Federal Reports

The Office of the Inspector General OIG audited the Tennessee Valley Authority’s (TVA) use of remote application and desktop virtualization due to the risk of increased remote users during the COVID-19 pandemic and recent publicized remote access vulnerabilities. We found several areas where TVA was consistent with cybersecurity remote access best practices. However, we identified gaps in TVA’s configuration settings, architectural design, and administrative procedures. We recommend the Vice President and Chief Information and Digital Officer, Technology & Information, review the identified gaps and remediate as appropriate. Specifics of the identified issues were omitted from this report due to their sensitive nature in relation to TVA’s cybersecurity but were formally communicated to TVA management in a briefing on November 15, 2021.

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 Charles George VA Medical Center in Asheville, North Carolina. The inspection covers key clinical and administrative processes associated with promoting quality care, focusing 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: Interfacility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.At the time of the OIG inspection, the acting Director had been in the position for two days, but the Associate Director for Patient Care Services/Nurse Executive had been in the role for over 18 years, with other leaders in their roles for over a year. Employee survey responses demonstrated satisfaction with leadership and the workplace. Patient experience survey data implied satisfaction with the care provided, and selected survey results were generally more favorable than those for VHA patients nationally.The OIG’s review of the system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Executive leaders were knowledgeable within their scope of responsibilities and tenure about selected VHA data used by the Strategic Analytics for Improvement and Learning models.The OIG issued five recommendations for improvement in two areas:(1) Care Coordination• Inter-facility patient transfer monitoring and evaluation• Transfer form completion• Medication list transmission(2) High-Risk Processes• Disruptive behavior committee meeting attendance• Staff training

We audited the Buffalo Municipal Housing Authority’s management of its Commodore Perry Homes development. We selected the Authority based on congressional interest. Half of the development’s buildings were demolished more than 20 years ago, and the majority of the remaining buildings and units have been vacant for years without redevelopment activity. The objective of the audit was to determine whether the Authority properly managed its Commodore Perry Homes development. Our work focused on the period beginning in July 2013.The Authority did not properly manage the Commodore Perry Homes development to address longstanding redevelopment needs and health and safety issues. While the Authority had made various redevelopment plans for the property since 2013, none fully materialized, and all dwelling units in the development are now vacant. Further, the Authority did not adequately address urgent, ongoing health and safety issues with the vacant development. These issues occurred for various reasons, including that the Authority did not consistently prioritize taking action at its Commodore Perry Homes development, lacked a cohesive redevelopment strategy over time, and lacked sufficient processes to address recurring issues. While HUD and the Authority had recently taken steps toward developing a plan forward, no redevelopment had occurred at the site. As a result, fewer low-rent units were available to families in need, the vacant development continued to deteriorate, and the surrounding residents and local community continued to be exposed to significant blight and health and safety issues.We recommend that HUD determine (1) whether the development represents an imminent threat to public safety and activities to control the situation could be taken before the full environmental review process, and (2) which environmental review process would be most beneficial to ensure that it is completed as soon as possible. Further, we recommend that HUD continue to provide training and technical assistance to the Authority and require it to (1) identify and address urgent health and safety issues; (2) develop and implement a plan to routinely identify and address recurring urgent health and safety issues; and (3) develop and implement plans for the remaining public housing units at the development and for the original property related to the units converted during previous redevelopment efforts. Last, if the Authority does not follow through on its asset repositioning plans, misses deadlines, or the plan is no longer feasible, we recommend that HUD consider and use available remedies.

Transmittal of the Final Report Assessing the Federal Trade Commission’s Compliance with the Federal Information Security Management Act for Fiscal Year 2021 (Redacted for public release)