Federal Reports

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 Durham VA Health Care System in North Carolina. 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; 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 review, the executive team had worked together in a permanent capacity for four months; however, the Executive Director and the Chief of Staff had served in their positions for over three years. Healthcare system leaders had recently received approval and started recruiting for a second assistant director. Employee survey data revealed satisfaction with leadership, but highlighted opportunities to reduce employees’ feelings of moral distress at work. Selected patient survey results implied lower satisfaction than the VHA average and highlighted opportunities to improve inpatient and outpatient care experiences.The OIG’s review of the healthcare system’s accreditation findings, sentinel events, and disclosures of adverse patient events did not identify any substantial organizational risk factors. Executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to improve performance.The OIG issued eight recommendations for improvement in four areas:(1) Registered Nurse Credentialing• Primary source verification of licenses(2) Mental Health• Suicide prevention training(3) Care Coordination• Transfer monitoring and evaluation• Transfer form completion• Medication list transmission(4) High-Risk Processes• Disruptive behavior committee attendance• Patient notification of Orders of Behavioral Restriction• Staff training

The U.S. Commodity Futures Trading Commission Office of Inspector General reviewed the audit operations of Denali Commission OIG.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Vancouver Main Post Office (MPO) in Vancouver, WA (Project Number 22-032). The Vancouver MPO is in the Washington District of the WestPac Area. The post office services ZIP Codes 98660, 98661, 98663, 98665, 98685, and 98686. There are about 135,114 people living in these ZIP Code areas, with about 133,721 (99 percent) living in urban communities and about 1,393 (1 percent) living in rural communities. We judgmentally selected the Vancouver MPO based on the number of customer inquiries per route the unit received. From June 1 through August 31, 2021, the unit received 12 inquiries per route, which was more than the average of 10.62 inquiries per route for all sites serviced by the Portland Processing and Distribution Center (P&DC).

A Customer Service Representative at Rensselaer Station, New York, violated Amtrak policies by committing theft of a co-worker’s personal property while on duty. During the joint investigation with the Amtrak Police Department, the employee admitted to the thefts and resigned from the company shortly thereafter. The employee is ineligible for rehire.

As part of our annual audit plan, we audited costs billed to the Tennessee Valley Authority (TVA) by World Wide Technology, LLC (WWT) under Contract No. 10786 for Cisco hardware, maintenance, services, and support. The contract provided for TVA to compensate WWT for products and services on either a time and materials or fixed price basis. Our audit objective was to determine if costs were billed in compliance with the contract's terms. Our audit scope included about $72.5 million in costs billed to TVA for the period of December 1, 2015, through December 31, 2020.In summary, we determined WWT: Overbilled TVA $38,302 in labor service costs, including (1) $31,341 for unsupported labor hours, and (2) $6,961 in excessive hourly pay rates. Could not provide adequate support for the Cisco list prices used to apply contractual discounts for products and maintenance. Therefore, we could not determine if the majority of costs billed for products and maintenance agreements were in accordance with the contract terms. Overbilled TVA $4,051 because the contractual discounts were not applied correctly on the limited product costs we were able to review. (Summary Only)