Federal Reports

The Office of Inspector General (OIG) is initiating an evaluation of the Commission’s information security program pursuant to the Federal Information Security Modernization Act of 2014 (FISMA).

The objective of the evaluation is to determine the effectiveness of the Commission’s information security program and practices. The evaluation will assess information security program controls to support the OIG’s reporting of FISMA metrics into the Department of Homeland Security’s CyberScope application. The independent public accounting firm Harper, Rains, Knight & Company will conduct the evaluation with the OIG providing oversight as required by the IG Act of 1978, as amended.  

This review will be performed in accordance with the Quality Standards for Inspection and Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency.

The Fiduciary Program within the Veterans Benefits Administration (VBA) was established to protect beneficiaries who are unable to manage their VA benefits by appointing and overseeing fiduciaries—individuals or legal entities charged with stewarding the funds on behalf of beneficiaries for their well-being. VA-appointed fiduciaries can be removed and barred from future service if they are found to have misused or misappropriated benefits, been convicted of a qualifying felony offense, or knowingly violated or refused to comply with VA regulations. Staff are required to flag these barred fiduciaries in VBA’s electronic system to prevent a reappointment. The OIG conducted this review to determine whether VBA’s oversight ensures individuals and entities barred from serving as a VA fiduciary are identified and flagged.

When fiduciaries were removed for a reason that would constitute a bar to future service, the OIG found that staff did not flag them in 88 of 129 sampled cases, or 68 percent of the time. This occurred because the Fiduciary Program Manual lacked clear procedures about when the flag should be placed and by whom. Unclear guidance in the manual also led to inadequate staff training and insufficient oversight. Training did not address use of the flag or its purpose in protecting vulnerable beneficiaries, and checklists used for the quality assurance process had no specific questions or error descriptions to confirm the flag was properly applied.

Failure to properly flag barred fiduciaries increases the risk that they will be reappointed. The OIG made three recommendations to the under secretary for benefits, including updating the program’s manual to specify when a removed fiduciary should be flagged, developing and providing training about updated manual procedures regarding flagging, and updating the quality review process.

The audit objectives were to determine whether program funds were managed in accordance with the ARC and Federal grant requirements.

During this semiannual reporting period, the National Endowment for the Arts (NEA) Office of Inspector General (OIG) completed the Congressionally mandated NEA financial statement audit for fiscal year (FY) 2024, and a performance audit of the Georgia Council for the Arts. We also collaborated with the NEA on the follow-up process required by the Office of Management and Budget, leading to corrective actions on eight OIG recommendations by the NEA and awardees during this period. Additionally, we resolved all hotline complaints received during the semiannual reporting period.

I applaud the NEA and the OIG staff for continuing to press forward and effectively work together to deliver our respective missions in a high-quality manner. The value-added work that the NEA and OIG accomplished this period is due to their commitment, leadership, and effectiveness; while helping to ensure integrity, excellence, and value in the delivery of NEA’s mission.

The Office of Inspector General is issuing this management advisory to gain an understanding of the U.S. Small Business Administration’s (SBA) Coronavirus Disease 2019 (COVID-19) servicing processes and determine its capability to service more than 2 million COVID-19 Economic Injury Disaster Loans (EIDL).

We found the COVID-19 EIDL Servicing Center (CESC) demonstrated that it was capable of servicing over 2 million COVID EIDLs during the period of our review. The CESC appeared to be adequately staffed as evidenced by its ability to complete over 23,500 servicing actions per month with an average processing time of 5.44 days per action. However, we identified opportunities for improvement related to formal documentation and issuance of performance goals and written COVID-19 EIDL servicing guidance.

We made two recommendations for SBA to ensure appropriate processes are followed and to effectively monitor CESC operations. SBA management agreed with both recommendations and has taken actions to implement both. Management’s actions satisfy the intent of the recommendations; therefore, both recommendations will be closed upon issuance of this report.

We evaluated FNS’ fraud risk assessment process for SNAP EBT and the design and implementation of its strategy to mitigate fraud risks.

The Office of the Inspector General conducted an evaluation to determine if fire‑protection and ammonia safety systems at TVA coal plants were being properly maintained and identified issues were being addressed.  We determined ammonia systems were being properly maintained and identified issues were being addressed.  However, we determined fire protection systems were not always properly maintained and issues were not always being addressed timely.  Specifically, (1) some inspections and testing of fire-protection systems were not performed as required, (2) some fire-protection system issues were not resolved timely, and (3) one fire-protection subsystem was missing safety locks at 1 plant, which was subsequently addressed.  In addition, we identified concerns with documentation, including incomplete fire-protection impairment documentation and discrepancies in the required frequency of inspections between the fire protection Standard Programs and Processes and site‑specific job plans, which provides details of each plant’s fire-protection subsystems. 

The National Security Agency (NSA) Office of the Inspector General (OIG) publicly released an unclassified version of its Semiannual Report (SAR) to Congress summarizing the OIG’s oversight work during the first half of fiscal year 2025. 

As required by the Inspector General Act of 1978, as amended (IG Act), the SAR was transmitted to Congress on 29 May 2025. 

Semiannual Report to Congress, highlighting the activities and accomplishments of the U.S. AbilityOne Commission Office of Inspector General from October 1, 2024, through March 31, 2025.

VBA provides tax-free monthly compensation payments to veterans for disabilities incurred or aggravated during active military service. Additionally, VBA awards special monthly compensation (SMC) for certain severe disabilities or combinations of disabilities.

SMC is a difficult topic for claims processors to learn and apply. When this review began, VBA had two versions of an SMC calculator to help claims processors. One version was the Veterans Benefits Management System for Rating (VBMS-R) calculator, which allowed information generated by the calculator to automatically populate in the appropriate fields. In November 2023, the VA OIG received an allegation that the VBMS-R calculator did not generate accurate results for several disability combinations, and that these errors could result in veterans being underpaid. The OIG conducted this review to assess whether the VBMS-R calculator was producing inaccurate results as alleged.

The OIG review team confirmed that the VBMS-R calculator generated inaccurate results for the disability scenarios listed in the allegation and for several others identified by the team. For some errors, the VBMS-R calculator produced incorrect results that would cause incorrect payments—most of which would be underpayments—if claims processors relied on them. Additionally, the VBMS-R calculator sometimes generated an alert message that the request failed rather than producing SMC results. Officials from VBA and VA’s Office of Information and Technology could not determine the cause of the errors or how long they had been occurring. In October 2024, the VBMS-R calculator was disabled and was still inactive as of February 2025.

The OIG made two recommendations to the under secretary for benefits to ensure all erroneous scenarios in the VBMS-R calculator identified in this review are corrected and establish a plan to conduct additional testing of the tool to ensure its accuracy.

Congress enacted the Comprehensive Addiction and Recovery Act (CARA) of 2016 to improve opioid therapy and pain management for veterans. Within CARA, the Jason Simcakoski Memorial and Promise Act (Jason’s Law) requires each Veterans Health Administration (VHA) medical facility to have a pain management team (PMT) to coordinate and oversee pain management therapy. The Pain Management, Opioid Safety, and Prescription Drug Monitoring Program (PMOP) was established in part to ensure the requirements of CARA and Jason’s Law are met.

In fiscal years (FY) 2022 through 2024, the PMOP received $647 million in specific purpose funds to support pain management and opioid safety programs primarily at the medical-facility level. However, the PMOP returned about $126.7 million unused in FYs 2022 and 2023. The VA Office of Inspector General (OIG) conducted this audit to evaluate the PMOP’s management of specific purpose funds.

The OIG found the PMOP did not always effectively communicate with VISNs and medical centers so that they could plan for efficient use of funds. In addition, the program did not always communicate important funding information with key officials before allocating funding. Finally, VHA and the PMOP need to strengthen oversight to ensure fully compliant PMTs are in place at each VHA facility.

The OIG made five recommendations to the under secretary for health. The OIG agreed to close two; VHA has already taken sufficient action related to instructing the PMOP to communicate pertinent funding information with key staff before the start of the next fiscal year. VHA also agreed to ensure the program clarifies and defines PMT requirements and establishes a way to periodically validate PMT information and to require the program and the chief operating officer to address each medical facility’s lack of progress in achieving a PMT.

Section 487(a)(17) of the Higher Education Act of 1965, as amended (HEA), requires postsecondary schools participating in Title IV programs to annually report data, including data relevant to students’ cost of attendance and financial aid and the schools’ graduation rates, to the U.S. Department of Education’s (Department) Integrated Postsecondary Education Data System (IPEDS) to the satisfaction of the Secretary. The objective of our inspection was to determine whether the University of Texas Permian Basin (UT Permian Basin) reported verifiable data to IPEDS for the 2021–2022 reporting period. We determined that the UT Permian Basin reported verifiable data to the Department’s IPEDS for the 2021-2022 reporting period. Specifically, all data elements that we selected and reviewed that the school reported through the Graduation Rates, Institutional Characteristics, and Student Financial Aid surveys for the 2021–2022 reporting period were supported by datasets, information system reports, or other records. Because all the data sets that we reviewed were verifiable, we do not make any recommendations in this report. However, our results are limited to the data sets we reviewed, and it is critical that the UT Permian Basin continue to report verifiable data to IPEDS. 

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 Oklahoma City Healthcare System in Oklahoma. 

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
     •    Safe and accessible pathways to clinical areas
     •    Medical equipment preventive maintenance
   2.    Patient safety
     •    Recording leader attendance at meetings to monitor test result communication data

The In-Office Cost System (IOCS) is the U.S. Postal Service’s primary probability sampling system used for estimating the cost of processing mail and parcels. The data collected from IOCS enables the Postal Service to allocate the labor costs from the handling of mail, parcels, and related activities performed by clerks, mail handlers, city carriers, and supervisors to all mail classes and rate categories. The Postal Service uses the data collected from IOCS to allocate about $21 billion per year in costs to mail products. The Postal Service uses the allocated costs to each mail category collected from IOCS to determine prices. Therefore, collecting consistent, accurate data is essential.

This semiannual report informs Congress of the Peace Corps Office of Inspector General's work from October1, 2024, through March 31, 2025.

As part of our annual audit plan, we performed an audit of costs billed to the Tennessee Valley Authority (TVA) by Terracon Consultants, Inc. (Terracon) for geotechnical and hydrogeological site investigations and groundwater quality monitoring services under Contract No. 15087.  Our audit objective was to determine if costs were billed in compliance with the contract’s terms.  Our audit scope included $9.93 million in costs paid from January 3, 2022, through October 21, 2024.

In summary, we determined Terracon overbilled TVA an estimated $387,879, including (1) an estimated $304,431 in overbilled labor costs (of which TVA has recovered $3,164), (2) $81,898 in ineligible subcontractor markups, and (3) $1,550 in overbilled travel costs.  In addition, we identified instances where meals and incidental costs associated with travel were not billed in accordance with the contract, resulting in a net immaterial overbilling.  We also found TVA did not include a pricing schedule containing the time and material billing rates until March 28, 2024, although the contract was effective July 13, 2020.

Why We Did This Report

The U.S. Environmental Protection Agency Office of Inspector General conducted this audit to determine whether the EPA complied with the Payment Integrity Information Act for fiscal year 2024 reporting and to review the EPA’s implementation of its corrective action plans for prior audit recommendations.

Summary of Findings

The EPA did not comply with applicable Office of Management and Budget requirements for the Payment Integrity Information Act of 2019 for its fiscal year 2024 reporting. Specifically, for its grants payment stream, the EPA published a 0.77 percent improper payment estimate with no unknown payments. The Agency’s estimate was not based on an accurate sampling and estimation methodology plan, referred to as a statistical sampling plan. Therefore, we could not determine whether the published estimate is valid and representative of the grant program characteristics. In addition, the EPA needs to improve its documentation to ensure compliance with policies and procedures. The Office of the Chief Financial Officer does not require staff to document who performed the risk assessment review and what information staff considers in the qualitative risk assessment reviews.

We found that the Agency completed corrective actions for the three recommendations from our FY 2023 audit report and for one recommendation from our FY 2021 audit report.

Why We Did This Report

The U.S. Environmental Protection Agency Office of Inspector General performed this audit to determine whether the U.S. Chemical Safety and Hazard Investigation Board, known as the CSB, complied with the Payment Integrity Information Act of 2019 in fiscal year 2024.

Summary of Findings

In FY 2024, the CSB complied with PIIA and OMB improper payment requirements. The outlays for the CSB totaled $11.34 million. The CSB reported gross improper payments totaling $2,659. These improper payments were associated with payroll and travel expenses. The CSB reported no unknown payments, resulting in a total improper and unknown payment of $2,659, or 0.02 percent of total outlays. This total was significantly less than the statutory threshold of 1.5 percent of program outlays established in PIIA for improper and unknown payments. In addition, we confirmed that the CSB complied PIIA reporting requirements to (1) publish payment integrity information with the Agency’s annual financial statement and accompanying materials and (2) post the annual financial statement and accompanying materials on its website.

The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered at vet centers. This inspection report evaluated four randomly selected vet centers throughout Midwest district 3 zone 2: Evanston, Illinois; Gary Area, Indiana; and La Crosse and Milwaukee, Wisconsin.

This OIG inspection focused on four review areas: suicide prevention; consultation, supervision, and training; outreach; and environment of care. The suicide prevention review evaluated vet center staff participation on VA medical facility mental health executive councils, resulting in one recommendation across three of the four vet centers inspected. The consultation, supervision, and training review identified concerns with external clinical consultation, monthly client record reviews, and completion of select trainings, resulting in three recommendations across all four vet centers inspected. The outreach review evaluated outreach plan completion, inclusion of strategic components, and tailoring of outreach activities to eligible individuals, which resulted in one recommendation across three of the four vet centers inspected. The environment of care review evaluated vet centers’ physical environment and general safety, resulting in one recommendation at one of the three vet centers inspected. One vet center was closed and had a temporary location; therefore, an environment of care review was not completed at this site. However, the inspection did result in additional findings related to the vet center’s closure and relocation, resulting in two recommendations.

The OIG issued a total of eight recommendations for improvement.

The objective of our audit was to determine whether the U.S. Department of Education (Department) complied with the Payment Integrity Information Act of 2019 (PIIA) for FY 2024. We found that the Department complied with the PIIA for the FY 2024 reporting period because it met all six compliance requirements as described in Finding 1. However, we found that the Department could improve its processes for implementing its methodologies for estimating improper payments and unknown payments. While we found that the point estimates for the Federal Pell Grant (Pell) and William D. Ford Federal Direct Loan (Direct Loan) programs reflect the programs' annual improper payments and unknown payments, we found that the Department’s improper payment and unknown payment estimates for these programs were not reliable because of issues in the calculation of the confidence intervals, as described in Finding 2. Specifically, the improper payment sampling and estimation plans for the Pell and Direct Loan programs included nonrandom student-level sampling from some of the compliance audits Federal Student Aid (FSA) used to calculate the estimates, which affected the accuracy and appropriateness of the confidence intervals used in the calculation of the improper payment and unknown payment estimates. The nonrandom student-level sampling issue has been a repeat finding since our report on the Department’s compliance with improper payment reporting requirements for FY 2019. We recommend that FSA develop sampling and estimation plans for the Pell and Direct Loan programs that will produce reliable estimates. 

The Payment Integrity Information Act (PIIA) requires agencies to annually review and identify programs and activities that may be susceptible to significant improper payments, estimate the improper payment rates in agency programs, and report on their actions to reduce and recover those payments. For FY 2024, AmeriCorps met eight of ten PIIA compliance requirements. We made three findings relating to the two remaining requirements.  We found that: (1) AmeriCorps reported an improper payment rate above the ten percent compliance threshold for one program, the Foster Grandparent Program (FGP); (2) AmeriCorps’ published improper payment estimates for AmeriCorps State and National (ASN) and FGP are not accurate, reliable, or consistent with OMB guidance; and (3) AmeriCorps’ published improper payment estimates for the National Service Trust (NST) are not accurate, reliable, or consistent with OMB guidance. AmeriCorps concurred with the first finding and agreed to continue to develop and implement actions to reduce improper payment rates below ten percent. AmeriCorps did not concur with our second and third findings. We made six new recommendations related to our second and third findings in this report on unmatched reporting errors, payments to ineligible recipients, and published improper payment estimates for the NST. AmeriCorps declined to implement all six recommendations. We will keep open the two prior year recommendations related to the first finding until AmeriCorps submits documentation to demonstrate the completion and sufficiency of the corrective actions. The six recommendations related to the second and third findings will remain open and be classified as unresolved (disagreed) in our Semiannual Report to Congress.

HUD’s Office of Single Family Housing did not consistently monitor its Field Service Management (FSM) contractors’ property preservation and protection services.  Specifically, HUD provided inconsistent monitoring for 34 of the 79 statistically sampled records we reviewed, and these involved discrepancies between HUD’s assessment, the support, and the performance work statement.  HUD did not develop and apply a clear and uniform review framework to ensure that its process and procedures provided for effective FSM contract monitoring.  As a result, HUD (1) cannot ensure its REO inventory is being maintained in an adequate condition and (2) is not aware of whether contracting actions are needed to address deficient performance.  

We recommend that HUD (1) develop and implement uniform procedures for the FSM desk monitoring review, including a second level review for the FSM monitoring reviews and process for each inspection type; (2) update the FSM monitoring plan and FSM qualitative monitoring database to (a) clearly define the monitoring questions, (b) include a section for Q7 New Not Ready to Show properties, (c) define which routine inspection reports will be reviewed to conduct the routine inspection monitoring reviews and (d) develop a monitoring question to evaluate photo date stamps; and (3) ensure that program officials periodically provide all FSM CORs and staff involved in the monitoring process uniform property inspection training.

The Railroad Retirement Board Complied with the Payment Integrity Information Act of 2019 for Fiscal Year 2024

OIG reviewed USDA’s compliance with improper payment and high-dollar overpayment requirements for FY 2024.

The Inspector General Act of 1978 requires the Inspector General to prepare semiannual reports summarizing the activities of the Office of Inspector General for the preceding six-month period. The semiannual reports are intended to keep the Secretary and Congress fully informed of significant findings, progress the Agency has made, and recommendations for improvement.

The FCC OIG’s audit concluded that FCC was compliant with respect to 10 Phase 1 programs and one Phase 2 program. However, FCC was non-compliant with PIIA overall because for two of the 13 assessed FCC programs (the USF-LL and the USF-HC Legacy programs), FCC complied with nine of the 10 required PIIA criteria.  The FCC OIG issued three findings and offered eight recommendations to improve FCC’s PIIA reporting.

The Department of Homeland Security complied with the Payment Integrity Information Act of 2019 (PIIA) during fiscal year 2024. According to Office of Management and Budget (OMB) Circular A-123, an agency must meet all 10 PIIA requirements to comply, which DHS did.
DHS also met OMB’s requirement to designate programs with improper payment estimates greater than or equal to $100 million, in annual monetary loss, as high priority and to provide quarterly reporting submissions to the PaymentAccuracy.gov website. Specifically, DHS identified the Federal Emergency Management Agency’s Public Assistance – Validate As You Go (VAYGo) program as a high-priority program and provided the required initial quarterly reporting submission to OMB.
Based on our review, DHS’ overall efforts to prevent and reduce improper and unknown payments appear adequate. Our review determined DHS implemented internal controls that were operating as intended to provide oversight of its components’ completion of program identification templates, risk assessments, and improper payment testing.

EAC OIG performed this review to determine whether the EAC complied with the Payment Integrity Information Act of 2019 reporting requirements for fiscal year 2024.

The Office of Inspector General is tasked with ensuring efficiency, accountability, and integrity in the U.S. Postal Service. We also have the distinct mission of helping to maintain confidence in the mail and postal system, as well as to improve the Postal Service's bottom line. We use audits and investigations to help protect the integrity of the Postal Service. Our Semiannual Report to Congress presents a snapshot of the work we did to fulfill our mission for the six-month period ending March 31, 2025. Our dynamic report format provides readers with easy access to facts and information, as well as succinct summaries of the work by area. Links are provided to the full reports featured in this report, as well as to the appendices.

We evaluated the Defense Intelligence Agency’s (DIA’s) compliance with the Payment Integrity Information Act for Fiscal Year 2024.  For this evaluation, conducted from December 2024 to April 2025, we interviewed personnel from the Office of the Chief Financial Officer (CFO) and reviewed the Agency Financial Report and supporting documentation, including a selection of samples tested by CFO to support its annual risk assessment.  We retested 54 samples from the original 233 tested by CFO for DIA’s Commercial Contract pay and Commercial Non-Contract Pay (Vendor Pay) program transactions to verify CFO’s conclusion that the program is not susceptible to significant improper and unknown payments.  We issued our results in a classified report on May 23, 2025.

The Semiannual Report to Congress summarizes the results of VA OIG oversight, provides statistical information, and lists all 103 oversight reports and other products issued from October 1, 2024, to March 31, 2025. During this reporting period, VA OIG audits, evaluations, investigations, inspections, and other reviews identified nearly $3.3 billion in monetary impact for a return on investment of $28 for every dollar spent. The OIG hotline received and triaged almost 17,200 contacts in the past six months—to help identify wrongdoing and address concerns with VA activities. Also, during the past six months, special agents opened 256 investigations and closed 213, with efforts leading to 144 arrests. Collectively, the OIG’s work also resulted in 598 administrative sanctions and corrective actions during the six-month reporting period.

Our objective was to determine whether USDA’s password management practices effectively prevented the use of passwords that are commonly used, expected, or compromised.

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 Augusta Health Care System in Georgia. This evaluation focused on five key content domains:
•    Culture
•    Environment of care
•    Patient safety
•    Primary care
•    Veteran-centered safety net
The OIG issued five recommendations for improvement in three domains:
1.    Culture
•    The Under Secretary for Health evaluates facility leaders for appropriate supervisory behavior and professional communication, and takes actions as needed.
•    The Under Secretary for Health determines whether the Veterans Integrated Service Network Director and other leaders were aware of facility leaders’ unprofessional behavior and communication, and takes actions as needed.
2.    Environment of care
•    The Under Secretary for Health ensures the Veterans Integrated Service Network and facility directors oversee the inventory management system and resolve medical supply deficiencies, and monitor actions for sustained improvement.
3.    Patient Safety
•    Facility leaders develop action plans to ensure providers communicate test results to patients timely.
•    The Under Secretary for Health directs the national VHA Quality and Patient Safety Program staff to review the facility’s quality management program and determine whether actions by facility and Veterans Integrated Service Network leaders effectively addressed system issues affecting patient safety, including nursing leaders’ lack of access to safety reports, and missed opportunities for institutional disclosures, and takes action as needed.

We performed an audit of costs billed to the Tennessee Valley Authority (TVA) by Wright Brothers Contracting, Inc. (Wright Brothers) for site grading services and materials under Contract No. 16512.  The contract provided for TVA to compensate Wright Brothers for work on a fixed price basis for deliverables and materials and on a time and material (T&M) basis for performance of the work.  Our audit objectives were to determine (1) if costs were billed in accordance with the contract terms and (2) the reasonableness of TVA’s process for evaluating and awarding proposed fixed price tasks issued under the contract.  Our audit scope included approximately $28.7 million in costs paid by TVA between September 3, 2021, and May 31, 2024.  This included approximately $24.5 million for 17 fixed price tasks and $4.2 million for one T&M task.

In summary, we determined:

•    Wright Brothers billed TVA $1,401,563 in T&M billings for cost categories that were not included in the contract, Wright Brothers proposal, or TVA’s purchase order.  Additionally, the proposal and invoice documentation did not provide adequate detail for a field invoice approver to effectively review invoices. 
•    Wright Brothers billed TVA $49,355 in unsupported T&M costs, including (1) $43,860 in unsupported equipment costs and (2) $5,495 in unsupported labor costs.  (Note:  $11,320 of the $49,355 unsupported cost were also included in the $1,401,563 ineligible T&M billings.)
•    There were opportunities to strengthen TVA’s process for evaluating and awarding fixed price tasks.  Specifically, TVA did not always compete fixed price tasks as required by the contract.  In addition, when TVA received only one bid for a fixed price task, there were no policies or guidance for steps TVA should take to ensure the fairness of the fixed price amount. 

The VA OIG conducted this review to determine whether VA complied with the requirements of the Payment Integrity Information Act of 2019 (PIIA) for FY 2024. PIIA requires federal agencies to identify and review all programs and activities they administer that may be susceptible to significant improper payments based on OMB guidance. PIIA also requires each OIG to review its agency’s improper payment reports and issue an annual report. In FY 2024, VA reported improper and unknown payment estimates totaling $2.2 billion for seven programs. Of that amount, $1.1 billion (about 50 percent) represented a monetary loss, and the remaining $1.1 billion was considered either a nonmonetary loss that cannot be recovered or an unknown payment. These results represent a reduction of about $1 billion (32 percent) from FY 2023 results. VA satisfied five of the six requirements under PIIA. VA did not meet requirement 6 because it did not report an improper and unknown payment rate of less than 10 percent for two programs that had estimates in the materials accompanying their financial statements. VA met additional requirements for high-priority programs by providing quarterly updates to OMB that included plans to prevent and recover monetary losses from improper payments. The OIG recommended the under secretary for benefits reduce improper and unknown payments to below 10 percent for the Pension Program—a repeat recommendation from the previous two fiscal years’ reports—and the under secretary for health reduce improper and unknown payments to below 10 percent for the Purchased Long-Term Services and Supports Program—a repeat recommendation each year since the OIG’s first PIIA report for FY 2020.

Why We Did This Report

The U.S. Environmental Protection Agency Office of Inspector General conducted this audit to examine locality pay for employees working in a telework and remote work status. The objective was to determine whether the EPA ensures employees are paid the correct locality pay in accordance with regulations and policy.

Summary of Findings

The EPA cannot ensure that employees are paid the correct locality pay because it does not have comprehensive or reliable data to verify employees’ worksite locations. Without a mechanism to verify an employee’s worksite location against his or her locality pay, the Agency remains at risk of overpaying or underpaying employees.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations related to the care of a female patient who presented with “near constant” vaginal bleeding to the Martinsburg VA Medical Center (facility) Emergency Department. 

While no deficiencies were found in the care provided by emergency department physicians, the OIG identified multiple deficiencies in nursing care. The OIG also identified failures in leaders’ oversight to ensure deficiencies were sufficiently remediated.

The OIG determined that the emergency department was equipped to perform gynecologic exams. However, the gynecologic cart, which featured hinged foldable footrests used in extension with the emergency department bed, was not utilized by some providers due to concerns of discomfort for patients.

The OIG substantiated delays in the patient’s transfer to a higher level of care, with an avoidable delay by the facility fire department’s ambulance service. Facility fire department leaders attributed the delay to lack of available staff and inability to mandate overtime for transports. However, the OIG determined that the practice of prohibiting mandatory overtime for emergency transports was incongruent with facility policy and facility leaders’ expectations. The OIG also found that facility leaders failed to assess concerns about the transport delay identified during a factfinding. 

The OIG learned that while the facility initiated a formal review to address broader patient transport challenges in May 2023, more than a year later, recommended policy and protocols identified from the review had not yet been approved by facility leaders.

The OIG made 10 recommendations to the Facility Director related to emergency department communication, adherence to Veterans Health Administration and facility policies, review of implemented actions to ensure quality of care concerns are remediated, evaluation of emergency department equipment for gynecologic examinations, review of overtime practices for staff providing emergency transports, and review of transportation concerns.

This report details the Office of Inspector General's Spring 2025 - Semiannual Report to Congress. The following topics are included:

• Overview of the SBA and the OIG
• SBA's Top Management and Performance Challenges
• Summary of OIG Oversight Work
• Small Business Access to Capital
• Disaster Assistance Program
• Contracting and Counseling Programs
• Agency Management
• Other Significant OIG Activities
• OIG Hotline
• Organizational Overview
• Appendices