Federal Reports

Because the EPA did not disconnect unneeded GSA services in a timely manner, the Agency paid at least $7,850 for services it was not using.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Cheyenne VA medical center. The inspection covered key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; 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.When the OIG conducted this inspection, the medical center’s leaders had worked as a team for approximately 14 months. Employee satisfaction survey results indicated that the Associate Director had opportunities to model servant leadership and improve staff’s perception of workplace respect and their ability to discuss concerns. The Associate Director for Patient Care Services had an opportunity to reduce staff’s feelings of moral distress. Patient experience survey results showed general satisfaction with the care provided.The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. However, the Chief of Staff and Associate Director for Patient Care Services had opportunities to improve their understanding of selected Strategic Analytics for Improvement and Learning data, and all leaders should continue actions to improve and sustain quality and efficiency.The OIG issued seven recommendations for improvement in three areas:(1) Quality, Safety, and Value• Surgical work group meeting attendance(2) Care Coordination• Patient transfer monitoring and evaluation• Transfer form completion• Medical record transmission(3) High-Risk Processes• Disruptive behavior reporting and tracking• Disruptive Behavior Reporting System• Staff training

The VA OIG assessed the Southeast Louisiana Veterans Health Care System’s oversight and stewardship of funds for fiscal year 2019 and identified opportunities to improve cost efficiency.The review focused on four areas:I. Use of the Medical/Surgical Prime Vendor Next Generation program. VA maintains contracts with vendors to streamline medical supply purchasing and distribution. Because its prime vendor did not fill orders consistently, the system bought only about 75 percent of its supplies through the program, falling short of VA’s recommended 90 percent goal. The system also did not always monitor the prime vendor’s performance or report performance problems to VA.II. Purchase card use. The team sampled 102 purchase card transactions and determined the system could instead have pursued contracts for 19 of them. Quarterly internal audits were also not completed on time, and approving officials did not adequately monitor cardholder purchases. In addition, the team identified 16 purchases that were split into smaller transactions to circumvent purchase limits, resulting in improper payments of about $140,016.III. Administrative staffing levels and accuracy of labor costs. The system used 251.6 more administrative full-time equivalents than other systems of similar size and complexity. The system’s director said this was partly due to initial staffing costs associated with a new medical center. The system has, however, implemented strategies to improve staffing efficiency and management.IV. Pharmacy operations and cost avoidance efforts. The system spent approximately $9 million more on prescription drugs than similar systems did. This was partly due to inaccurate or outdated prices in the system’s list of drugs and to low annual turnover of its drug supplies, but the system has made progress in improving efficiency and cost-saving efforts.The OIG made six recommendations to the healthcare system director to address the issues identified in this review.

We found several areas of the privacy program to be generally effective, including (1) completion of privacy impact assessments, (2) privacy related training taken by network users, (3) privacy considerations during the authority to operate process, (4) system categorization, (5) privacy incident response, (6) privacy-related contract terms and conditions, and (7) desktop and laptop sanitization. However, we identified seven issues that should be addressed by TVA management to further increase the effectiveness of the privacy program. Specifically, we found:1. Unsecured electronic restricted personally identifiable information on SharePoint and shared network drives. 2. Unsecured hard copy restricted personally identifiable information.3. No end user notifications for e-mail security violations.4. No technical controls for removable media.5. We could not confirm that all desktops and laptops utilize encryption.6. Privacy Act notices on TVA forms did not include all required elements.7. Not all external Web sites included privacy policies. (Note: Prior to completion of our audit, TVA Technology and Innovation took action to address the external Web sites that were missing required privacy policies.)We also found gaps between TVA’s policies and procedures and applicable federal privacy regulations and guidance.

This report presents the results of the System and Organization Controls 1 Type 2 examination conducted in accordance with Statement on Standards for Attestation Engagements No. 18 for the United States Department of Agriculture’s (USDA) National Finance Center (NFC) description of its payroll and personnel systems used to process user entities payroll and human resource transactions throughout the period October 1, 2020 to June 30, 2021.

This report presents the results of the System and Organization Controls 1 Type 2 examination conducted in accordance with Statement on Standards for Attestation Engagements No. 18 for the United States Department of Agriculture’s (USDA) National Finance Center (NFC) description of its payroll and personnel systems used to process user entities payroll and human resource transactions throughout the period October 1, 2020 to June 30, 2021.

Our objective was to assess the U.S. Postal Service’s service performance for all mail classes over an 18-month period and determine the most common failure points in the mail flow process.Mail is divided into different categories called “classes,” each having different features, service levels, and postage rates. The Postal Service has service standards for delivering mail in each class after receiving it from the customer. The delivered mail is measured against the service standards and the service performance targets for each mail class to determine the percentage of mail delivered on time.We analyzed service performance for Priority, First-Class, Periodicals, Marketing, and Bound Printed Matter mail classes. We also reviewed data to identify where in the mail flow process service failures occurred.

We focused on the Trusted Traveler Programs (TTP) membership revocations of three U.S. citizens associated with the migrant caravan and whether CBP revoked the TTP memberships in retaliation for the individuals’ support of the migrant caravan. We also addressed systemic issues related to TTP revocations that we identified while reviewing those three revocations. We found that CBP revoked three U.S. citizens’ TTP memberships after discovering links to information that it considered derogatory and a potential security risk. In two of the revocations, CBP did not assess the quality or accuracy of the potentially derogatory information at any step of the process. Specifically, we determined that CBP officers did not evaluate unsubstantiated information, and made unsupported conclusions and placed lookouts in TECS on these two individuals. Further, because of CBP’s policy to revoke memberships based on positive matches to TECS records, CBP revoked these two memberships without evaluating the underlying information. We made two recommendations to ensure two TTP membership revocations were based on quality and accurate information and to issue guidance to personnel about TTP revocation standards.

The evidence did not support a finding of retaliation because the letter issued by the senior official was not considered a personnel action.

Objective: To report internal control weaknesses, noncompliance issues, and unallowable costs identified in the single audit to the Social Security Administration (SSA) for resolution.

The OIG Audit Division assessed the GPO congressional detailee program; specifically, workhours administration.

DERA Staff Research and Publications Support the SEC’s Mission, But Related Controls and Agency-wide Communication and Coordination Could Be Improved, Report No. 567

The Postal Service’s Informed Visibility (IV) system enables plant management at postal processing facilities to advance operational efficiency in a variety of ways.To enhance operational efficiency at postal processing facilities further, the Postal Service could address IV system issues, leverage its capabilities more fully, and periodically solicit feedback from IV users.

While conducting site visits at the Los Angeles Terminal Handling Services (THS) for our ongoing Air Mail Not Moving as Assigned audit, the OIG found significant opportunities to improve the Postal Service’s air carrier contract management. The purpose of this alert is to bring these issues to the Postal Service’s attention and make recommendations for immediate corrective action.The Postal Service’s air transportation network costs for fiscal year (FY) 2021 were about $3 billion, as of July 31, 2021. In FY 2020, costs totaled $3.5 billion, an increase of about $390 million (or 12.7 percent) over FY 2019. These costs consisted of contracted services from [redacted], commercial airlines (CAIR), [redacted], supplemental charters, and THS operations.

As part of our annual audit plan, we audited costs billed to the Tennessee Valley Authority (TVA) by Black & Veatch Corporation (B&V) for engineering services under Contract No. 10820. Our audit objective was to determine if costs were billed in accordance with the terms and conditions of the contract. Our audit scope included about $42.46 million in costs billed to TVA from November 2, 2015, through February 13, 2020. In summary:We determined B&V overbilled TVA an estimated $5,771,839, including (1) an estimated $5,657,998 for unapproved OT costs for exempt labor categories, (2) $69,383 in travel and temporary living allowance costs, and (3) a net $44,458 for incorrect hourly billing rates.We noted several opportunities to improve contract administration by TVA. Specifically, we determined TVA paid an estimated $3.3 million more in labor costs by using fixed hourly labor rates instead of negotiating cost reimbursable compensation terms in its contract with B&V. We also found (1) invoices were not submitted timely, (2) B&V did not submit an electronic billing file to the TVA Office of the Inspector General in the format provided for in the contract, (3) site expenses were not provided for in the contract, and (4) the labor categories included in the contract's pricing schedule did not correspond to B&V's internal job titles.(Summary Only)

During our unannounced inspection of Otay Mesa in San Diego, California, we identified violations of ICE detention standards that compromised the health, safety, and rights of detainees. Otay Mesa complied with standards for classification and generally provided sufficient medical care to detainees. In addressing COVID-19, Otay Mesa did not consistently enforce precautions including use of facial coverings and social distancing. Overall, we found that Otay Mesa did not meet standards for grievances, segregation, or staff-detainee communications. Specifically, Otay Mesa did not respond timely to detainee grievances and did not forward staff misconduct grievances to ICE as required.

To see our report, click on the link below

The OIG reviewed 31 proposals for sole source healthcare provider contracts in fiscal year 2020 and provided information that VA contracting officers could use to help negotiate fair and reasonable prices. These contracts allow VA to fill, at a fixed price, positions for which it is unable to hire staff. The proposals typically come from VA affiliated schools of medicine or their associated hospitals or physician practice groups.The combined estimated contract value of the 31 proposals reviewed was $209 million. The OIG identified a total of $81 million in potential cost savings for 29 proposals. As of March 2021, VA contracting officers have awarded 25 of the 31 proposals and have sustained over $16 million in cost savings.OIG reviews of the individual contract proposals were not previously published because they contain clinical staff’s sensitive personal data. This report summarizes the OIG’s prior findings and recommendations in three areas:• Costs underlying proposed hourly rates. For 25 of the 27 proposals reviewed that contained hourly rate pricing, the OIG determined that the prices offered to the government were higher than the supported amounts. Frequently occurring issues included unsupported provider salaries, administrative expenses, fringe benefit amounts, or malpractice insurance premiums.• Offered per procedure prices. The OIG reviewed six proposals with per procedure pricing and determined that they all offered prices higher than the properly calculated Medicare rates.• Potential conflicts of interest. The OIG found potential conflicts of interest for VA personnel for 24 of the 31 proposals reviewed. These personnel held faculty appointments at the affiliated institutions and potentially would also have responsibilities such as monitoring performance of the affiliate’s services. In each instance, the OIG recommended the contracting officer request an opinion from VA’s Office of General Counsel on whether these individuals would have a financial interest in the proposal.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations that staff at the facility denied a patient’s discharge requests and did not ensure the patient’s access to a patient advocate. The inspection also evaluated OIG-identified concerns related to Inpatient Mental Health Unit and Community Living Center (CLC) staff’s administrative actions during the patient’s admissions.The OIG substantiated that staff denied the patient’s discharge requests. The OIG found that staff failed to follow informed consent procedures. The OIG also found that staff did not conduct a sufficient or timely decision-making capacity evaluation and documented unsupported, conflicting decision-making capacity information in the patient’s electronic health record.The patient remained on voluntary status during Inpatient Mental Health Unit and CLC admissions for nearly 2 years and 11 months. Staff did not adequately assess the patient’s admission status as voluntary or involuntary and did not follow commitment requirements during the first two of the patient’s three Inpatient Mental Health Unit admissions.The OIG found that staff did not comply with requirements when the patient requested an against medical advice discharge. The OIG also determined that staff did not properly identify a surrogate decision-maker and did not address ethical concerns regarding the appropriateness of the patient’s surrogate decision-maker.The OIG substantiated that staff failed to ensure the patient’s access to the patient advocate. Staff did not properly manage a letter from the patient that was intended for a public official.The OIG made seven recommendations to the Facility Director related to informed treatment consent processes, decision-making capacity evaluation completion and documentation, commitment requirements, against medical advice discharge procedures, surrogate decision-maker assignment, patient advocate reporting and tracking processes, and management of the patient’s correspondence request.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the White River Junction VA Medical Center, which includes outpatient clinics in New Hampshire and Vermont. The inspection covered key clinical and administrative processes that are associated with promoting quality care. This inspection focused 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.When the OIG conducted the virtual review, the executive leadership team had worked together for over one year. Employee satisfaction survey results demonstrated satisfaction with leadership and maintenance of an environment where staff felt respected. However, responses also pointed to opportunities for the Director and Chief of Staff to improve employee feelings of moral distress at work. Patient experience survey results indicated satisfaction with the care provided. The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. The executive leaders were knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue efforts to sustain and further improve medical center performance.The OIG issued two recommendations for improvement in two areas:(1) Quality, Safety, and Value• Surgical work group meetings(2) High-Risk Processes• Disruptive behavior training

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the outpatient settings of the Manchester VA Medical Center. The inspection covered key clinical and administrative processes that are associated with promoting quality care. It focused 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.The leadership team appeared stable, with a vacancy in only one of four key positions. Employee survey data revealed satisfaction with leadership and a workplace where staff felt respected and discrimination was not tolerated. However, the OIG noted opportunities to improve servant leadership behaviors and reduce staff feelings of moral distress at work. Patient experience survey results indicated opportunities to improve female veterans’ satisfaction in the outpatient settings. The OIG’s review of the healthcare system’s accreditation findings, sentinel events, and disclosures of adverse patient events did not identify any substantial organizational risk factors. Executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to improve performance.The OIG issued seven recommendations for improvement in three areas:(1) Quality, Safety, and Value• Surgical work group attendance(2) Care Coordination• Monitoring and evaluation of patient transfers• Transfer form completion• Medication list transmission• Nurse-to-nurse communication(3) High-Risk Processes• Disruptive behavior committee attendance• Staff training

The Menlo Park (owned), Excelsior (leased), and Sutter Street (leased) post offices are in the California 1 District. The Postal Service is required to maintain a safe and healthy environment for both employees and customers in accordance with its internal policies and procedures and Occupational Safety and Health Administration (OSHA) safety laws. Our objective was to determine if Postal Service management is adhering to building maintenance, safety and security standards, and employee working condition requirements at post offices.We found that building maintenance, safety, and security at the Menlo Park, Excelsior, and Sutter Street post offices did not meet prescribed standards. We identified 50 deficiencies at the three facilities that ranged from minor to more serious violations.

We performed procedures agreed upon by the U.S. Office of Personnel Management’s (OPM) Office of the Chief Financial Officer. This attestation engagement is an annual requirement of the U.S. Office of Management and Budget.Our objective was to assist the OPM in assessing the reasonableness of Postal Service employee health benefits, life insurance, and retirement withholdings; Postal Service benefit contributions; and enrollment information submitted via the headcount report.

We audited the U.S. Department of Housing and Urban Development’s (HUD) oversight of voucher utilization and reallocation in the Housing Choice Voucher Program based on the HUD Office of Inspector General’s (OIG) report on HUD’s top management challenges for fiscal year 2020 and HUD’s strategic goals and objectives reported in its 2018-2022 strategic plan. In addition, while responding to a congressional inquiry from Senator Chuck Grassley’s office, regarding portability in the Program (audit report number 2020-CH-0006, issued September 9, 2020), we identified that as of September 2019, HUD had more than 300,000 unused vouchers that could potentially be used to house families in need of affordable housing. Our audit objective was to assess HUD’s oversight of voucher utilization and reallocation in the Housing Choice Voucher Program.HUD remains challenged to ensure that the maximum number of eligible families benefits from its Housing Choice Voucher Program. Specifically, while HUD’s voucher utilization rate had decreased, it estimated that as of November 2020, more than 62 percent of public housing agencies in the Program had leasing potential and that leasing potential could increase in 2021. In addition, HUD had not exercised its regulatory authority to reallocate housing choice vouchers and associated funding when public housing agencies were underutilizing their vouchers. HUD remains challenged with voucher utilization because some public housing agencies continue to encounter difficulties that are not within their control to overcome and which negatively impact the agencies’ ability to increase leasing in their service areas. In addition, HUD believed that it could not implement its reallocation regulation because of legislative changes dating back to 2003. As a result, nearly 81,000 available housing choice vouchers could potentially be used to provide additional subsidized housing for eligible families. Further, more than 191,000 authorized vouchers were unused and unfunded, meaning that more than 191,000 additional low- to moderate-income families could possibly benefit from subsidized housing by using these vouchers. However, HUD would need an additional appropriation of nearly $1.8 billion to fund these vouchers. We recommend that HUD’s Office of Field Operations establish and implement a plan to assist public housing agencies in optimizing leasing potential to maximize the number of assisted families and prevent additional vouchers from becoming unfunded. We also recommend that HUD’s Office of Public Housing and Voucher Programs establish and implement a plan for the unused and unfunded vouchers to mitigate or prevent additional vouchers from becoming unused and unfunded.

An Amtrak Sheetmetal Worker Mechanic based in Beech Grove, Indiana, resigned from the company on September 14, 2021, following the release of our investigative report. Our investigation found that the former employee violated company policies by engaging in self-employment that interfered with his job duties and responsibilities. On some occasions, he used a personal leave of absence and leave granted under the Americans with Disabilities Act to operate his lawn care service.

As part of our annual audit plan, we audited costs billed to the Tennessee Valley Authority (TVA) by Mesa Associates, Inc. (Mesa) under Contract No. 13191 for engineering, design, and construction support services in support of TVA's dam safety, generation, and transmission work. The contract provided for TVA to compensate Mesa for these services on either a cost-reimbursable or fixed price basis. Our audit objectives were to determine if (1) costs were billed in accordance with the terms and conditions of the contract and <br> (2) tasks were issued using the most cost efficient pricing methodology. Our audit scope included about $57.5 million in costs billed to TVA from March 12, 2018, through August 31, 2020. This included $25.8 million for cost-reimbursable projects and $31.7 million for fixed price projects.In summary, we determined:Mesa overbilled TVA $213,545 on cost-reimbursable projects, including (1) $147,045 in temporary living allowances and travel costs, (2) $34,298 in subcontractor costs, <br> (3) $18,576 in labor costs, (4) a net $7,195 in performance fee payments, and (5) $6,431 in volume discounts not provided to TVA.The use of fixed price payment terms on projects caused TVA to pay at least $1.52 million more than it would have if cost-reimbursable payment terms had been used for those projects. Additionally, if TVA utilized cost-reimbursable pricing for the remaining spend on its current contract with Mesa (i.e., Contract No. 15396), we estimated TVA could potentially avoid up to $8.69 million in future costs.(Summary Only)

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Central Western Massachusetts Healthcare System in Leeds, which includes multiple outpatient clinics in Massachusetts. The inspection covered key clinical and administrative processes that are associated with promoting quality care. It focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.The executive leadership team had worked together for seven months at the time of the OIG virtual review. Survey data revealed opportunities for the Director to reduce employee feelings of moral distress and improve workgroup respect and sharing of concerns. The healthcare system’s patient experience scores were generally higher than VHA averages, except for female patients’ access to timely outpatient appointments. The OIG’s review of the hospital’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Executive leaders were knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance.The OIG issued five recommendations for improvement in two areas:(1) Care Coordination• Patient transfer monitoring and evaluation(2) High-Risk Processes• Disruptive behavior committee meeting attendance• Order of Behavioral Restriction and patient notification documentation• Completion of training

The VA Office of Inspector General (OIG) evaluated an August 2019 hotline complaint alleging mismanagement of supplies, equipment, and operating rooms while activating the New Orleans VA Medical Center in Louisiana.The OIG substantiated that the medical center purchased about $1.85 million in excess surgical supplies. Employees also violated VA supply chain management policies by not properly accounting for nor advertising the excess supplies to other facilities. Employees violated Federal Acquisition Regulations and VA financial policy when they used purchase cards instead of contracts to obtain supplies.The OIG did not substantiate that the facility purchased unnecessary equipment, nor that funds were wasted on purchasing surgical equipment and related service contracts. The OIG was unable to determine if operating rooms were underused because sufficient data on percentage of surgeries being outsourced were not available. However, the OIG substantiated that two operating rooms were not being used two years after the surgical department opened and the department’s activation was delayed. Employees provided evidence supporting the decisions to not yet open all the operating rooms. COVID-19 also affected delays in surgical department activation.The OIG recommended the Southeast Louisiana Veterans Health Care System director account for undocumented excess supplies and determine if any administrative action should be taken on some $675,000 in missing supplies listed in a report of survey. The director should also ensure identified FAR violations are reported to the Financial Services Center, appropriate remedies or penalties are imposed, and all unauthorized commitments are ratified per policy. The director should ensure employees coordinate with and obtain guidance from National Purchase Card Program staff when they are uncertain about proper use of government purchase cards. Leased equipment should be returned to the contractor for any operating rooms that will not be used for at least one year.

Restricted

Phong Hung Tran, a licensed physician and surgeon in the state of California, was sentenced in United States District Court, Southern District of California, on September 13, 2021, to time served, two years’ probation and 12 months of home confinement for conspiracy to commit honest services mail fraud and health care fraud.Our investigation found that Tran and other doctors arranged for and accepted kickback payments from suppliers of health care services and products. The kickback scheme involved the referral of prescriptions for medically unnecessary compounded drugs and other items that were reimbursed by health care benefit programs. As a result of the scheme, Amtrak’s insurance providers were fraudulently charged approximately $22,000. Criminal judicial proceedings for other defendants in this case are pending.

See the additional details link below for the full report, report summary, multimedia or any agency follow-up.

VA must report annually to Congress on its capacity in five areas: (1) spinal cord injury and disorder, (2) traumatic brain injury, (3) blind rehabilitation, (4) prosthetics and sensory aids, and (5) mental health. This reporting requirement was established to ensure that VA’s capacity to serve disabled veterans does not fall below 1996 levels. The OIG is required to report to Congress on the accuracy of VA’s report.The OIG found some minor errors, data omissions, inaccuracies, and inconsistencies, but found nothing that caused it to believe the capacity report was not fairly stated and accurate in all material respects, with some exceptions noted. Some source data obtained by the review team differed materially or were excluded from some parts of the capacity report appendix, and some statements in the narrative were not consistent with data in accompanying tables. Limitations in data sources and reporting occurred in staffing data that included nonclinical time and in expenditure and cost data whose reliability was uncertain. VA also did not provide all required data. Still, the OIG found VA improved its reporting as a result of the OIG’s previous review.Despite these improvements, as the OIG previously noted, VA cannot compare its current mental health capacity with its 1996 capacity because of changes in diagnosis and treatment, service provision, and data collection. For example, VA must report on the number of veterans with “serious mental illness,” but VA no longer uses that term. And non-VA care, which veterans increasingly seek, must be excluded from reports on VA’s capacity to provide care. The OIG believes that by modernizing the reporting metrics, Congress would be better positioned to assess VA’s capacity to provide care for today’s disabled veterans.

This report presents the results of the System and Organization Controls 1 Type 2 examination conducted in accordance with Statement on Standards for Attestation Engagements No. 18 for the United States Department of Agriculture’s (USDA) Financial Management Services (FMS) description of its financial systems used to process user entities financial transactions throughout the period October 1, 2020, to June 30, 2021.

This report presents the results of the System and Organization Controls 1 Type 2 examinationconducted in accordance with Statement on Standards for Attestation Engagements No. 18 forthe United States Department of Agriculture’s (USDA) Financial Management Services (FMS)description of its financial systems used to process user entities financial transactions throughoutthe period October 1, 2020, to June 30, 2021.

CBP did not effectively manage its aviation fleet acquisitions to meet operational mission needs. Specifically, AMO acquired and deployed 16 multi-role enforcement aircraft (MEA) that did not contain the necessary air and land interdiction capabilities to perform its mission. In addition, CBP AMO initiated the MEA and medium lift helicopter program without well-defined operational requirements and key performance parameters — critical items in the acquisition planning process. This occurred because CBP did not provide oversight and guidance to ensure acquisition personnel followed key steps required by the DHS Acquisition Lifecycle Framework. As a result, AMO expended approximately $330 million procuring multi-role enforcement aircraft that, at the time of acceptance, did not effectively respond to emergent air threats along the northern or southern borders, and experienced schedule delays deploying the medium lift helicopter. Without effective oversight and guidance, AMO risks aviation acquisitions taking longer to deliver, at a greater cost, and without the needed capabilities. We made four recommendations aimed at improving CBP’s acquisition management of aviation fleet to meet operational needs. CBP concurred with three of the four recommendations.

The OIG used data analytics to identify offices with potentially fraudulent Voyager card activity. The Penn Hills Branch had 1,807 transactions posted from October 1, 2020, through March 31, 2021, totaling $65,062. This included 109 transactions flagged as high‑risk in FAMS.Our objective was to determine whether Voyager card PINs were properly managed, and Voyager card transactions were properly reconciled at the Pittsburgh, PA, Penn Hills Branch.

As part of its mission to protect human health, the EPA communicates risks from contaminated sites to the public. Without accurate, clear, and timely information, residents living on or near contaminated sites cannot take precautions, if necessary, to protect their health and safety.

ICE has taken various actions to prevent the pandemic’s spread among detainees and staff at their detention facilities. At the nine facilities we remotely inspected, these measures included maintaining adequate supplies of PPE such as face masks, enhanced cleaning, and proper screening for new detainees and staff. However, we found other areas in which detention facilities struggled to properly manage the health and safety of detainees. For example, we observed instances where staff and detainees did not consistently wear face masks or socially distance. In addition, we noted that some facilities did not consistently manage medical sick calls and did not regularly communicate with detainees regarding their COVID-19 test results. Although we found that ICE was able to decrease the detainee population to help mitigate the spread of COVID-19, information on detainee transfers was limited. We also found that testing of both detainees and staff was insufficient, and that ICE headquarters did not generally provide effective oversight of their detention facilities during the pandemic. Overall, ICE must resolve these issues to ensure it can meet the challenges of not only the COVID-19 pandemic, but future pandemics as well. We made six recommendations to improve ICE’s management of COVID-19 in its detention facilities. ICE concurred with all six recommendations.

Our objective was to determine if the Postal Service has adequate controls over awarding noncompetitive contracts and whether business scenario justifications were adequately supported.The goal of the Postal Service’s supply chain activities is to obtain the best value, which is generally achieved through competition. Competition brings market forces to bear and helps purchase/supply chain management teams compare the relative value of proposals and prices. Competition also encourages the adoption of innovative ideas and solutions and promotes fairness and openness that leads to public trust. However, there are business situations when the noncompetitive purchase method better suits or is needed to meet the business objectives of the Postal Service.

As a part of our IT Audit program, the OIG reviewed a Postal Service IT system to assess the security posture. This audit involved a technical review to identify potential issues and provide recommendations. The technical details of our work are shared directly with Postal Service management. Due to the sensitive nature of this information, we did not post details of our work.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Edith Nourse Rogers Memorial Veterans’ Hospital and three outpatient clinics in Massachusetts. The inspection covered key clinical and administrative processes that are associated with promoting quality care. It focused 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.The executive leadership team had worked together for approximately eight months at the time of the OIG virtual review. Survey data revealed opportunities for the Chief of Staff to improve employee perceptions of leaders and the workplace, and the Associate Director Nursing and Patient Care Services to improve employee feelings of respect. The OIG’s review of the hospital’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Executive leaders were knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance.The OIG issued seven recommendations for improvement in three areas:(1) Mental Health• Suicide prevention training(2) Care Coordination• Transfer form completion• Medical record transmission• Nurse-to-nurse communication(3) High-Risk Processes• Disruptive behavior committee meeting attendance• Disruptive behavior and threat assessment training