Federal Reports

For the independent program evaluation of National Institute of Standards and Technology (NIST) Pandemic Relief Program, the evaluation objective was to determine whether NIST grantees and subrecipients accounted for and expended pandemic relief funds provided under the Coronavirus Aid, Relief, and Economic Security Act and subsequent funding authorizations in accordance with federal laws and regulations. We contracted with the Institute for Defense Analyses (IDA), an independent firm, to perform this evaluation. Our office oversaw the evaluation’s progress to ensure that IDA performed it in accordance with the Council of the Inspectors General on Integrity and Efficiency’s Quality Standards for Inspection and Evaluation (December 2020) and contract terms. However, IDA is solely responsible for the attached report and the conclusions expressed in it.In its evaluation, IDA identified that multiple recipients spent more than the approved budgeted amounts by category or in new budget categories without receiving the required prior approval, resulting in questioned costs of approximately $2.55 million.In addition, IDA made the following observations:• NIST’s technical oversight of awards encouraged process efficiencies where possible. • NIST leveraged existing processes to expedite awards, program objectives were aligned with award activities, and NIST can improve oversight by tracking quantitative goals and progress toward goals in progress reports.

What We Looked AtThe Federal Railroad Administration’s (FRA) recent data show that human factors, which include fatigue, remain the leading cause of reportable non-grade crossing train accidents. In particular, the rate of human factor-caused train accidents reached a 14-year high of 1.43 per million train miles in 2022. According to FRA, overseeing railroad fatigue management and compliance with Federal Hours of Service (HOS) requirements is part of the Agency’s ongoing efforts to address the adverse impacts and underlying causes of fatigue in the railroad industry. Given these factors, we assessed FRA’s (1) oversight of HOS compliance, (2) pursuit of civil penalties for HOS violations, and (3) oversight of passenger railroad compliance with fatigue management requirements. What We Found Three FRA staff in two divisions—the HOS subject matter expert (SME) and two fatigue SMEs—oversee HOS compliance and fatigue management for the entire railroad industry. However, the oversight processes and analyses are not fully documented and there is no evidence of risk-based planning. Specifically, there are no detailed procedures documenting how FRA’s staff plan or perform oversight of HOS compliance or required analyses of passenger railroad work schedules and fatigue mitigation plans. FRA also lacks guidance for many HOS violation penalty amounts as well as procedures for producing accurate Annual Enforcement Reports. As a result, FRA does not have the procedures and accurate data necessary to effectively target its limited resources to the highest risk areas or adequately oversee different railroad types. Our Recommendations FRA concurred with all 19 of our recommendations to improve its oversight of HOS and fatigue management and provided appropriate actions and completion dates. We consider these recommendations resolved but open, pending completion of planned actions.

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 VA Black Hills Health Care System, which includes the Fort Meade and Hot Springs VA Medical Centers and multiple outpatient clinics in Nebraska, North Dakota, South Dakota, and Wyoming. 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 four recommendations for improvement in three areas:1. Medical staff privileging• Completion of Ongoing Professional Practice Evaluations• Review of Ongoing Professional Practice Evaluation data and documents2. Environment of care• Completion of environment of care inspections3. Mental health• Completion of Comprehensive Suicide Risk Evaluations