Federal Reports

We found that an oil and gas company did not violate safety and environmental regulations.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Piedmont Station in Portland, OR (Project Number 22-030). The Piedmont Station is in the Idaho-Montana-Oregon District of the WestPac Area and services ZIP Code 97211, which services about 31,531 people and is considered to be an urban community. We chose the Piedmont Station based on the number of stop-the-clock (STC) scans occurring at the delivery unit, rather than at the customer’s delivery address.

Neither the NPS nor the USGS consistently reviewed and approved modifications made to the construction contracts reviewed in our sample.

Our objective was to determine whether U.S. Customs and Border Protection (CBP) complied with the National Standards on Transport, Escort, Detention, and Search (TEDS) standards.

Our objectives for this report were to identify and assess the challenges associated with cost sharing on state-supported routes and the extent to which the company is working independently, and with its state partners, to address them.Although the company has addressed some of the concerns associated with cost sharing on its state-supported routes, we found that three challenges persist. First, there remain conflicting perspectives between Amtrak and its state partners about control over decision-making and the level of support Amtrak provides to those partners. Second, there remain unaddressed issues with the cost-sharing methodology despite the company’s efforts to improve its ability to directly assign costs to state partner’s trains. Third, the company’s state partners question whether the company has effective quality controls in its cost-calculation and bill-development process, and some state partners do not understand the company’s process. State partners’ perceptions about these issues affect their trust in the company, with about one-third having high trust around cost-sharing, one-third moderate trust, and one-third low trust.The ongoing congressionally mandated discussions about the cost-sharing methodology offer a meaningful opportunity to begin resolving the challenges we identified. To capitalize on this opportunity, we recommended that Amtrak coordinate with state partners and the Federal Railroad Administration, likely through the State-Amtrak Intercity Passenger Rail Committee, to clarify which decisions affecting state partner costs the company must control and the level of support the company can provide. We also recommended the company clarify and document decisions about the relationship between costs and service and how to handle capital costs. In addition, we recommended taking steps to better assure state partners that their bills are accurate, such as documenting the cost-calculation and bill-development process and sharing this information with them.

We have completed a review of the DOI’s progress in implementing our past audit recommendations addressing Government charge card internal controls.

At least every 3 years, the Office of Inspector General is required to review the report and provide a conclusion about the reliability of each assertion made in the report.

At least every 3 years, the Office of Inspector General is required to review the report and provide a conclusion about the reliability of each assertion made in the report.

At least every 3 years, the Office of Inspector General is required to review the report and provide a conclusion about the reliability of each assertion made in the report.

At least every 3 years, the Office of Inspector General is required to review the report and provide a conclusion about the reliability of each assertion made in the report.

At least every 3 years, the Office of Inspector General is required to review the report and provide a conclusion about the reliability of each assertion made in the report.

This report presents the results of our self-initiated audit of cash and stamp inventory, financial differences, and postage validation imprinter (PVI) label voids – Panorama City, CA, Branch Office (Project Number 21-271). This site is located in the California 3 District of the WestPac Area. This audit was designed to provide U.S. Postal Service management with timely information on potential financial control risks at Postal Service locations.The U.S. Postal Service Office of Inspector General’s (OIG) data analytics identified Panorama City Branch Office had $100,734 in refunds recorded to account identification code (AIC)1 509, Voided Postage Validation Imprinter (PVI) Labels for fiscal year (FY) 2021. This was the highest in the nation for FY 2021. In addition, they had variances in financial activities.

This report contains information about recommendations from the OIG's audits, evaluations, reviews, and other reports that the OIG had not closed as of the specified date because it had not determined that the Department of Justice (DOJ) or a non-DOJ federal agency had fully implemented them. The list omits information that DOJ determined to be limited official use or classified, and therefore unsuitable for public release.The status of each recommendation was accurate as of the specified date and is subject to change. Specifically, a recommendation identified as not closed as of the specified date may subsequently have been closed.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Louis A. Johnson VA Medical Center and multiple outpatient clinics in West Virginia. The inspection covered key clinical and administrative processes associated with promoting quality care, focusing on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.At the time of the virtual CHIP visit, medical center leaders had worked together for seven weeks; all were from other VA facilities and in acting executive roles. The OIG identified multiple recent leadership transitions and vacancies in quality management and equal employment opportunity roles. Employee survey data identified opportunities to improve staff perceptions of leaders and the workplace. Medical center leaders shared observations of staff resistance and guarding, and described changes implemented to improve morale and psychological safety. Overall, patients appeared satisfied with the care received. Leaders were generally knowledgeable about Strategic Analytics for Improvement and Learning data and should continue to take actions to sustain and improve performance and employee and patient satisfaction.The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures involved follow-up from a previous OIG report on care and oversight deficiencies. The OIG Rapid Response team was on site for follow-up during the week of the OIG CHIP virtual visit.The OIG issued five recommendations for improvement in three areas:(1) Quality, Safety, and Value• Systems redesign and improvement coordinator designation• Surgical work group attendance(2) Care Coordination• Inter-facility transfer documentation• Nurse-to-nurse communication(3) High-Risk Processes• Disruptive behavior training

What We Looked AtIn accordance with the Government Corporation Control Act of 1945, we audited the financial statements of the Great Lakes Saint Lawrence Seaway Development Corporation (GLS), a U.S. Government corporation, as of and for the years ended September 30, 2021 and September 30, 2020. We are now issuing a management letter that discusses control matters that we were not required to include in our audit report. What We FoundWe found three internal control matters based on interim testing of GLS’s Operating Expenses, Minority Bank Certificates of Deposits, and Inventory. RecommendationsWe made seven recommendations. GLS concurred with all seven recommendations.

What We Looked AtThis report presents the results of our quality control review (QCR) of KPMG LLP’s management letter for its audit, conducted under contract with us, of the Department of Transportation’s (DOT) consolidated financial statements for fiscal years 2021 and 2020. The management letter discusses four internal control matters that KPMG was not required to include in its audit report. What We FoundOur QCR of the management letter disclosed no instances in which KPMG did not comply, in all material respects, with U.S. generally accepted Government auditing standards. Our RecommendationsKPMG made seven recommendations in its management letter. DOT concurred with all seven recommendations.

What We Looked AtThis report presents the results of our quality control review (QCR) of Allmond & Company, LLC's management letter regarding the audit it conducted, under contract with us, of the Surface Transportation Board's (STB) financial statements as of and for the fiscal year ended September 30, 2021. The management letter discusses internal control matters that Allmond was not required to include in its report on the audit.What We FoundOur quality control review of the management letter disclosed no instances in which Allmond did not comply, in all material respects, with generally accepted Government auditing standards.RecommendationsAllmond made eight recommendations in its management letter. STB concurred with all eight recommendations.

What We Looked AtThis report presents the results of our quality control review (QCR) of the management letter that KPMG issued on its audit, under contract with us, of the Federal Aviation Administration’s (FAA) consolidated financial statements for fiscal years 2021 and 2020. This management letter discusses internal control matters that KPMG was not required to include in its audit report. What We FoundOur QCR disclosed no instances in which KPMG did not comply, in all material respects, with U.S. generally accepted Government auditing standards. Our RecommendationsKPMG made six recommendations to FAA in its management letter. FAA concurred with all six recommendations.

The NSA OIG produced 22 audits, inspections, evaluations, and other oversight products for impactful findings and recommendations regarding a wide swath of NSA's work.

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We audited costs claimed and grant compliance by the Delaware Department of Natural Resources and Environmental Control under grants awarded by the FWS.

We audited costs claimed by the State of Georgia, Department of Natural Resources, under grants awarded by the FWS through WSFR.

This letter responds to the Government Charge Card Abuse Prevention Act of 2012 (Charge Card Act) reporting requirement for the Federal Trade Commission (FTC) for fiscal year 2022.

Management Report: FY 2021 Charge Card Risk Assessment Report

At least every 3 years, the Office of Inspector General is required to review the agency’s submission and provide a conclusion about the reliability of each assertion in the report.

At least every 3 years, the Office of Inspector General is required to review the agency’s submission and provide a conclusion about the reliability of each assertion in the report.

At least every 3 years, the Office of Inspector General is required to review the agency’s submission and provide a conclusion about the reliability of each assertion in the report.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations concerning Sterile Processing Services (SPS) at the Carl T. Hayden VA Medical Center (facility) in Phoenix, Arizona.The OIG substantiated that SPS staff failed to don personal protective equipment (PPE) in SPS decontamination areas. The OIG observed SPS and other facility staff enter decontamination areas without required PPE.The OIG did not substantiate that SPS staff falsified Resi-Tests by documenting the same lot number for endoscopes. The OIG found that some Resi-Test kits had the same lot numbers but that was not indicative of falsified tests. Additionally, the OIG identified missing documentation of Resi-Test results from October through December 2020; however, based on review of subsequent documentation, direct observations, and interviews, the OIG concluded that SPS staff completed Resi-Tests in accordance with policy.The OIG did not substantiate that SPS staff failed to follow validation testing requirements for biological indicators and Bowie-Dick tests for sterilizers. The OIG found no infection concerns associated with inadequate reprocessing of equipment.The OIG found that SPS staff followed reprocessing steps according to standard operating procedures and instructions for use. The OIG did not substantiate that SPS staff did not have adequate reprocessing supplies. The OIG found that floor grade instruments received in decontamination areas were discarded and not reprocessed. The OIG found that SPS staff reviewed instructions for use for loaner trays upon receipt at the facility. The OIG did not substantiate that SPS staff failed to receive documentation for instruments sterilized at another VA facility. The OIG concluded that SPS leaders were knowledgeable of the practice standards. The OIG made one recommendation to the Facility Director to ensure staff comply with requirements for donning required personal protective equipment prior to entry into decontamination areas.

For our final report on our audit of the U.S. Department of Commerce's (the Department's) system security assessment process, our objective was to assess the effectiveness of the Department's system security assessment and continuous monitoring program to ensure security deficiencies were identified, monitored, and adequately resolved. We found the Department did not effectively execute its continuous monitoring and systemassessment process. Specifically, we found the following: I. the Department did not effectively plan for system assessments; II. the Department did not consistently conduct reliable system assessments; III. the Department did not resolve security control deficiencies within defined completion dates; and IV. the Department’s security system of record—i.e., the cyber security asset and management tool—did not provide accurate and complete assessment and plan of action & milestone data.

Registered Investment Adviser Examinations: EXAMS Has Made Progress To Assess Risk and Optimize Limited Resources, But Could Further Improve Controls Over Some Processes, Report No. 571

The objectives of our audit were to determine whether the Massachusetts Department of Elementary and Secondary Education (Massachusetts) ensured that (1) displaced student count data provided to the U.S. Department of Education (Department) were accurate and complete, (2) Temporary Emergency Impact Aid for Displaced Students (Emergency Impact Aid) program funds were appropriately allocated to local educational agencies (LEA), and (3) LEAs appropriately accounted for Emergency Impact Aid program funds within Federal guidelines.We determined that Massachusetts did not ensure that displaced student count data provided to the Department were accurate and complete because it did not have adequate controls to prevent or detect inaccurate displaced student counts.We also determined that Massachusetts did not ensure LEAs appropriately accounted for Emergency Impact Aid program funds in accordance with Federal requirements.

A Chicago man pleaded guilty and was sentenced in the Circuit Court of Cook County, Illinois, to possession of cannabis on January 24, 2022. Andre Jordan was previously arrested on February 8, 2021, after agents found him to be in possession of approximately 2.2 pounds of cannabis after he deboarded an Amtrak train in Chicago. Jordan was sentenced to 9 months in prison.

Letter to Shalanda Young, Acting Director, Office of Management and Budget

Amtrak terminated the contract of a contractor based in Camarillo, California, on January 21, 2022, following the issuance of our investigative report. Our investigation found that the contractor stole two train horns from the Beech Grove Maintenance Facility and later sold them to individuals he met on various train-related internet sites and online forums. In addition, Amtrak required the contractor to remove all equipment from Amtrak property and barred the contractor from entering any Amtrak property in the future.

The PRAC examined whether the Small Business Administration (SBA) Phase III fraud controls, which were applied to process Paycheck Protection Program (PPP) loans in 2021, would have likely detected the earlier fraud found in PPP criminal cases. SBA designed the PPP Phase III controls to address significant fraud identified in the earlier phases of the program and some were later used by the SBA in its Restaurant Revitalization Fund (RRF) program.

The Bureau of Safety and Environmental Enforcement should implement policies and procedures if it establishes a special case royalty relief program to address declines in commodity prices.

The official embezzled $95,001 by making personal purchases.

We substantiated allegations that a leaseholder failed to make timely royalty payments for minerals (gravel) a subcontractor removed from a tribally owned gravel pit.

The Office of Inspector General (OIG) is initiating a risk assessment of the Commission’s Government Charge Card Programs. Our overall objectives are to 1) assess, identify and analyze the risks of illegal, improper or erroneous purchases and payments; and 2) determine whether the results of the risk assessment justify performing an audit in compliance with the Government Charge Card Abuse Prevention Act of 2012.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of VHA facilities’ selected requirements and guidelines for medication management. This evaluation focused on compliance with program requirements and processes related to long-term opioid use for pain.This report describes medication management findings from healthcare inspections initiated at 36 VHA medical facilities from November 4, 2019, through September 21, 2020. Each inspection involved interviews with facility leaders and staff and reviews of clinical and administrative processes. The results in this report are a snapshot of VHA performance at the time of the fiscal year 2020 OIG reviews.The OIG found general compliance with many of the selected requirements. However, the OIG identified weaknesses with• aberrant behavior risk assessments,• concurrent benzodiazepine therapy,• urine drug testing,• informed consent,• patient follow-up, and• quality measure oversight.

Letter to Shalanda Young, Acting Director, Office of Management and Budget