Federal Reports

The OIG’s administrative investigation examined the circumstances surrounding the death of a veteran on the Edith Nourse Rogers Memorial Veterans Hospital campus in Bedford, Massachusetts (the medical center). Mr. Timothy White was a resident of the Bedford Veterans Quarters (BVQ), an independent living facility operated by Caritas Communities, Inc. (Caritas), in space leased to it through VA’s enhanced-use lease program. A month after Mr. White was reported missing, his body was found in the emergency exit stairwell of the building that houses the BVQ. This stairwell down the hall from his room was VA property and not leased to Caritas.The VA police department’s failure to locate Mr. White resulted in part from the police and others at VA not considering the veteran an at-risk missing patient, which would have required a stairwell search. The Veterans Health Administration and the Office of Security and Law Enforcement lacked clear guidance regarding the obligations of VA police to search for nonpatients reported missing on VA property.VA police also did not discover Mr. White in the stairwell because of an improper order by the then police chief to cease patrols of the building in which Mr. White was found. The OIG found that the VA police chief exceeded his authority as both VA policy and the lease required VA police to patrol VA property.Lastly, because medical center staff mistakenly believed the emergency exit stairwells were not VA space, they did not clean them. The confusion among medical center leaders and staff regarding the lease scope and VA’s obligations stemmed from a lack of clear guidance from the Office of Asset and Enterprise Management. Routine police patrols and stairwell cleanings likely would have led to Mr. White being found earlier.VA concurred with the OIG’s seven recommendations to improve policies and procedures.

The Cybersecurity and Infrastructure Security Agency (CISA) cannot demonstrate how its oversight has improved Dams Sector security and resilience. We attribute this to CISA’s inadequate management of Dams Sector activities. Specifically, CISA has not:coordinated or tracked its Dams Sector activities;updated overarching national critical infrastructure or Dams Sector plans; orcollected and evaluated performance information on Dams Sector activities.In addition, CISA does not consistently provide information to the Federal Emergency Management Agency (FEMA) to help ensure FEMA’s assistance addresses the most pressing needs of the Dams Sector. CISA and FEMA also do not coordinate their flood mapping information. Finally, CISA does not effectively use the Homeland Security Information Network Critical Infrastructure Dams Portal to provide external Dams Sector stakeholders with critical information.As a result, CISA could improve its oversight, coordination, and communication to better support the Dams Sector security and resilience. These changes would enhance the Sector’s ability to adapt to the risk environment and decrease the likelihood of future dam failures and flooding events.

NASA manages more than 5,000 buildings and structures, a $2.66 billion deferred maintenance backlog, and a $357 million annual facility construction budget. In this audit, we assessed whether NASA is effectively managing its facility construction efforts to modernize, consolidate, and repair its critical infrastructure.

The OIG is conducting an audit to determine whether VA’s Financial Management Business Transformation Service identified and addressed issues with a new IT system following its initial deployment at the National Cemetery Administration (NCA). The Integrated Financial and Acquisition Management System will be used throughout VA to manage budgetary, financial, and contracting activities.The OIG issued a management advisory memorandum to share observations from the ongoing audit and expects to publish the final report in fiscal year 2022.The audit team found that NCA was experiencing significant challenges with the system’s ability to produce business intelligence reports that it needs to make well informed, mission critical decisions. Although the Financial Management Business Transformation Service attempted some corrective actions, issues persisted as of July 8, 2021, or about eight months after go-live. As of this date, NCA did not have a comprehensive report showing the total amount of funds available for the administration. This was despite the fact that NCA leaders informed the Financial Management Business Transformation Service in April 2019 that the report was the administration’s highest priority and needed to identify funding available at every level of the budget. Other high priority reports used to track and forecast payroll and full-time equivalent employees were also not available for NCA’s widespread use. These reports would allow staff to monitor how much has been expended in payroll and project the funding required to pay employee salaries throughout the fiscal year. NCA staff noted that they spend considerable time trying to understand and validate reports by extracting data from other reports and queries and manipulating that data in spreadsheets.The OIG requested that the Office of Management inform the OIG what action, if any, the Office of Management takes to address the issued identified.

We did not find any evidence of wrongdoing regarding a contract award.

Why OIG Did This Audit Prior OIG work found that Medicare inappropriately paid for services that were billed as being distinct or significant and separately identifiable from other services provided on the same day. Our analysis showed that in 2018, an ophthalmology clinic in Florida (the Clinic) frequently billed for other services as being distinct from or significant and separately identifiable from intravitreal (inside the eye) injections of the drugs Avastin, Eylea, and Lucentis. Our objective was to determine whether the Clinic complied with Medicare requirements when billing for intravitreal injections of Avastin, Eylea, and Lucentis and for other services provided on the same day as the injections. How OIG Did This AuditOur audit covered Medicare Part B payments of $2.1 million for intravitreal injections of Avastin, Eylea, and Lucentis (and for other services provided on the same day as the injections) that the Clinic provided in 2018. We reviewed a stratified random sample of 100 beneficiary days, consisting of 543 services and drugs. (A beneficiary day consisted of all services and drugs provided on a date of service to a beneficiary in which intravitreal injections of Avastin, Eylea, or Lucentis were administered.) For each sampled beneficiary day, we provided copies of the medical records to an independent medical review contractor to determine whether the services and drugs were properly billed.

The U.S. Environmental Protection Agency's Office of lnspector General has identified a failure to follow Agency procedure—specifically EPA Classification No. CIO 2150-P-08.2, EPA Information Procedure, Information Security – Incident Response Procedures—concerning reporting and response requirements for cybersecurity incidents. The failure to follow this procedure occurred after EPA employees were notified of a potential data breach of EPA information related to the EPA Facility Registry Service, or FRS.

Every Postal Service-owned vehicle is assigned a Voyager Fleet card (Voyager card) to pay for its commercially purchased fuel, oil, and routine maintenance. U.S. Bank operates the program and Voyager provides a weekly electronic transaction detail file of all Voyager card transactions to the Postal Service’s Fuel Asset Management System (FAMS) eFleet application. OIG data analytics identified offices with potentially fraudulent Voyager card activity. The Norwalk, CT, Post Office had 3,166 posted transactions from October 1, 2020, through March 31, 2021, totaling $92,872. This includes 262 (8 percent) transactions totaling $30,005 that FAMS flagged as high risk.The objective of this audit was to determine whether Voyager card PINs were properly managed and Voyager card transactions properly reconciled at the Norwalk, CT, Post Office.

Our review confirmed that the Bureau of Safety and Environmental Enforcement implemented all five recommendations from our 2019 report.

Our objective was to evaluate service performance for First‑Class Single Piece (FCSP) letter mail nationally and in 17 selected districts. This report responds to a congressional request regarding concerns of low service performance in these districts in the last month leading up to the November 2020 general election. The OIG addressed issues on election mail service performance in a prior report. This audit focuses on overall service performance for FCSP letter mail in fiscal year (FY) 2020 through March 31, 2021.

Without internal controls to track ETF program performance, the EPA risks underreporting environmental and human health outcomes.

Joseph Kieffer, a marketer from Los Angeles, was sentenced on September 8, 2021, in U.S. District Court, Central District of California, to six months in prison, three years’ probation, a $10,000 fine, and he was ordered to pay restitution in the amount of $1,250,000 and a money judgment of forfeiture of $328,835. Kieffer previously pleaded guilty to paying kickbacks to marketers and some patients to obtain medically unnecessary compounded drugs, which allowed Fusion RX Compounding Pharmacy to bill health care providers for those drugs. Many of the prescription claims were reimbursed at rates much higher than average medications. The owner of Fusion Rx Compounding Pharmacy was also charged for his role in the scheme. Amtrak’s health insurance plan was fraudulently billed $17,000 as a result. Criminal judicial proceedings for other defendants are pending.

Since 1991, veterans who served in the Republic of Vietnam are presumed to have been exposed to herbicides such as Agent Orange. The Blue Water Navy Vietnam Veterans Act of 2019 extended this presumption to include veterans who served within 12 nautical miles of Vietnam. The objective of this OIG review was to determine whether Veterans Benefit Administration (VBA) employees (1) notified Navy veterans of their potential eligibility to receive medical benefits under the act; (2) correctly determined the eligibility of the veterans who filed claims for benefits; and (3) made accurate decisions on claims. The OIG found that VBA met the outreach requirements outlined in the act. VBA employees also generally determined Blue Water Navy veterans’ eligibility for benefits correctly. However, VBA has not established procedures for its employees to follow when the computer search tool they use to determine ship locations during claimant service dates returns unlikely results (for example, providing an inland location in a search for an aircraft carrier). In addition, VBA employees inaccurately decided approximately 46 percent of veterans’ claims (2,100 of 4,600) from April through June 2020, which led to about $37.2 million in improper payments to veterans ($25.2 million in overpayments and $12 million in underpayments) during that period. About 95 percent of these errors resulted from VBA employees deviating from policies governing disability-rating decisions. The OIG made three recommendations to the under secretary for benefits: (1) establish procedures to follow when the ship locator tool provides unlikely results based on deck log coordinates, (2) ensure VBA employees understand how to accurately decide and evaluate herbicide-related medical conditions, and (3) begin periodic local reviews of rating decisions involving such medical conditions to mitigate error trends identified.

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 Eastern Oklahoma VA Health Care System. 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; 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.At the time of the OIG virtual review, all leadership positions were permanently filled. Survey data revealed opportunities to improve employee perceptions of leadership, reduce feelings of moral distress at work, and reduce fears of retaliation. Patient experience survey data highlighted a need to address outpatient care experiences. The OIG identified concerns with institutional disclosures for sentinel events. Leaders were generally knowledgeable within their scope of responsibilities 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 9 recommendations for improvement in 4 areas:(1) Leadership and Organizational Risks• Institutional disclosures for sentinel events(2) Quality, Safety, and Value• Designated systems redesign and improvement coordinator• Surgical work group attendance(3) Care Coordination• Inter-facility transfer form completion• Active medication list transmission(4) High-Risk Processes• Disruptive behavior committee meeting attendance• Patient notification of behavioral restriction order• Staff training

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 Oklahoma City VA Health Care System. 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; 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.The healthcare system’s executive leadership team appeared stable; all positions were permanently assigned, and the team had worked together for over two years. The Director, who was assigned in June 2016, was the most tenured leader. The Assistant Director, assigned in May 2018, was the newest executive leader. Employee survey data revealed opportunities for the Associate Director of Patient Care Services, Associate Director, and Assistant Director to improve employee feelings of moral distress at work. Patient experience survey results highlighted challenges with outpatient care. The OIG’s review of the system’s accreditation findings, sentinel events, and disclosures 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 sustain and improve performance.The OIG issued five recommendations for improvement in four areas:(1) Registered Nurse Credentialing• Primary source verification of registered nurses’ licenses(2) Mental Health• Suicide prevention training(3) Care Coordination• Monitoring and evaluation of patient transfers(4) High-Risk Processes• Disruptive behavior committee attendance• Staff training

To determine delivery windows and expected arrival times, the Postal Service has specific service standards. These standards may seem like simple ranges of days, but behind them is a complex system that accounts for factors about each mailpiece, such as the type of mail it is and where and when it is entered into the postal network. In this report, the OIG provides an overview of how service standards for the delivery of mail and packages are established and defined, service performance is measured, and standards are revised.

In fiscal year (FY) 2020, the Postal Service used about 255,000 delivery vehicles to distribute mail to 160 million delivery points across the nation. While about $292 million was spent on vehicle parts through 16 suppliers, the Postal Service spent about $190 million (65 percent) with two primary consignment vehicle part suppliers.These suppliers are contracted through national ordering agreements for the sale of vehicle parts through consignment with a period of performance from 2007 to 2050. The agreements also include a most favored customer pricing clause which allows the Postal Service to obtain an equal to or lower unit price for vehicle parts provided to the suppliers’ other customers.Our objective was to assess if the management of Postal Service vehicle parts agreements is consistent with pricing requirements.

Our objective for this report was to assess the effectiveness of the company’s efforts to achieve compliance with the Americans with Disabilities Act.We found that the company has clearer lines of authority, responsibility, and accountability for the Americans with Disabilities Act (ADA) program, and that its reorganization, based on our prior recommendations, has helped it bring 36 more stations into compliance since October 2017 through April 2021. The company cannot, however, reasonably expect to execute its aggressive plan to achieve compliance at the remaining 312 stations over the next six years until it develops the requisite planning to achieve its timeline. Although the company appears fully committed to achieving ADA compliance, it acknowledges that it currently does not have enough staff to manage additional projects or monitor the contractors it hired to support them. We also found that achieving cooperation with third parties at the remaining noncompliant stations remains a significant program risk. Finally, we found that Amtrak’s Information Technology department and its ADA Stations team did not coordinate to ensure that passenger information display systems (PIDS) installations were compliant, and they did not effectively coordinate to ensure that they were tracking the same number of stations at which the company is responsible for PIDS, which led to inconsistent reporting.We recommended that the company 1) assess the current and future resources the ADA program needs to implement its timeline, including resources from other groups, and identify actions to address any shortfalls, 2) ensure it reviews contractor timesheets and invoices more thoroughly, reconcile contractor timesheets and invoices from fiscal year 2015 through fiscal year 2020, and, if applicable, recover any costs, 3) develop guidance that institutionalizes steps program staff can take when they reach a stalemate with a third party, and 4) take and document actions to ensure the ADA Stations team and Information Technology department are coordinating so installations are compliant and reporting is consistent and accurate. 

An Amtrak passenger conductor based in Florence, South Carolina, was terminated from employment on September 2, 2021, following his administrative hearing. Our investigation found that the former employee violated company policy by engaging in outside employment while on a medical leave of absence from the company and by being dishonest on his pre-employment physical exam form when responding to questions regarding previous injuries and hospitalizations.

The United States currently faces a nationwide public health emergency because of the COVID-19 pandemic. Federal regulations, effective May 8, 2020, required nursing homes to report COVID-19 information, such as the number of confirmed COVID-19 cases among residents, at least weekly to the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network. Each week, CDC aggregates the reported information and sends the data to the Centers for Medicare & Medicaid Services (CMS) for posting to the CMS website. These data are used to assist with national surveillance of COVID-19 in nursing homes and to support actions to protect the health and safety of nursing home residents. Our objective was to determine whether CMS’s COVID-19 data for nursing homes were complete and accurate.

Coronavirus disease 2019 (COVID-19) has affected millions of Americans, resulting in more than 600,000 deaths. Medicare beneficiaries have been particularly affected and remain vulnerable to new variants and additional surges of the virus. Clinicians and researchers are still working to fully understand the damage to the body from the disease and what underlying chronic conditions potentially lead to more severe complications or hospitalization.Understanding the types of conditions for which Medicare beneficiaries with COVID-19 are being treated and who was more likely to be hospitalized with COVID-19 can help hospitals and health officials better prepare for and address the wide-ranging and extensive needs of COVID 19 patients, particularly in the event of localized surges of cases. Such knowledge will also assist in the Federal, State, and local response to the pandemic by providing a better picture of the needs of these hospitalized beneficiaries.This report describes the complex care needs of beneficiaries hospitalized with COVID-19. It focuses on surges in COVID-19 hospitalizations in six localities and builds upon prior OIG work that describes the extent to which hospitals have been strained by COVID-19. As we noted in the 2021 report about hospital experiences during the pandemic, hospitals have been operating in "survival mode" for an extended period of time. They have also experienced difficulty balancing the complex and resource-intensive care needed for COVID-19 patients with efforts to resume routine hospital care.

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 Providence VA Medical Center and multiple outpatient clinics in Massachusetts and Rhode Island. 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; 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.The medical center’s executive team had worked together for over seven months at the time of the OIG virtual site visit. The Director was the newest member of the executive team and had served in the role since June 2020. The other team members had been in their positions for more than two years. Employee survey data revealed opportunities for the Chief of Staff and Director to improve feelings of servant leadership and reduce moral distress at work, respectively. Patient experience survey data 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. Executive leaders were knowledgeable within their scope of responsibilities 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 three recommendations for improvement in two areas:(1) Quality, Safety, and Value• Systems Redesign and Improvement Program• Surgical work group(2) Care Coordination• Nurse-to-nurse communication

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 Salt Lake City Health Care System. 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; 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.At the time of the OIG’s inspection, the Chief of Staff and Director had served in their roles since 2012 and 2017, respectively. However, the remaining three executive leaders had assumed their roles within the past 10 months. Employee survey results demonstrated satisfaction with most executive leaders and maintenance of a work environment where staff felt respected and discrimination was not tolerated. Patient survey results indicated general care satisfaction among male veterans, but opportunities to improve female veterans’ experiences. The OIG’s review of the healthcare system’s accreditation findings, sentinel events, and disclosures 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 sustain and improve performance.The OIG issued six recommendations for improvement in three areas:(1) Mental Health• Suicide prevention training(2) Care Coordination• Monitoring and evaluation of inter-facility transfers• Transfer form completion• Documentation of active medication lists• Nurse-to-nurse communication(3) High-Risk Processes• Disruptive behavior training

Our objective was to determine if the Postal Service has an effective security posture to protect its Information Technology (IT) infrastructure from external cyberattacks and prevent unauthorized access to restricted data.

What We Looked AtWe queried and downloaded 70 single audit reports prepared by non-Federal auditors and submitted to the Federal Audit Clearinghouse between April 1, 2021 and June 30, 2021. We used the reports to identify significant findings related to programs directly funded by the Department of Transportation (DOT).What We FoundThe reports contained a range of findings that impacted DOT programs. The auditors reported significant noncompliance with Federal guidelines related to 13 grantees that require prompt action from DOT's Operating Administrations (OA). The auditors also identified questioned costs totaling $32,153,264 for eight grantees. Of this amount, $31.2 million was related to Amtrak and $212,788 to COVID-19 Formula Grants for the Rural Areas Program.RecommendationsWe recommend that DOT coordinate with the impacted OAs to develop a corrective action plan to resolve and close the findings identified in this report. We also recommend that DOT determine the allowability of the questioned transactions and recover $32,153,264, if applicable.

Kevin Nelson, a resident of New York, pleaded guilty in U.S. District Court, Eastern District of New York, on August 30, 2021, to Aggravated Identity Theft for his involvement in an Amtrak eVoucher scheme. Nelson and his co-conspirators used stolen credit card and personal information to make unauthorized purchases of Amtrak tickets and then cancelled or exchanged those tickets for eVouchers. Subsequently, they sold the fraudulently obtained eVouchers on the internet. The approximate loss to Amtrak from the scheme is $450,000. Nelson’s sentencing is pending.

Account Identifier Code (AIC) 553, Refund Postage and Fees, is used to record refunds of customers postage and fees paid for special services not received. OIG data analytics identified the Norristown Tri‑County Post Office had about $266,790 recorded to AIC 553 from January 1, 2020, to December 31, 2020, the highest in the nation. For fiscal year (FY) 2020, the total was $248,298 — 48 percent of the total for the DE-PA2 district. For FYs 2018 and 2019, the totals for AIC 553 were only $691 and $967 (0.53 percent and 0.58 percent of the district total), respectively.The objective of this audit was to determine whether postage and fee refunds are valid and properly supported and processed at the Norristown Tri‑County Post Office.

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The objective of our audit was to determine whether the Department of Education (Department) is providing adequate oversight of grantee performance and funds awarded under the Student Support and Academic Enrichment (SSAE) program and is ensuring that State educational agencies (SEA) are meeting reporting requirements as established by the Every Student Succeeds Act. We found that the Office of Safe and Supportive Schools (OSSS) has provided inadequate oversight of grantee performance and funds awarded under the SSAE program. While OSSS has provided some general oversight of the SSAE program, formal monitoring activities have been limited. We also found that OSSS’ risk assessment process could benefit from consideration of additional risk factors in calculating risk scores.

The Postal Service offers up to $5,000 of insurance coverage as protection against the loss of or damage to a customer’s package. When an insured item is lost or damaged, the customer may request compensation by filing an indemnity claim online, by mail, or at a postal retail unit. If an indemnity claim is domestic and valued at [redacted] or less, it is automatically adjudicated; otherwise, it is manually adjudicated. All international indemnity claims are manually adjudicated.Our objective was to determine whether the Postal Service properly processed and paid manually adjudicated indemnity claims.

Audit report of the NLRB's submission of procurement data and compliance with the DATA Act.

An Amtrak senior manager based in Beech Grove, Indiana, was terminated from employment on August 30, 2021. Our investigation found that the former employee violated company policy by failing to formally document, investigate, and report a workplace violence incident involving an employee and by encouraging another employee to change his statement regarding the incident. Another manager at the Beech Grove facility received a letter of written warning for failure to ensure the incident was properly investigated.

Postal Service management is responsible and accountable for the prevention of accidents and responsible for controlling losses, such as ensuring quality of performance and operating within cost and budget guidelines. Management’s role is to share responsibility for the safety and health of employees.The Employee Health and Safety (EHS) application is used to enter and manage accident, injury, and claim information related to vehicle and industrial incidents. The application included information for 455,099 accidents from fiscal years (FY) 2016 to 2020, of which 144,607 (32 percent) were motor vehicle accidents and 310,492 (68 percent) were industrial accidents.Our objective was to review and assess the effectiveness of management’s controls over reporting accidents.

Our objective for this report was to identify the internal control weaknesses that allowed a potential identity theft crime to occur in Chicago and to assess the company’s processes for overseeing and safeguarding items at selected stations.We found that the company has taken steps to strengthen its Lost and Found program to include addressing issues that contributed to an employee theft of 13 state and government customer identification cards and 21 social security cards from the Chicago Union Station Lost and Found program in October 2020. Additionally, we found the company is securing sensitive and high-value items at the stations we reviewed, and, in 2018, automated inventory controls through its use of the third-party software system, Chargerback. We identified opportunities that could further improve the company’s Lost and Found program to include 1) improving program monitoring by station managers, 2) ensuring staff are well trained, 3) resuming monthly lost and found reporting to station management, and 4) provide guidance on how employees should safeguard items found at maintenance yards and on trains and how quickly the items should be transferred to the Lost and Found area. The company agreed with these observations and plans to take corrective actions.

As part of our annual audit plan, we audited the Tennessee Valley Authority's (TVA) utility-scale Solar Purchased Power Agreements (PPA). Our audit objectives were to determine if TVA has (1) approached Solar PPAs to better understand the industry and market trends being developed prior to entering into multiple agreements and (2) developed Solar PPAs to recognize positive financial value earlier in the term of the PPAs. The scope of our review was utility-scale solar PPAs in place as of December 31, 2020. We found TVA had (1) taken a measured approach to solar PPAs to better understand the industry and market trends and (2) generally developed solar PPAs to recognize positive financial value or breakeven.(Summary Only)

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of Veterans Health Administration facilities’ quality, safety, and value (QSV) programs. This evaluation examined committee processes for QSV oversight functions, protected peer reviews of clinical care, utilization management, and patient safety.This report describes QSV-related findings from healthcare inspections performed at 36 Veterans Health Administration medical facilities from November 4, 2019, through September 21, 2020. Each inspection involved interviews with key staff and reviews of clinical and administrative processes. The OIG reviewers evaluated meeting minutes, protected peer reviews, root cause analyses, annual patient safety reports, and other relevant documents. The results in this report are a snapshot of Veterans Health Administration 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 in various key QSV functions, noted repeat findings from the fiscal year 2018 and 2019 QSV evaluations, and issued four recommendations related to the• implementation of action items recommended by committees responsible for QSV oversight,• peer review of all applicable suicide deaths,• inclusion of required processes in root cause analyses, and• implementation and monitoring of action items resulting from root cause analyses.

We are pleased to provide the Office of Inspector General (OIG) Quarterly Audit Recommendation Status Report. As of July 30th, 2021, there are 81 open recommendations, 36 of which are considered “Overdue,” and another 26 reported by management as “Implemented.” Since the date of the OIG’s last semiannual report to Congress, dated March 31st, 2021, 13 new recommendations were added, and no recommendations were closed.

The VA Office of Inspector General (OIG) reviewed allegations referred by Congressman Ron Kind regarding the care of a patient at the Tomah VA Medical Center (facility) who subsequently died from a presumed anoxic brain injury.The OIG did not substantiate staff over-sedated the patient. The OIG found that physicians’ failure to provide adequate benzodiazepine dosing to address the patient’s delirium tremens, review the patient’s abnormal electrocardiogram prior to haloperidol administration, and transfer the patient earlier likely contributed to the patient’s deterioration and ultimate death.The OIG substantiated that a non-VA paramedic documented that the oxygen flow was not active. Facility leaders and staff reported lack of knowledge about the failed oxygen delivery. The OIG did not substantiate that staff failed to document non VA emergency medical services.Nursing staff did not complete all required alcohol withdrawal assessments. A physician improperly ordered restraints, nurses failed to obtain full vital signs while the patient was in restraints, and nurses did not receive restraint training as expected.The OIG substantiated that facility leaders and staff did not communicate initiation of emergency detention with the patient’s family; however, notification is not required. Leaders did not conduct an institutional disclosure with the patient’s family timely or in person and did not provide a relevant update.The OIG made 10 recommendations to the Facility Director related to education regarding alcohol withdrawal, cardiac risks, review to determine causes of failed oxygen delivery, root causes and performance deficiencies, workgroup outcome, alcohol withdrawal assessment protocol adherence, restraint management and training, compliance with admission criteria, emergency detention, and institutional disclosure.

Our objective was to evaluate the effectiveness of U.S. Postal Inspection Service policies and procedures for managing cryptocurrency in its law enforcement activities. Cryptocurrency is a decentralized form of digital currency that uses a blockchain, or public ledger, to record transactions. The anonymity of cryptocurrency transactions and the significant fluctuations in the value of cryptocurrency create opportunities for abuse or theft when used during law enforcement activities. We evaluated the Postal Inspection Service’s use and seizure of cryptocurrency in cases closed in fiscal years (FY) 2019 and 2020. The Postal Inspection Service established the Cryptocurrency Fund Program (the Program) in 2017 to establish standards and policies to account for cryptocurrency transactions and reduce operational risk.

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 had fully implemented them. The list omits information that the Department of Justice 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.

The OIG found that, over the past decade, the Postal Service has focused its technology development efforts on two areas: mail innovations and data analytics. The Postal Service’s recently released Delivering for America: Our Vision and Ten-Year Plan to Achieve Financial Sustainability and Service Excellence indicates that these technologies are and will continue to be a priority going into the future. Other emerging technologies that are expected to grow in importance in the near future are the Internet of Things, autonomous vehicles, and blockchain. Making effective use of new and emerging technologies will enable the Postal Service to become a more efficient organization that exceeds its customers’ expectations.

The purpose of this flash report is to share with the U.S. Department of Education (Department) observations made by the Office of Inspector General (OIG) concerning grantees and subgrantees inconsistently reporting audit data on Department subprograms, or unique components of a program, to the Federal Audit Clearinghouse (FAC), the designated repository of single audit data. We found that grantees and subgrantees are not consistently reporting expenditures of Education Stabilization Fund (ESF) subprogram awards in the FAC. Specifically, when entering Federal award information into the Data Collection Form, grantees and subgrantees either (1) did not identify which ESF subprogram their expenditures were awarded under or (2) used widespread variations of subprogram identifying information to identify which subprogram their expenditures were awarded under.

Although ICE had controls in place that required Capgemini Government Solutions, LLC to provide qualified labor, ICE did not properly construct or monitor the contract. This occurred because ICE awarded a firm-fixed-price contract but required a labor-hour performance measurement to monitor and track work hours, which was not appropriate for this type of contract. The contractor also did not provide the number of staff ICE required for specific labor categories. As a result, ICE cannot ensure it received all services, and it overpaid $769,869 in labor costs. Finally, ICE did not ensure the contractor met statement of work requirements for staff skill sets, education, and work experience, nor did it ensure all contractor staff worked at the designated place of performance

We did not substantiate the allegation that the WV Department of Environmental Protection showed preferential treatment to the West Virginia Governor.

During our audit period, CGS was a subsidiary of BCBS South Carolina, whose home office is in Columbia, South Carolina. CGS performed Medicare work upon being awarded the MAC contracts for Medicare Durable Medical Equipment (DME) Jurisdiction C and Medicare Parts A and B Jurisdiction 15 (including home health and hospice services), effective September 27, 2006, and July 8, 2010, respectively. , CGS continues to perform Medicare work for DME Jurisdiction C (re-awarded August 31, 2012) and Medicare Parts A and B Jurisdiction 15. During our audit period, CMS and BCBS South Carolina entered into an agreement called the “Advance Agreement on the Computation of Nonqualified Defined-Benefit Pension Plan Costs for Periods Beginning January 1, 2015” (agreement). This agreement allowed BCBS South Carolina to change its accounting methodology from a pay-as-you-go to an accrual method. This agreement also closed costs prior to January 1, 2015. Starting with January 1, 2015, the Excess Plan would, under the terms of this agreement, have three Medicare segments: (1) Palmetto Government Benefits Administrator, LLC (Palmetto), (2) Companion Data Services, LLC (CDS), and (3) Partial Medicare. This report addresses CGS’s compliance with the provisions of the Federal requirements and its Medicare contracts in claiming Excess Plan costs. We are addressing the Excess Plan costs claimed for the Palmetto and CDS Medicare segments in separate audits. The disclosure statement that CGS submits to CMS states that CGS uses pooled cost accounting. Medicare contractors use pooled cost accounting to calculate the indirect cost rates (whose computations include pension plan, Excess Plan, Supplement Executive Retirement Plan III, and PRB plan costs) that they submit on their ICPs. Medicare contractors use the indirect cost rates to calculate the contract costs that they report on their ICPs. In turn, CMS uses these indirect cost rates in determining the final indirect cost rates for each contract. Blue Cross Blue Shield of South Carolina Excess PlanBCBS South Carolina sponsors the Excess Plan. The purpose of the Excess Plan is to provide benefits in excess of the limits imposed by the Employee Retirement Income Security Act of1974 for participants in BCBS South Carolina’s qualified defined-benefit plan.

During our audit period, CGS was a subsidiary of Blue Cross Blue Shield of South Carolina (BCBS South Carolina), whose home office is in Columbia, South Carolina. CGS performed Medicare work upon being awarded the MAC contracts for Medicare Durable Medical Equipment (DME) Jurisdiction C and Medicare Parts A and B Jurisdiction 15 (including home health and hospice services), effective September 27, 2006, and July 8, 2010, respectively. , CGS continues to perform Medicare work for DME Jurisdiction C (re-awarded August 31, 2012) and Medicare Parts A and B Jurisdiction 15. BCBS South Carolina sponsors a PRB plan, called the BCBS South Carolina Postretirement Health and Life Insurance Programs, which is offered to CGS employees. The purpose of this PRB plan is to provide retiree health and life insurance benefits to eligible retirees and their dependents. CGS claimed PRB costs using the accrual basis of accounting and funded those accrual costs through a Voluntary Employee Benefit Association (VEBA) trust in conjunction with a 401(h) account. The disclosure statement that CGS submits to CMS states that CGS uses pooled cost accounting. Medicare contractors use pooled cost accounting to calculate the indirect cost rates (whose computations include pension and PRB costs) that they submit on their ICPs. Medicare contractors use the indirect cost rates to calculate the contract costs that they report on their ICPs. In turn, CMS uses these indirect cost rates in determining the final indirect cost rates for each contract. Medicare Reimbursement of Postretirement Benefit CostsCMS reimburses a portion of the Medicare contractors’ annual PRB costs, which are funded by contributions that contractors make to their dedicated trust funds. The PRB costs are included in the computation of the indirect cost rates and reported on the ICPs. In turn, CMS uses indirect cost rates in reimbursing costs under cost-reimbursement contracts. Federal regulations (FAR 31.205-6(o)) require that to be allowable for Medicare reimbursement, PRB costs must be (1) measured, assigned, and allocated in accordance with Financial Accounting Standards Board (FASB) Accounting Standards Codification (ASC) 715-60 (formerly Statement of Financial Accounting Standards (SFAS) 106) and (2) funded as specified by part 31 of the FAR. In claiming costs, contractors must follow cost reimbursement principles contained in the FAR and the Medicare contracts.

Based on the results of this review, FHFA-OIG has reopened a recommendation made in AUD-2019-008, "FHFA Conducted BSA/AML Program Examinations of 10 of 11 Federal Home Loan Banks During 2016-2018 in Accordance with its Guidelines, But Failed to Support a Conclusion in the Report of Examination for the Other Bank" (July 10, 2019).

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 Eastern Colorado Health Care System. 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; 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.The system’s executive leadership team appeared stable and had worked together for over a year at the time of the OIG review. The system was recruiting for a new associate director position, and the Associate Director for Patient Care Services had been detailed to another role since March 2020. Employee survey data revealed opportunities for leaders to improve workplace satisfaction. Patients appeared satisfied with inpatient care, although the OIG noted opportunities to improve patient-centered medical home and specialty care. The OIG’s review of the healthcare system’s accreditation findings, sentinel events, and disclosures did not identify any substantial 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 sustain and improve performance.The OIG issued seven recommendations for improvement in four areas:(1) Quality, Safety, and Value• Quality management committee participation• Surgical work group attendance(2) Mental Health• Suicide prevention training(3) Care Coordination• Inter-facility transfer policy• Patient transfer monitoring and evaluation• Medical record transmission(4) High-Risk Processes• Disruptive behavior training

The U.S. Postal Service considers mail to be delayed when it is not processed in time to meet the established delivery day or when it is processed but not on the dock in time for scheduled transportation to delivery units. Delayed mail can adversely affect Postal Service customers and harm the organization’s brand.The Postal Service launched the new Mail Condition Visualization (MCV) system in January 2019. The system provides near real-time visibility of a facility’s on-hand volume, delayed processing volume, delayed dispatch volume, and oldest mail date by mail category and processing operation; and stores historical trailer information.

OIG reviewed FNS’ controls over the SNAP Online Purchasing Pilot in response to the COVID 19 pandemic.

The objective of our ongoing inspection is to evaluate FNS’ oversight of TEFAP—this report provides interim results on whether FNS identified risks related to the safeand efficient distribution of USDA-food assistance to States during the COVID-19pandemic.