Federal Reports

The VA Office of Inspector General (OIG) conducted an inspection to assess allegations that senior leaders failed to practice high reliability organization (HRO) principles and created a culture of fear at the VA Eastern Colorado Health Care System (facility) in Aurora.The OIG substantiated the allegations and found key senior leaders created an environment where a significant number of clinical and administrative leaders and frontline staff, from a multitude of service lines, felt psychologically unsafe, deeply disrespected, and dismissed, and feared that speaking up or offering a difference of opinion would result in reprisal. Further, the OIG substantiated that following the addition of two key senior leaders to the peer review committee (PRC) in 2023, the culture of the committee changed to an environment perceived by six members, as well as non-PRC service leaders and staff, to be psychologically unsafe and punitive. When learning of concerns, key senior leaders missed opportunities to understand concerns and make efforts to foster a psychologically safe environment.The OIG substantiated that mid-level leadership had been eroded and three key senior leaders held a monopoly of control. The OIG found leadership instability at the service level, with many clinical service and section-level resignations and extended vacancies. Further, numerous former leaders left facility employment citing that a psychologically unsafe work environment was a major factor in their decision to leave. Despite these losses, key senior leaders did not seek or utilize employee exit survey data to identify and address employee retention challenges.Turnover in VISN leadership positions and ineffective communication contributed to the VISN Director’s lack of awareness regarding the extent of the staffing and culture challenges at the facility. The OIG made two recommendations to the Under Secretary for Health, four recommendations to the VISN Director, and one recommendation to the Facility Director.

The objective of our evaluation was to assess USPTO’s actions in response to the exposure of domicile addresses to determine whether USPTO complied with federal and U.S. Department of Commerce (the Department) information technology (IT) security standards.We found that USPTO mishandled the required reporting and notification to the affected trademark filers after domicile addresses had been exposed for 3 years. We also found that USPTO leadership allowed domicile addresses to remain publicly accessible after they were aware of the exposure, risking unauthorized disclosures in violation of the Privacy Act. Additionally, USPTO did not report that additional sensitive PII was exposed during the incident or notify the affected filers that additional data had been exposed. Lastly, the Department’s Chief Privacy Officer (CPO) did not assist USPTO in responding to this incident because of a lapse in the Department reporting process. See appendix B for a timeline of the events discussed in our findings.USPTO’s exposure of trademark filer data may not only reduce public confidence, but also may have equipped bad actors with additional data that could be used to defraud trademark holders. Bad actors could aggregate the pieces of exposed data to convincingly create official-looking USPTO correspondence or impersonate a filer’s attorney. Despite these risks, USPTO leadership did not comply with federal, departmental, and USPTO incident response reporting requirements and knowingly allowed domicile addresses to remain publicly accessible during incident mitigation. USPTO must improve its efforts in safeguarding trademark filers’ personal data to rebuild public trust and honor trademark holders’ privacy.

While the U.S. Postal Service is viewed by the American people as one of the most trusted government organizations, it has suffered a history of financial net losses dating back to 2007. The Postal Service sought to address these challenges through its 10-year strategic plan, Delivering for America (DFA); published in March 2021. The DFA plan calls for over $40 billion in capital investments and calculates projected savings through initiatives that include $24 billion in revenue improvements, $34 billion in management cost savings, $44 billion in regulatory changes, and $58 billion in legislative and administrative actions.

This report was issued in conjunction with the Office of Inspector General for the Railroad Retirement Board's Semiannual Report to the Congress. It was incorporated by reference in the corresponding Semiannual Report which is available at the link below.

The report summarizes the PRAC’s work during the first half of Fiscal Year 2024 and updates Congress on our efforts to promote transparency and ensure coordinated oversight of more than $5 trillion in pandemic relief. It also highlights the success of the PRAC’s Pandemic Analytics Center of Excellence (PACE), demonstrating the value of the data analytics platform as a good-government initiative that should transition from fighting pandemic-related fraud to preventing and curbing waste in other government spending programs.