Federal Reports

The Office of Inspector General (OIG) is issuing this inspection report to present the results of our assessment of the U.S. Small Business Administration’s (SBA) initial response to Hurricanes Fiona and Ian, including staffing adequacy, loan application volume, and timeliness of disaster loan approvals.We found SBA’s initial response to Hurricanes Fiona and Ian was timely and effective. The agency established a field presence within 3 business days and opened a Business Recovery Center within 10 business days for both hurricanes, meeting its strategic goal. Additionally, SBA successfully addressed initial staffing concerns and maintained adequate staffing levels throughout its response to both hurricanes.The agency reacted to anticipated resource needs by implementing a hiring initiative and providing advanced specialty training. These actions addressed a projected staffing shortfall, including the need for bilingual staff who were brought in to assist from other SBA offices.

The Veterans Community Care Program allows the Veterans Health Administration (VHA) to purchase care for veterans through Community Care Network (CCN) contracts or veterans care agreements. While the CCN groups VA medical facilities into regions managed by third-party administrators (TPAs), the Office of Integrated Veteran Care (IVC) is responsible for overseeing execution of CCN contracts.The VA Office of Inspector General (OIG) conducted this audit to determine whether VHA provided effective oversight of its TPAs and VA medical facilities. The review team evaluated IVC’s oversight of the TPAs’ adherence to four contract requirements designed to ensure facilities have enough community providers to administer care within the timeliness and drive-time standards established in the contracts. The OIG found that IVC did not hold TPAs accountable for implementing these contract requirements, causing staff to struggle to convince TPAs to add community providers to their networks at the eight facilities the audit team visited.While IVC provided proof of TPA discussing community care needs with three facilities, similar evidence for other facilities was not provided. Furthermore, IVC did not conduct any analyses of facilities’ network adequacy needs to help TPAs build provider networks and did not ensure TPAs maintained provider networks that were accepting VA patients. IVC also did not position itself to defend facilities’ needs for additional community care providers.The OIG recommended to the undersecretary for health that the IVC holds future TPAs accountable for operational readiness and provider network adequacy; develop processes to update and maintain CCN data, challenges, and needs; conduct Advanced Medical Cost Management Solution training on evaluating network adequacy through the tool for community care staff; and not only develop its own network adequacy performance reports but also evaluate TPAs’ reports, holding them accountable for resolving identified issues.

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 Syracuse VA Medical Center, which includes multiple outpatient clinics in New York. 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 12 recommendations for improvement in four areas:1. Quality, safety, and value• Peer review committee • Peer review level reassignments • Review of data by medical executive committee2. Medical staff privileging• Ongoing Professional Practice Evaluation completion• Specialty-specific criteria for professional practice evaluations3. Environment of care• Environment of care inspections• Safe and clean patient care areas• Mental health inpatient unit: • Panic and over-the-door alarm testing • Maintaining a safe environment • Ceiling tiles checked semiannually• Biomedical staff inspection and testing of medical equipment• VISN oversight of biomedical program4. Mental health• Comprehensive Suicide Risk Evaluation completion

The VA Office of Inspector General (OIG) conducted a focused national review to assess concerns with Veterans Health Administration’s (VHA’s) process to identify providers who have been removed from VA employment due to violations of policy “relating to the delivery of safe and appropriate care” and exclude those providers from the VA Community Care Program (VCCP), as required by the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 (MISSION Act).The OIG found that VHA’s process failed to identify all healthcare providers removed from VA employment. The OIG determined that VHA’s process also failed to accurately identify personnel actions that indicate healthcare providers were removed for violating policies relating to the delivery of safe and appropriate care. Furthermore, VHA did not consider whether a provider was removed for reasons related to delivery of safe and appropriate care. These process failures resulted in both inclusion of ineligible providers and exclusion of eligible providers from the VCCP.Deficiencies in VHA’s process to identify providers who should be excluded precluded a complete evaluation of the exclusion process. As a result, this inspection focused on the initial steps to identify ineligible providers for exclusion. The OIG remains concerned about VHA’s inability to exclude and prevent ineligible healthcare providers from delivering care to veterans through the VCCP. The OIG issued this brief report to provide timely oversight and share concerns to facilitate VA action.The OIG made two recommendations to the Under Secretary for Health related to the criteria and processes used to identify and exclude ineligible healthcare providers from the VCCP, and to review previous personnel actions to determine whether the reason(s) for those removals were for violation of policy related to the delivery of safe and appropriate care.

Jason Chan and Jamar Rogers, both California residents, were sentenced on April 8, 2024, and March 27, 2024, respectively, in the U.S. District Court, Eastern District of California, for Wire Fraud and Aiding and Abetting. Chan was sentenced to 3 years’ probation and Rogers was sentenced to 12 months and one day in prison followed by 3 years’ probation. The men were also ordered to pay a total of $43,518.32 in joint restitution.Our investigation found that Rogers purchased Amtrak tickets with stolen credit cards and exchanged the tickets for vouchers that he then advertised for sale. Chan purchased the vouchers from Rogers at a discounted rate, used them to buy new tickets, cancelled those tickets to obtain new vouchers, and then offered Amtrak tickets for sale at a discount. As a result of the scheme, Rogers and Chan caused Amtrak to issue approximately $38,000 in ticket vouchers and caused losses of over $45,000 to Amtrak, card-issuing banks, and card holders.

Why We Did This ReportThe U.S. Environmental Protection Agency Office of Inspector General conducted this audit to determine to what extent (1) the EPA is providing guidance and reviewing states’ clean water state revolving fund intended use plans, or IUPs, to ensure that the plans, as they relate to climate change resiliency, meet the intent of the presidential policy directive to strengthen and maintain secure, functioning, and resilient critical infrastructure; and (2) the states, in their clean water state revolving fund planning, are considering climate change resiliency to safeguard federal investments, including funding provided by the Infrastructure Investment and Jobs Act. Summary of FindingsThe EPA prioritized climate adaptation and provided guidance to states during the development of their annual clean water state revolving fund intended use plans, or CWSRF IUPs. Despite these EPA actions, the EPA had limited success in getting states to include climate adaptation or related resilience efforts, such as those addressing natural disasters, in their IUPs. Just 13 states included this in their 2020 IUPs. After passage of the Infrastructure Investment and Jobs Act and after the federal government established its climate adaptation priority in 2021, the number increased to 25 states for the 2022 IUPs, an increase of 12 states over two years. In addition, only 13 states included climate adaptation or related resilience efforts as part of the project prioritization criteria documented in their 2022 IUPs. In federal fiscal year 2022, the EPA awarded $1.2 billion out of the available $3 billion CWSRF funds—which included annual and Infrastructure Investment and Jobs Act appropriations—to states that did not include resilience in their IUPs. Funded projects may become inoperable if the impacts of climate change are not considered.

A primary goal of the National Telecommunications and Information Administration (NTIA) is to expand U.S. broadband Internet access and adoption. To help meet this goal, NTIA administers six broadband programs, including the Tribal Broadband Connectivity Program (TBCP). Our objective for this audit was to determine whether NTIA properly disbursed the federal funds provided for the TBCP. We reviewed awards made under NTIA’s first round of TBCP funding. Between September 1, 2021, and December 31, 2022, NTIA awarded about $1.73 billion. Overall, we found that NTIA did not adequately design and implement the award process to ensure that TBCP funds were awarded only for eligible proposed service areas. For the awards we reviewed, we determined that NTIA did not (1) independently verify that grant recipients needed funding for broadband infrastructure deployment and (2) consistently document its process for reviewing TBCP applications. As a result of these issues, the TBCP’s fraud risk is higher, and NTIA could not provide assurance that TBCP awards were made to tribes that did not have access to broadband and actually needed the funds.

We found that the Government email address of a former BIE employee was spoofed to change the employee’s direct deposit information.