Federal Reports

The VA Office of Inspector General (OIG) conducted a national review to determine compliance with Veterans Health Administration (VHA) policy on the management of emergent care needs of acute sexual assault victim-survivors. Sexual assault is an invasive form of interpersonal violence that can have medical, psychological, and legal consequences, requiring a coordinated and compassionate response from medical providers and law enforcement officers when victim-survivors seek care.The OIG found deficiencies in adherence to VHA policy, including requirements to ensure the provision of sexually transmitted infection prophylaxis and pregnancy prophylaxis when clinically indicated, to offer psychological counseling, and in the documentation of signature informed consent for forensic examinations. The majority of VHA facilities utilized community sexual assault forensic examiner (SAFE) resources to provide forensic examinations, which was identified as a best practice for most VHA sites.Care related to acute sexual assault is a low frequency but crucial occurrence in VHA, presenting challenges maintaining staff knowledge and training. Additionally, facility and community resources as well as jurisdictional requirements on reporting and evidence collection for acute sexual assault vary across facilities. VHA policy establishes requirements to ensure that veterans have access to safe, high-quality care. However, supplemental facility policy or guidance is needed to ensure facility procedures align with local community resources and jurisdictional requirements to ensure frontline staff have easy access to current clinical practices when responding to acute sexual assault. The OIG determined that opportunities exist for many facilities to improve guidance addressing management of acute sexual assault patients. Improved facility guidance would help ensure implementation of VHA policy by providing frontline staff and VA police with relevant, accessible local procedures and resources when responding to patients presenting with acute sexual assault.The OIG made eight recommendations to the Under Secretary for Health related to practice deficiencies and improving guidance.

An Amtrak Coach Cleaner based in Beech Grove, Indiana, was terminated from employment on December 12, 2023, following his administrative hearing. Our investigation found that the employee violated company policies by falsely claiming employment with the U.S. Army from 2004-2015 on a resume he submitted to the company, when he was actually serving time in prison for arson.

An Amtrak electrician based in Wilmington, Delaware, violated company policies by engaging in outside employment by operating his general contracting business while on a medical leave of absence. The employee was on a medical leave of absence since February 2020 and had not returned to work as of the issuance of our investigative report. The employee resigned on December 12, 2023, prior to his scheduled administrative hearing.

The Pandemic Response Accountability Committee’s (PRAC) Semiannual Report to Congress, covering the period from April 1, 2023 through September 30, 2023.

Like other organizations, Amtrak (the company) faces the inherent cybersecurity risk that employees or contractors are “insider threats”—that is, that they could maliciously or unintentionally use information systems or data in a manner that harms the company. Insider threats may cause more harm and are more difficult to detect than external cyber‐attackers because individuals within an organization already have access to systems and data. Amtrak Office of Inspector General’s (OIG) recent investigations identified company employees and contractors who misused or took advantage of their system access and exposed sensitive company information. Accordingly, our objective was to assess the effectiveness of company controls to protect its information systems and data from insider threats. Our recommendations included conducting an insider threat risk assessment, establishing a policy for insider threat activities, and developing a process to track and enforce company access requirements. In commenting on a draft of this report, company executives agreed with our recommendations and identified actions that the company plans to take to address them.THE TRANSPORTATION SECURITY ADMINISTRATION AND THE DEPARTMENT OF TRANSPORTATION HAVE DETERMINED THAT THIS REPORT CONTAINS SENSITIVE SECURITY INFORMATION (SSI) that is controlled under 49 CFR parts 15 and 1520 to protect Sensitive Security Information exempt from public disclosure. For Amtrak OIG, public disclosure is governed by 5 U.S.C. § 552 and 49 CFR parts 15 and 1520. This public version of the report has been redacted.