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Brought to you by the Council of the Inspectors General on Integrity and Efficiency
Federal Reports
Report Date
Agency Reviewed / Investigated
Report Title
Type
Location
Department of Defense
WHISTLEBLOWER REPRISAL INVESTIGATION HONEYWELL INTERNATIONAL INC. MINNEAPOLIS, MINNESOTA
The Office of the Inspector General performed an audit of TVA’s transmission network cybersecurity. The audit scope was limited to a specific type of connectivity within TVA’s transmission network. The audit objective was to determine the level of cybersecurity in place for this type of connectivity.
We determined the connectivity within TVA’s transmission network had a high level of cybersecurity in place commensurate with the level of associated risk. In addition, our testing of internal controls identified process improvements related to configuration management. We recommend the Senior Vice President, Grid, update configuration management processes to improve periodic reviews.
Delayed Diagnosis and Treatment for a Patient’s Lung Cancer and Deficiencies in the Lung Cancer Screening Program at the VA Eastern Kansas Healthcare System in Topeka and Leavenworth
The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate allegations related to a patient’s care and the lung cancer screening (LCS) program at the VA Eastern Kansas Healthcare System (system) in Topeka and Leavenworth.
The OIG substantiated that a patient experienced a delay in the diagnosis of and treatment for lung cancer. Neither the patient aligned care team (PACT) provider nor the system pulmonologist took the necessary steps to ensure a bronchoscopy was ordered and completed. The PACT provider ordered, but failed to track, a positron emission tomography (PET) scan completed by a community provider; and failed to communicate the abnormal results to the patient and initiate clinical actions as indicated. System leaders conducted an institutional disclosure to the patient; however, the institutional disclosure documentation did not include required details.
The OIG identified concerns related to the absence of an established process for community care providers to communicate abnormal test results directly to the system’s ordering providers.
Community care staff did not make timely, sufficient efforts to retrieve the patient’s PET scan results. The OIG found a broad system failure of community care staff not making three attempts to retrieve patient records within 90 days of completed appointments, which leaders partially attributed to metrics that prioritized receiving and scheduling community care appointments.
System and program leaders failed to develop the LCS program infrastructure prior to implementation. The LCS program lacked oversight, multidisciplinary engagement, policy, and adequate primary care training and engagement.
The OIG made one recommendation to the Under Secretary for Health related to the communication of patients’ abnormal test results and one recommendation to the Veterans Integrated Service Network Director regarding the system’s LCS program. The OIG made four recommendations to the System Director related to test results, institutional disclosures, and community care records.
FSA’s launch of the 2024–2025 FAFSA was plagued by multiple system implementation issues that prevented students and families from successfully applying for financial aid within critical timeframes. As a result, FSA developed actions to improve the 2025–2026 FAFSA process and increase transparency and communication. The objective of our review was to describe FSA’s plans to solicit, analyze, and incorporate feedback from students, families, institutions of higher education, and other stakeholders for the completion, submission, and processing of the 2025–2026 FAFSA. We found that although FSA did not have a formal plan with specific details about how it would solicit, analyze, and incorporate the feedback it received regarding the completion, submission, and processing of the 2025–2026 FAFSA, FSA and the Department established multiple channels of communication for receiving feedback. On November 14, 2024, FSA announced that since the start of beta testing on October 1, 2024, more than 14,000 students successfully submitted their 2025–2026 FAFSAs and that the Department had successfully processed their applications, sending over 81,000 records to more than 1,850 schools and 43 States.
We contracted with the Joachim Group CPAs & Consultants (Joachim Group) to examine the management of government issued purchase and travel cards. The Joachim Group conducted the audit in accordance with Generally Accepted Government Auditing Standards (GAGAS) and is responsible for the attached audit report and the conclusions expressed therein. The OIG monitored the auditor’s progress throughout the compliance audit and reviewed the respective audit report and related documentation.
The Pesticide Registration Improvement Act requires the U.S. Environmental Protection Agency Office of Inspector General to perform an annual audit of the financial statements for the Pesticide Registration Fund.
Summary of Findings
We rendered an unmodified opinion on the EPA’s fiscal years 2023 and 2022 (Restated) Pesticide Registration Fund—also known as the Pesticide Registration Improvement Act, or PRIA, Fund—financial statements, meaning that the statements were fairly presented and free of material misstatement. We noted the following material weakness: the EPA materially misstated the on-top adjustment involving the PRIA income and expenses from other appropriations, which is the PRIA 23-02A on-top adjustment, in its fiscal year 2023 draft financial statements by over $2.6 million. An on-top adjustment is a journal entry that is made at the end of an accounting period to adjust the accounts to accurately reflect revenues and expenses of the current period.