An official website of the United States government
Here's how you know
Official websites use .gov
A .gov website belongs to an official government organization in the United States.
Secure .gov websites use HTTPS
A lock (
) or https:// means you’ve safely connected to the .gov website. Share sensitive information only on official, secure websites.
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
General Services Administration
GSA’s Office of Administrative Services Awarded an Invalid $13.7 Million Task Order
VBA Did Not Take All Corrective Actions for Veterans Prematurely Denied Service Connection for Conditions That Could Be Associated with Burn Pit Exposure
In July 2022, the VA Office of Inspector General (OIG) published a report finding that Veterans Benefits Administration (VBA) staff prematurely denied service connected compensation to veterans with conditions that could be associated with burn pit exposure. The OIG made seven recommendations, and VBA took corrective action on five, which the OIG closed. The two remaining recommendations were to review two datasets the OIG believed contained prematurely denied claims of veterans seeking service connection for burn pit-related conditions, correct any errors, and provide certification of completion. In May and August 2024, VBA requested closure of both open recommendations, asserting it had taken corrective actions as needed on all the claims. However, further review by the OIG of the claim population, as detailed in this management advisory memorandum, determined VBA did not take required corrective actions on at least an estimated 25 percent of veterans’ denied claims related to burn pit exposure.
Given the considerable errors identified in this second review of claims, the OIG lacks assurance that VBA has taken sufficient corrective action to address the original findings and remains concerned that, after nearly three years, veterans affected by these errors could still be missing service-connected compensation benefits to which they are entitled. Accordingly, the OIG did not concur with VBA’s requests to close recommendations 2 and 3 from the July 2022 report. These recommendations will remain open, and the OIG will continue to request quarterly updates from VBA on the progress it has made to appropriately remediate all errors and ensure corrective actions are taken for veterans’ denied claims related to burn pit exposure from the population identified by the OIG. In response to this memorandum, VBA will establish a workgroup to develop and implement a plan to correct the identified issues.
High-Income Individual Examinations Increased in Fiscal Year 2024, But Key Terms and Methodologies for Compliance With the 2022 Treasury Directive Remained Unresolved
This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the Sheridan VA Health Care System in Wyoming.
This evaluation focused on five key content domains: • Culture • Environment of care • Patient safety • Primary care • Veteran-centered safety net
The OIG issued three recommendations for improvement in two domains: 1. Environment of care • Facility navigation tools for sensory-impaired veterans 2. Patient safety • Patient test result communication effectiveness • Service-specific workflows for test result communications
The Tennessee Valley Authority’s (TVA) Supply Chain organization enters into blanket contracts with vendors to support TVA goals and lower total costs to TVA. Blanket contracts are defined as open-scope contracts under which TVA may place multiple orders for designated products or services over a set timeframe. Defined scopes of work and TVA’s commitment to buy are established through purchase orders (PO) issued against existing blanket contracts.
Under appropriate circumstances, TVA may group multiple blanket contracts that have the same general scope of work under a master contract. TVA’s Supply Chain Buyer Guide, which defines best practices for contracting officers, describes this process as the competitive model. According to the Buyer Guide, competitions between vendors under a competitive model can often be conducted quickly to better support organizational needs.
Due to issues identified in previous audits related to TVA’s lack of competition of fixed price POs, we conducted an audit to assess TVA’s process for evaluating and awarding POs issued under blanket contracts. Our audit scope focused on POs issued under blanket contracts where TVA has multiple blanket contracts for a general scope of work.
In summary, we determined TVA does not have an overall policy and there are limited procedures and guidance for evaluating and awarding POs issued under blanket contracts where TVA has multiple blanket contracts for a general scope of work. This has resulted in inconsistencies in how Supply Chain and the organizations have evaluated and awarded POs. Specifically, we determined there were inconsistencies in the level of (1) competition between prequalified vendors when issuing POs and (2) Supply Chain involvement in the evaluation and selection of vendors. With limited guidance on evaluating and awarding POs issued under blanket contracts, TVA increases its risk of not achieving best value for TVA.
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 Coatesville Healthcare System in Pennsylvania.
This evaluation focused on five key content domains: • Culture • Environment of care • Patient safety • Primary care • Veteran-centered safety net
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 Boston Healthcare System in Massachusetts.
This evaluation focused on five key content domains: • Culture • Environment of care • Patient safety • Primary care • Veteran-centered safety net
The OIG issued 11 recommendations for improvement in two domains: 1. Environment of care • Processes to prevent repeat findings • Biological hazard signs • Safe and clean patient care areas • Medication storage areas o Restricted access o Pharmacy staff inspections o Temperature and humidity • Urgent Care Center operates according to VHA Directive 1101.13 • Repeat findings and sustained improvements • Trends, performance improvement plans, and outcome measures 2. Patient safety • Test result communication policy complies with VHA directives for critical test results
High-Income Individual Examinations Increased in Fiscal Year 2024, But Key Terms and Methodologies for Compliance With the 2022 Treasury Directive Remained Unresolved
The IRS’s FY 2024 enterprise-wide examination plan signaled a shift towards auditing high-income individuals, which we found consistent with the goals of the 2022 Treasury Directive.
Audit of the Office of Justice Programs Victim Assistance Funds Subawarded by the Missouri Department of Social Services to Synergy Services, Inc., Parkville, Missouri