Federal Reports

The Office of the Inspector General determined that bid evaluation and negotiation processes related for major equipment suppliers of gas construction projects were operating as intended; however, improvements were needed in TVA’s solicitation process. Specifically, we identified an opportunity for improvement related to the development of technical standards used in the solicitation process. In addition, we determined that TVA had a plan for addressing supply chain cybersecurity risk for procurements; however, it did not address how to determine when certain cybersecurity standards applied to equipment procurements.

We performed an audit of costs billed to the Tennessee Valley Authority (TVA) by BFI Waste Systems of North America, LLC dba South Shelby Landfill (BFI) for the transportation and off-site disposal of coal combustion residual (CCR) material from TVA’s Allen Fossil Plant to BFI’s South Shelby Landfill under Contract No. 15327. Our audit objective was to determine if costs were billed in compliance with the contract’s terms. Our audit scope included about $37.6 million in costs paid from December 23, 2020, through January 31, 2024.In summary, we determined BFI (1) overbilled TVA $459,356 in fuel charges and (2) did not perform a true up of performance bond costs billed to actual performance bond costs, resulting in $96,072 owed to TVA. In addition, we noted some opportunities to improve contract administration by TVA. Specifically, we determined (1) TVA approved BFI to bill $427,654 in costs that were not provided for in the pricing terms or work scope of the contract, and (2) TVA’s request for BFI to increase its workload and then subsequently reducing the number of operating hours resulted in a $3 increase to the per ton disposal rate and could cost TVA $9.07 million through the life of the contract.

NASA uses rocket propulsion test (RPT) sites to see how engines and components will react in launch conditions and in space and address any issues before launch. Much of NASA’s RPT infrastructure is aging and requires significant funding to maintain, while demand for NASA’s large-scale RPT facilities is in decline and funding is insufficient to address major maintenance projects.

We performed this review to determine whether the Matanuska-Susitna Borough School District expended Elementary and Secondary School Emergency Relief (ESSER) grant funds for allowable purposes in accordance with applicable requirements. We determined that all the ESSER expenditures we reviewed for Matanuska-Susitna were allowable and in accordance with applicable requirements. We also found that Matanuska-Susitna complied with key Federal procurement requirements, including those covering the procurement methods to be followed and contract cost, price, and provisions, when procuring the goods or services associated with each ESSER expenditure we reviewed. Because we identified no exceptions, our report does not include recommendations. However, our results are limited to the ESSER expenditures we reviewed, and it is critical that any remaining ESSER funds continue to be used appropriately.

We performed this review to determine whether the Southeast Polk Community School District t expended Elementary and Secondary School Emergency Relief (ESSER) grant funds for allowable purposes in accordance with applicable requirements. We determined that all 20 expenditures (5 personnel and 15 non-personnel) that we reviewed were allowable. Allowable activities generally include those authorized by the Elementary and Secondary Education Act, Individuals with Disabilities Education Act, Adult Education and Family Literacy Act, Carl D. Perkins Career and Technical Education Act of 2006, and subtitle B of title VII of the McKinney-Vento Homeless Assistance Act. However, for one expenditure totaling $62,000 for school bus air conditioners, Southeast Polk did not award or maintain documentation supporting its awarding of a contract to the selected vendor, which did not comply with Federal Regulations. We made one recommendation to address the procurement issue that we identified to ensure ESSER funds are used, documented, and managed in accordance with applicable requirements.

This Office of Inspector General (OIG) Healthcare Facility Inspections program report describes the results of a focused evaluation of the care provided at VA Hudson Valley Healthcare System, which includes the Franklin Delano Roosevelt Hospital in Montrose, New York. This evaluation focused on five key content domains: • Culture • Environment of care • Patient safety • Primary care • Veteran-centered safety netThe OIG issued four recommendations for improvement in one domain:1. Environment of care • Address snow removal on pathways to and from buses • Clarify signage on buildings • Implement navigation tools for the visually impaired • Distribute toxic exposure screening information

This Office of Inspector General (OIG) Healthcare Facility Inspections program report describes the results of a focused evaluation of the care provided at the VA Orlando Healthcare System in Florida. This evaluation focused on five key content domains: • Culture • Environment of care • Patient safety • Primary care • Veteran-centered safety netThe OIG issued two recommendations for improvement in two domains:1. Culture • Reevaluate bed level capacity and submit bed change request2. Environment of care • Secure pneumatic tube system

The VA Office of Inspector General (OIG) conducted this audit to determine whether VA and its contractor had sufficient controls to prevent, respond to, and mitigate the impact of major performance incidents affecting the electronic health record (EHR) system.In May 2018, VA awarded a 10-year contract to Cerner (now Oracle Health) to implement the system. Since then, it has experienced hundreds of major performance incidents affecting the five VA medical centers where the system was initially deployed.The OIG found VA and Oracle Health did not have adequate controls to prevent system changes from causing major incidents, to respond to those incidents uniformly and thoroughly, or to mitigate their impact by providing standard procedures and interoperable downtime equipment. Further, although major performance incidents can delay care to veterans, VA had no formal process to link reports of these delays to specific major performance incidents. Ultimately, the inadequate controls for handling major incidents stemmed from the May 2018 contract. In May 2023, VA modified the contract to strengthen some requirements for addressing major incidents but could do more.The EHR system’s estimated cost has grown. It was originally $16 billion. If VA does not improve controls, major performance incidents will continue, leading to further costly delays in system implementation and posing an ongoing risk to patient safety.The OIG made nine recommendations, including real-time data sharing to give VA greater awareness of potential problems in system operations, prioritizing major performance incident response in a clear and consistent manner, developing and enforcing response and other performance metrics to hold the contractor accountable, requiring sufficient detail in post-resolution reports, raising staff awareness of procedures and acquiring appropriate backup systems for downtime, and better identifying and addressing major performance incidents linked to negative patient outcomes.