Federal Reports

A management official based in Chicago, Illinois, was terminated from employment on April 24, 2025, as the result of our investigation. We found that the former employee violated company policies by engaging in outside employment while on a medical leave of absence and conducting outside business activities while on company time. The former employee is not eligible for rehire.

An Amtrak Supervisor based in Philadelphia violated company policy between 2022 and 2023 by not swiping out on a Time Entry Device after his shifts and, subsequently, swiping out and immediately back in when he returned to work. In addition, our investigation revealed that the supervisor directed multiple subordinates to follow this same swiping protocol. The scheme allowed recording of significant consecutive hours for each employee. The employees used this swiping protocol to inaccurately claim a full eight hours of regular pay in Amtrak’s timekeeping system, instead of correctly recording seven hours of regular pay and one hour of Code 29 pay (hours paid but not worked), thereby creating inaccurate financial accounting records and hiding Code 29 hours from management.

The supervisor was terminated after his disciplinary hearing in April 2025 and is not eligible for rehire.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess an allegation that a physician (subject physician), who was not privileged at the Overton Brooks VA Medical Center (facility) in Shreveport, Louisiana, provided care to intensive care unit (ICU) patients. The OIG also identified concerns with a quality review completed after facility leaders’ awareness of the event.

The OIG substantiated that the subject physician, a fellow in training at an academic affiliate, provided patient care for three hours in the ICU with attending physician oversight. Failure to follow the trainee Veterans Health Administration (VHA) onboarding process and lack of oversight of physician coverage for the ICU contributed to the event. The resident student coordinator facilitated the VHA trainee onboarding process before receiving the required verification letter, resulting in the improper onboarding of the subject physician. Additionally, the chief of medicine failed to ensure a process was implemented to verify ICU coverage-pool physicians were credentialed and privileged at the facility.

The Facility Director chartered a root cause analysis (RCA); however, the RCA team’s application of the RCA process left patient safety risks unresolved and did not explore how the subject physician was onboarded as a trainee or provided care in the facility’s ICU. The RCA team’s failure to follow VHA required guidelines affected the reliability of the RCA team’s assessment and conclusion. The OIG also identified a facility practice involving an additional concurrence step, which created vulnerabilities related to breaching RCA confidentiality and service line leaders influence on RCA findings. 

The OIG made one recommendation to the Under Secretary for Health to evaluate VHA using an additional RCA concurrence step and three recommendations to the Facility Director related to trainee onboarding requirements, oversight of intensive care unit physician credentialing and privileging, and completing root cause analyses as required. 

Our Objective(s)To evaluate FMCSA Motor Carrier Safety Assistance Program (MCSAP) grant oversight activities. Specifically, we reviewed FMCSAs (1) policies and procedures for monitoring MCSAP grant recipients, (2) annual risk assessments and monitoring plans for MCSAP recipients, and (3) tracking of recipients achievement of safety goals.
Why This AuditThe Federal Motor Carriers Safety Administration (FMCSA) reported that 5,176 fatalities involving large trucks and buses occurred in 2023. To reduce these incidents, FMCSA provides MCSAP formula grants to State agencies. The Infrastructure Investment and Jobs Act of 2021 (IIJA) authorized over $2 billion in appropriations for MCSAP grants and up to $400 million in supplemental funds.
What We FoundFMCSAs Division Offices do not always follow the Agencys MCSAP monitoring policies and procedures.

FMCSAs guidelines on Division Offices reviews of grantees MCSAP reimbursement requests are insufficient and outdated.

Why We Did This Report

The U.S. Environmental Protection Agency Office of Inspector General initiated this project to determine whether Bacon & Company, CPAs, LLC performed the fiscal year 2022 single audit of the Narragansett Bay Commission in Rhode Island in accordance with applicable auditing standards and federal requirements for single audits.

Summary of Findings

We determined that Bacon & Company complied with the applicable auditing standards and federal requirements when it performed the FY 2022 single audit of the Narragansett Bay Commission. As a result, we assign Bacon & Company a pass rating. During our review, we also identified an error in Bacon & Company’s major program determination for compliance testing. However, this error did not impact the overall quality or our assigned rating.

We reviewed the Office of Contracting and Procurement’s controls over Contractor Performance Assessment Reporting System requirements.

This report presents the results of our management advisory bringing the Small Business Administration’s (SBA) attention to concerns regarding forgiven Paycheck Protection Program (PPP) loans subsequently flagged as potentially ineligible using hold code 70 (potential clawback) for which the agency has not completed its review to facilitate recovery of improper payments for ineligible loans. A hold code is an identifier placed on a loan in the agency’s system indicating a potential issue needs to be resolved. SBA uses hold code 70 to flag forgiven PPP loans for which it subsequently suspects the borrower is potentially ineligible for the loan or for loan forgiveness. It is imperative that SBA completes its review to promote program integrity and mitigate financial loss by seeking recovery of improper payments for ineligible loans.

The unprecedented demand for PPP funds and the need to quickly award loans gave way to a pay and chase environment that relied heavily on post-payment reviews and resolving subsequent hold codes to ensure program integrity. SBA was required to issue PPP regulations no later than 15 days from the date the CARES Act was enacted (March 27, 2020) and lenders were to disburse loans within 10 days of approving applications and SBA reduced or eliminated key upfront controls as it sought to expedite aid.

As of May 24, 2024, SBA had forgiven over 10.5 million PPP loans, totaling over $750 billion, 37,938 of which (totaling approximately $4.6 billion) had an open hold code 70 (potential clawback). SBA’s guidance stipulates that all loans for which a forgiveness payment has been made and later determined to be potentially ineligible will be flagged using hold code 70 regardless of size; however, it also stipulates that if a forgiven loan is less than or equal to the $25,000 de minimis threshold, it may be considered immaterial, and recovery may not be prioritized. Of the 37,938 PPP loans subsequently flagged with a hold code 70, there were 26,234 loans, totaling $454 million, that were less than or equal to $25,000.

We found SBA did not complete its review process for the 37,938 PPP loans, totaling approximately $4.6 billion, that were flagged with a hold code 70 (potential clawback). Specifically, SBA only completed the first two steps of its four-step review process for loan and/or forgiveness amounts in which the reviewer and approver recommended the amount be denied in part or in full or for loans in which the approver disagreed with the reviewer’s loan review recommendation.

Management agreed with our recommendations to complete reviews for the 37,938 potentially ineligible PPP flagged with hold code 70 and to develop criteria to formalize policies and procedures for recovering improper payments for all loans subsequently flagged with hold code 70 and later deemed ineligible.