Federal Reports

Our objective was to assess the company’s efforts to identify and manage its risk of train strikes—incidents in which a train hits people or vehicles.

Train strikes have resulted in hundreds of fatalities and injuries in recent years and can take a heavy toll on the crew members involved—by our estimate, in fiscal year 2023, one in five of the company’s passenger engineers may have been involved in a strike.

We found that, like other railroads, the company faces inherent challenges to reducing train strikes because of factors that are difficult to control, such as suicide attempts and motorists who ignore crossing signals. Nonetheless, the company can better identify and manage train-strike related risks. It began new initiatives to do so during our audit; however, embedding ongoing initiatives into a more comprehensive, proactive risk management process could help the company better identify all major risks and make informed decisions about where to allocate its limited resources. We identified a list of key practices to aid this effort, such as collecting input from train crews about specific hazards and doing a cost-benefit analysis of different mitigation steps. The company already has many positive efforts underway that align with each of these practices. In addition, we found the data Amtrak collects on train strikes and reports to the Federal Railroad Administration had some discrepancies, which the company corrected during our audit.

We recommended that Amtrak develop a comprehensive, proactive process to identify and manage the risk of train strikes. As it institutes this process, the company should consider expanding implementation of the key practices we identified, as appropriate. We also recommend that it implement a process to regularly review and reconcile its train strike data to ensure its accuracy.
 

As part of the Office of Inspector General’s (OIG) oversight responsibility, we reviewed the results of prior OIG engagements that were relevant to the funded trade programs. We identified areas with reported past weaknesses and recommendations that may provide the Foreign Agricultural Service (FAS) insight when disbursing funds under these programs.

This report provides information about the processes that the Food and Nutrition Service uses to disburse Supplemental Nutrition Assistance Program benefits using the EBT system, as well as the related oversight activities.

This inaugural disaster recovery biannual report and subsequent reports will provide curated information regarding the U.S. Department of Housing and Urban Development (HUD) and its grantees’ use of the more than $109 billion in disaster recovery funds approved by Congress since the 2001 World Trade Center attack, as well as information on new or completed HUD OIG oversight work related to HUD’s disaster recovery program.

HUD’s grantees use these essential funds to assist impacted communities and low- and moderate-income families in recovering from disasters and to mitigate damages from future disasters, including damage from water, wind, and fire. For our first report, we have benchmarked disaster recovery funding, grantee spending, and spending by activity type to help our stakeholders better understand HUD’s disaster recovery portfolio.

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The Tennessee Valley Authority's (TVA) transmission planning process includes assessing the capacity of the transmission system to reliably deliver power from generation resources to customer loads.  Due to the importance of ensuring TVA’s transmission system can accommodate its generation strategy and ensure adequate system margins to allow for reliable customer supply, we performed an evaluation to determine if TVA’s plans for transmission capacity support (1) planned generation additions and (2) demand growth.  We determined TVA’s plans for transmission capacity account for generation additions and demand growth; however, we identified an increased risk to Transmission Planning and Projects’ ability to execute these plans.  These included (1) gaps between budgeted funding levels and forecasted spending needed to support TVA’s planned generation and demand growth through fiscal year 2029 and (2) some transmission projects that were forecast to exceed approved cost and/or time frames, which could impact the ability of Transmission Planning and Projects to support generation additions or demand growth. 

The overall objective is to identify AbilityOne Program data generated or maintained by Central Nonprofit Agencies (CNA) and/or Nonprofit Agencies (NPA), that is not currently available to the Commission.  

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Western Colorado Healthcare System in Grand Junction. 

This evaluation focused on five key content domains:
   •    Culture
   •    Environment of care
   •    Patient safety
   •    Primary care
   •    Veteran-centered safety net

The OIG issued eight recommendations for improvement in two domains:
  1.    Environment of care
   •    Toxic exposure screenings
   •    Fire extinguisher inspections
   •    Preventive maintenance inspections 
   •    Wheelchair disinfection, ceiling vent dust removal, and wall repair
   •    Equipment and supply access and storage 
   •    Video monitoring
   •    Veterans Integrated Service Network oversight of the environment of care program
  2.    Patient Safety
   •    Patient test result notification process

The OIG conducted this review to assess the merits of two hotline complaints—one in March 2024 and one in April 2024—alleging Omaha VA Medical Center leaders manipulated the clinically indicated date for consults, thereby limiting veterans’ access to community care. The OIG substantiated the allegations, determining that from March 7, 2024, through April 11, 2024, facility leaders implemented a prohibited 29-day default for the clinically indicated date field that applied to referrals for specialty care and for some primary and mental health care. The default was implemented because clinically indicated dates for many specialty care consults were, in the chief of staff’s and medical facility director’s opinion, sooner than the patient’s condition warranted.

Before implementing the default, both the medical facility director and the chief of staff were made aware that there should not be a default. After implementing, they were also notified by an Omaha VA Medical Center employee that the default was not allowed and should be removed, but facility leaders took 19 days to remove the default. Furthermore, the OIG found providers were not given training on clinically indicated dates. In early November 2024—more than six months after the default was removed—training was provided.

The OIG made four recommendations: to clarify that automatically prepopulating the clinically indicated date field is prohibited; to determine whether any administrative action should be taken; to direct the medical facility director to provide education and training on the consult process; and to assess the actions the medical facility has taken to review consults potentially affected by the default and ensure veterans received the care they needed.