terms for nonmanual labor.(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 Beckley VA Medical Center and two outpatient clinics in West Virginia. The inspection covered key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.At the time of the OIG’s inspection, the medical center’s executive leadership team had worked together for over one year. Employee survey data revealed general satisfaction with leaders. However, opportunities appeared to exist for the Chief of Staff to improve employees’ perceptions toward leaders and the workplace, and for the Chief of Staff, Associate Director/Patient Care Services, and Associate Director to reduce staff feelings of moral distress at work. Patient experience survey scores implied satisfaction with the care provided, but highlighted opportunities for leaders to improve female patients’ experiences with specialty care providers. The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Executive leaders were generally knowledgeable within their scope of responsibility about selected Strategic Analytics for Improvement and Learning model measures and should continue to take actions to sustain and improve performance.The OIG issued four recommendations for improvement in four areas:(1) Quality, Safety, and Value• Surgical workgroup meetings(2) Mental Health• Suicide safety plan training(3) Care Coordination• Medication list transmission(4) High-Risk Processes• Prevention and management of disruptive behavior training

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 Hershel “Woody” Williams VA Medical Center and multiple outpatient clinics in Kentucky, Ohio, and West Virginia. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.At the time of the OIG inspection, all leadership positions were permanently assigned and the executive team had worked together for over one year. The Director and Chief of Staff were assigned in February 2014 and June 2020, respectively. Employee survey data revealed an opportunity for the Director to decrease staff feelings of moral distress at work. Patient experience survey scores generally reflected similar or higher care ratings than the VHA averages, although leaders appeared to have an opportunity to improve female patients’ primary care access. The OIG’s review of the medical center’s accreditation findings did not identify any substantial organizational risk factors. However, the OIG identified concerns with conducting institutional disclosures for sentinel events. Executive leaders were knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue efforts to sustain and improve performance.The OIG issued six recommendations for improvement in four areas:(1) Leadership and Organizational Risks• Institutional disclosures(2) Quality, Safety, and Value• Systems Redesign Coordinator meeting participation• Surgical work group meetings(3) Care Coordination• Inter-facility transfer form completion(4) High-Risk Processes• Disruptive behavior committee meeting attendance

The post office lobby is the principal business office of the U.S. Postal Service. There are over 30,000 leased and owned Postal Service retail facilities nationwide. For most customers, the lobby is their only close-up view of Postal Service operations; therefore, its appearance directly affects the Postal Service’s public image. The Postal Service must maintain a safe environment for both employees and customers, including adherence to federal safety laws enforced by the Occupational Safety and Health Administration (OSHA) and internal policies and procedures regarding the appearance of lobbies and facilities, safety, and security of its facilities.Our objective was to summarize the results of prior property condition reviews of Postal Service retail facilities, identify systemic issues, and assess the effectiveness of management’s corrective actions.

By disclosing nonpublic information, the employees violated regulations that prohibit providing preferential treatment to any private organization.