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What We Looked AtMuch of the Federal Aviation Administration’s (FAA) safety oversight work is performed by its aviation safety inspector workforce, whose responsibilities include overseeing the maintenance practices of air carriers and other operators, certifying the airworthiness of new aircraft, and monitoring the work performed by individual and organizational designees. To help determine its future needs, FAA uses its inspector staffing model to produce annual forecasts of up to 10 fiscal years of inspector staffing levels. The FAA Reauthorization Act of 2018 directed FAA to update its safety-critical staffing model and our office to conduct an audit to determine the staffing model’s assumptions and methodologies and whether it accounts for FAA’s authority to fully use designees, which handle certification reviews and approvals on FAA’s behalf. Our audit objectives were to (1) assess the changes FAA made to update the inspector staffing model, (2) review the assumptions and methodologies the model uses to predict the number of aviation safety inspectors FAA needs to meet its current and future oversight responsibilities, and (3) determine how FAA’s model accounts for the use of designees. What We FoundSince 2013, FAA has taken constructive steps to improve the model but has not taken substantive action on three recommendations from the National Research Council, including developing performance measures to assess the accuracy of the model’s staffing estimates. Further, FAA has yet to implement two new models that would reflect organizational changes, and only uses the model to produce a single, national inspector staffing figure. Finally, the model accounts solely for the time inspectors spend overseeing individual and organizational designees, not the work these outside parties perform on FAA’s behalf or may perform in the future. Our RecommendationsWe made seven recommendations to improve the accuracy of FAA’s inspector staffing projections and enhance the capabilities of the staffing model. FAA concurred with five of our seven recommendations and partially concurred with two. We consider six recommendations resolved but open, pending completion of planned actions and have asked FAA to reconsider its action for one partially concurred recommendation.

We audited costs claimed and grant compliance by the Massachusetts Division of Fisheries and Wildlife under grants awarded by the FWS.

During our audit period, Palmetto was a subsidiary of Blue Cross Blue Shield of South Carolina (BCBS South Carolina), whose home office is in Columbia, South Carolina. Palmetto administers Medicare operations under the MAC contracts for Medicare Parts A and B Jurisdiction 1 and Jurisdiction 11 effective October 25, 2007, and May 21, 2010, respectively, as well as other CAS-covered and FAR-covered contracts. Currently, Palmetto is the Medicare Parts A and B contractor for Jurisdictions J and M (formerly Jurisdiction 11). Palmetto also continues to perform Railroad Retirement Board contract operations under a specialty MAC contract awarded on November 27, 2012. The disclosure statement that Palmetto submits to CMS states that Palmetto uses pooled cost accounting. Medicare contractors use pooled cost accounting to calculate the indirect cost rates (whose computations include pension, PRB, Supplemental Executive Retirement Plan and Excess 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. Medicare Reimbursement of Pension CostsCMS reimburses a portion of the annual contributions that contractors make to their pension plans. The pension costs are included in the computation of the indirect cost rates reported on the ICPs. In turn, CMS uses indirect cost rates in reimbursing costs under cost-reimbursement contracts. To be allowable for Medicare reimbursement, pension costs must be (1) measured, assigned, and allocated in accordance with CAS 412 and 413 and (2) funded as specified by part 31 of the FAR. In claiming costs, contractors must follow cost reimbursement principles contained in the FAR, the CAS, and the Medicare contracts. Previous Audits of Allocable Pension CostsWe previously reviewed Palmetto’s allocable pension costs (A-07-17-00505, Jul. 6, 2017) and the BCBS South Carolina’s allocable pension costs (A-07-17-00509, Aug. 28, 2017). Our Palmetto audit report identified allocable pension costs that Palmetto should have used when calculating its indirect cost rates for CYs 2006 through 2012. We recommended that Palmetto increase the Medicare segment pension costs used to calculate its indirect cost rates by $143,261 for CYs 2006 through 2012. Our BCBS South Carolina audit report identified Other segment allocable pension costs that BCBS South Carolina’s subsidiaries’ Medicare segments should have used when calculating the indirect cost rates for CYs 2006 through 2012. We recommended that BCBS South Carolina decrease the Medicare segment pension costs used to calculate its indirect cost rates by $6,193,748 for CYs 2006 through 2012. Incurred Cost Proposal AuditsAt CMS’s request, Figliozzi & Company CPAs P.C. (Figliozzi), the Defense Contract Audit Agency (DCAA), and CliftonLarsonAllen, LLP (Allen), performed audits of the ICPs that Palmetto submitted for CYs 2012 through 2016. The objectives of these ICP audits were to determine whether costs were allowable in accordance with applicable Federal regulations.

During our audit period, CDS was a subsidiary of Blue Cross Blue Shield of South Carolina (BCBS South Carolina), whose home office is in Columbia, South Carolina. CDS was created after being awarded the Enterprise Data Center (EDC) contract effective March 10, 2006. The EDC contract was replaced by a Virtual Data Center contract on November 15, 2012, which is still in effect. BCBS South Carolina sponsors a PRB plan, called the BCBS South Carolina Postretirement Health and Life Insurance Programs, which is offered to CDS employees. The purpose of this PRB plan is to provide retiree health and life insurance benefits to eligible retirees and their dependents. CDS 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 CDS submits to CMS states that CDS 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. Incurred Cost Proposal AuditsAt CMS’s request, Figliozzi & Company CPAs P.C. (Figliozzi), Mayer Hoffman McCann P.C. (McCann), the Defense Contract Audit Agency (DCAA), and CohnReznick (Reznick) performed audits of the ICPs that CDS submitted for CYs 2012 through 2016. The objectives of these ICP audits were to determine whether costs were allowable in accordance with applicable Federal regulations. For our current audit, we relied on the Figliozzi, McCann, DCAA, and Reznick ICP audit findings and recommendations when computing the allowable PRB costs discussed in this report. We incorporated the results of the Figliozzi, McCann, DCAA, and Reznick ICP audits into our computations of the audited indirect cost rates, and ultimately the PRB costs claimed, for the contracts subject to the FAR. CMS will use our report on allowable PRB costs, as well as the Figliozzi, McCann, DCAA, and Reznick ICP audit reports, to determine the final indirect cost rates and the total allowable contract costs for CDS for CYs 2012 through 2016. The cognizant Contracting Officer will perform a final settlement with the contractor to determine the final indirect cost rates. These rates ultimately determine the final costs of each contract.

During our audit period, Palmetto was a subsidiary of Blue Cross Blue Shield of South Carolina (BCBS South Carolina), whose home office is in Columbia, South Carolina. Palmetto administers Medicare operations under the MAC contracts for Medicare Parts A and B Jurisdiction 1 and Jurisdiction 11 effective October 25, 2007, and May 21, 2010, respectively, as well as other CAS-covered and FAR-covered contracts. Currently, Palmetto is the Medicare Parts A and B contractor for Jurisdictions J and M (formerly Jurisdiction 11). Palmetto also continues to perform Railroad Retirement Board contract operations under a specialty MAC contract awarded on November 27, 2012. BCBS South Carolina sponsors a PRB plan, called the BCBS South Carolina Postretirement Health and Life Insurance Programs, which is offered to Palmetto employees. The purpose of this PRB plan is to provide retiree health and life insurance benefits to eligible retirees and their dependents. Palmetto claimed PRB costs using the accrual basis of accounting and funded those accrual costs through a Voluntary Employee Benefit Association (VEBA) trust and in conjunction with a 401(h) account. The disclosure statement that Palmetto submits to CMS states that Palmetto uses pooled cost accounting. Medicare contractors use pooled cost accounting to calculate the indirect cost rates (whose computations include pension, PRB, Supplemental Executive Retirement Plan, and Excess 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. 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. Incurred Cost Proposal AuditsAt CMS’s request, Figliozzi & Company CPAs P.C. (Figliozzi), the Defense Contract Audit Agency (DCAA), and CliftonLarsonAllen, LLP (Allen), performed audits of the ICPs that Palmetto submitted for CYs 2012 through 2016. The objectives of these ICP audits were to determine whether costs were allowable in accordance with applicable Federal regulations.

During our audit period, Palmetto was a subsidiary of Blue Cross Blue Shield of South Carolina (BCBS South Carolina), whose home office is in Columbia, South Carolina. Palmetto administers Medicare operations under the MAC contracts for Medicare Parts A and B Jurisdiction 1 and Jurisdiction 11 effective October 25, 2007, and May 21, 2010, respectively, as well as other CAS-covered and FAR-covered contracts. Currently, Palmetto is the Medicare Parts A and B contractor for Jurisdictions J and M (formerly Jurisdiction 11). Palmetto also continues to perform Railroad Retirement Board contract operations under a specialty MAC contract awarded on November 27, 2012. 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 SERP III plan would, under the terms of the agreement, identify its segments by individual participant. These segments allocate to each of BCBS South Carolina’s Medicare subsidiaries: Palmetto; Companion Data Services, LLC; and CGS Administrators, LLC. This report addresses Palmetto’s compliance with the provisions of the Federal requirements and its Medicare contracts in claiming SERP III costs. The disclosure statement that Palmetto submits to CMS states that Palmetto uses pooled cost accounting. Medicare contractors use pooled cost accounting to calculate the indirect cost rates (whose computations include pension, postretirement benefit, SERP III, and Excess 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. BCBS South Carolina sponsors a SERP III plan. The purpose of this deferred compensation plan is to supplement participants’ benefits payable under BCBS South Carolina’s retirement plans. This plan is provided to a limited group of management employees who are responsible for earnings and long-term growth of the company. BCBS South Carolina allocated costs to the Palmetto Medicare segment. Accounting MethodologiesThe Medicare contracts require Palmetto to calculate the SERP III plan costs in accordance with the FAR and CAS 412 and 413. The FAR and the CAS require that the costs for nonqualified plans be measured under either the accrual method or the pay-as-you-go method. Under the accrual method, the allowable costs are based on the annual contributions that the employer deposits into its trust fund. For nonqualified plans that are not funded through the use of a funding agency, costs are to be accounted for under the pay-as-you-go method. This method is based on the actual benefits paid to participants, which are comprised of lump-sum payments and annuity payments. Palmetto claimed SERP III plan costs on an accrual basis. At CMS’s request, the Defense Contract Audit Agency (DCAA) and CliftonLarsonAllen, LLP (Allen), performed audits of the ICPs that Palmetto submitted for CYs 2015 and 2016. The objectives of these ICP audits were to determine whether costs were allowable in accordance with applicable Federal regulations.

During our audit period, Palmetto was a subsidiary of BCBS South Carolina, whose home office is in Columbia, South Carolina. Palmetto administers Medicare operations under the MAC contracts for Medicare Parts A and B Jurisdiction 1 and Jurisdiction 11 effective October 25, 2007, and May 21, 2010, respectively, as well as other CAS-covered and FAR-covered contracts. Currently, Palmetto is the Medicare Parts A and B contractor for Jurisdictions J and M (formerly Jurisdiction 11). Palmetto also continues to perform Railroad Retirement Board contract operations under a specialty MAC contract awarded on November 27, 2012. 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, (2) Companion Data Services, LLC (CDS), and (3) Partial Medicare. This report addresses Palmetto’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 CGS Administrators, LLC (CGS), and CDS Medicare segments in separate audits. The disclosure statement that Palmetto submits to CMS states that Palmetto uses pooled cost accounting. Medicare contractors use pooled cost accounting to calculate the indirect cost rates (whose computations include pension, PRB, Supplemental Executive Retirement Plan III, and Excess 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 Plan BCBS 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 of 1974 for participants in the qualified defined-benefit plan. Accounting MethodologiesThe Medicare contracts require Palmetto to calculate the Excess Plan costs in accordance with the FAR and CAS 412 and 413. The FAR and the CAS require that the costs for nonqualified plans be measured under either the accrual method or the pay-as-you-go method. Under the accrual method, the allowable costs are based on the annual contributions that the employer deposits into its trust fund. For nonqualified plans that are not funded through the use of a funding agency, costs are to be accounted for under the pay-as-you-go method. This method is based on the actual benefits paid to participants, which are comprised of lump-sum payments and annuity payments. Palmetto claimed Excess Plan costs on an accrual basis.

The OIG investigated allegations that a Bureau of Reclamation (BOR) employee misused a U.S. Government purchase card. Specifically, the complaint alleged that the employee deliberately overbought supplies for a BOR office and gave the excess items to a family member for personal use or sale.We did not substantiate the allegations. We concluded that all the purchases were properly authorized and were consistent with supply requirements at the facility. We also concluded the employee did not improperly dispose of any office supplies.This is a summary of an investigative report we issued to the BOR Commissioner.

Our objective was to determine whether the U.S. Postal Service is effectively managing capital equipment at the Information Technology Center (ITC) in Eagan, MN.In January 2021, the Eagan ITC had over 4,300 capital equipment items — such as computer servers — for operations, system enhancements, equipment replacement, or research and development. During calendar years 2019 and 2020, 628 items with an estimated value of $77 million were entered as capital equipment records.

We investigated a complaint of whistleblower reprisal by a former employee of a non-profit organization affiliated with the BIA.

In this audit, we examined NASA’s development of next-generation spacesuits for ISS and Artemis missions, specifically the extent to which the Agency is addressing cost, schedule, and performance challenges.

Since 1975, the Postal Service has leveraged its expansive retail network to accept passport applications on behalf of the U.S. Department of State (State Department). The State Department is primarily responsible for nationwide passport services. This includes designating entities to accept passport applications, providing passport information to the public, issuing U.S. passports, and ensuring program integrity. The Postal Service’s role is to accept passport applications at designated facilities, ensure all application documents are correct, and submit documents to the State Department. The Postal Service and State Department have an interagency agreement that governs passport acceptance. Our objective was to assess the Postal Service’s passport application acceptance operations and identify opportunities for improvement.

The NASA Office of Inspector General found the Agency appropriately managed those funds to meet congressional mandates as well as federal and Agency guidance.

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 Sheridan VA Medical Center and multiple outpatient clinics in Wyoming. The inspection covers key clinical and administrative processes associated with promoting quality care. For this inspection, the areas of focus were 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 OIG review, the leadership team had worked together for over two years. The Director, who was permanently assigned in August 2017, was the most tenured leader. Selected employee survey responses revealed satisfaction with leadership and a workplace where staff felt respected and discrimination was not tolerated. Patient experience survey results were generally higher than VHA averages for male inpatient care, but opportunities for improvement were identified for both genders in outpatient settings. Review of the facility’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risks. The executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and factors contributing to poorly performing quality and efficiency measures.The OIG issued three recommendations for improvement in three areas:(1) Quality, Safety, and Value• Peer review committee recommendation of improvement actions(2) Registered Nurse Credentialing• Primary source verification of registered nurses’ licenses prior to appointment(3) High-Risk Processes• Disruptive behavior committee attendance

The EPA could achieve cost savings and potentially put Agency funds to better use by improving compliance with BPA requirements.

DOL's reported Unemployment Insurance improper payment rate of 9.17 percent is compliant with Payment Integrity Information Act of 2019, it is not representative of total unemployment expenses for program year 2020. This occurred for the following reasons: (1) DOL excluded CARES Act of 2020 because these unemployment payments were not in existence for more than 12 months, and (2) DOL received direction from Office of Management and Budget to utilize the results from the first three quarters of the program year. This allowed state workforce agencies to suspend work on improper payment sampling to reduce the burden on program resources. The DOL-OIG's initial pandemic audit and investigation work indicate UI program improper payments, including fraudulent payments, is likely higher than 10 percent.

Effective January 1, 2015, the Centers for Medicare & Medicaid Services (CMS) established a policy for Medicare to pay under the Medicare Physician Fee Schedule for chronic care management (CCM) services rendered to beneficiaries whose medical conditions meet certain criteria. Effective January 1, 2017, CMS unbundled complex CCM from noncomplex CCM and began paying separately for complex CCM. Although scope of service and billing requirements are the same for noncomplex CCM as for complex CCM, the two types of services differ as to clinical staff time, medical decisionmaking, and care planning. CCM services are a relatively new category of Medicare-covered services and are at higher risk for overpayments. This audit expands on the findings of a previous OIG audit.

During our audit period, CDS was a subsidiary of Blue Cross Blue Shield of South Carolina (BCBS South Carolina), whose home office is in Columbia, South Carolina. CDS was created after being awarded the Enterprise Data Center (EDC) contract effective March 10, 2006. The EDC contract was replaced by a Virtual Data Center contract on November 15, 2012, which is still in effect. Upon creation of the CDS Medicare segment, BCBS South Carolina and CDS elected to follow CAS regulations regarding segmented accounting. The disclosure statement that CDS submits to CMS states that CDS 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 Pension CostsCMS reimburses a portion of the annual contributions that contractors make to their pension plans. The pension costs are included in the computation of the indirect cost rates reported on the ICPs. In turn, CMS uses indirect cost rates in reimbursing costs under cost-reimbursement contracts. To be allowable for Medicare reimbursement, pension costs must be (1) measured, assigned, and allocated in accordance with CAS 412 and 413 and (2) funded as specified by part 31 of the FAR. In claiming costs, contractors must follow cost reimbursement principles contained in the FAR, the CAS, and the Medicare contracts. Previous Audits of Allocable Pension CostsWe previously reviewed CDS’s allocable pension costs (A-07-17-00511; Aug. 28, 2017) and BCBS South Carolina’s allocable pension costs (A-07-17-00509; Aug. 28, 2017). Our previous CDS audit report identified allocable pension costs that CDS should have used when calculating its indirect cost rates for CYs 2008 through 2012. We recommended that CDS increase the allocable pension costs for CYs 2008 through 2012 by $30,436. Our previous BCBS South Carolina audit report identified Other segment allocable pension costs that its subsidiaries’ Medicare segments should have used when calculating BCBS South Carolina’s indirect cost rates for CYs 2006 through 2012. We recommended that BCBS South Carolina decrease the allocable pension costs used to calculate its Medicare segments’ indirect cost rates for CYs 2006 through 2012 by $6,193,748. Incurred Cost Proposal AuditsAt CMS’s request, Figliozzi & Company CPAs P.C. (Figliozzi), Mayer Hoffman McCann P.C. (McCann), the Defense Contract Audit Agency (DCAA), and CohnReznick (Reznick) performed audits of the ICPs that CDS submitted for CYs 2012 through 2016. The objectives of these ICP audits were to determine whether costs were allowable in accordance with applicable Federal regulations. For our current audit, we relied on the Figliozzi, McCann, DCAA, and Reznick ICP audit findings and recommendations when computing the allowable pension costs discussed in this report. We incorporated the results of the Figliozzi, McCann, DCAA, and Reznick ICP audits into our computations of the audited indirect cost rates, and ultimately the pension costs claimed, for the contracts subject to the FAR. CMS will use our report on allowable pension costs, as well as the Figliozzi, McCann, DCAA, and Reznick ICP audit reports, to determine the final indirect cost rates and the total allowable contract costs for CDS for CYs 2012 through 2016. The cognizant Contracting Officer will perform a final settlement with the contractor to determine the final indirect cost rates. These rates ultimately determine the final costs of each contract.

An Amtrak trackman/flagman based in Chicago, Illinois, resigned from employment on August 5, 2021, prior to his administrative hearing. Our investigation found that the former employee violated company policies by driving and operating company-owned vehicles without a valid driver’s license on a routine basis. We further determined that he was arrested and convicted on two occasions for operating a vehicle while intoxicated and did not report the incidents to the company as policy required.

Our objective was to determine whether NIST is complying with the requirements of the CARES Act. Specifically, we determined (1) what steps NIST took to implement and comply with the CARES Act, (2) challenges NIST faced during implementation, and (3) NIST’s status in the processing of applications and awarding funds under the CARES Act. Overall, we found that NIST implemented and followed the requirements of the CARES Act and applicable grant award policies and procedures. In addition, NIST implemented measures to mitigate challenges resulting from an increased workload and a forced transition to a virtual work environment prompted by the COVID-19 pandemic, and is on track to fully obligate and expend all CARES Act funds before September 30, 2021.

The Defense Department estimates that two of every three sexual assaults suffered during military service go unreported. As a result, evidence of the trauma can be difficult to subsequently produce or validate, posing a special challenge for VA when processing related veterans’ benefit claims for posttraumatic stress disorder.In response, the Veterans Benefits Administration (VBA) has established special procedures to help veterans support their claims when they do not have the evidence or documentation usually required. However, in an August 2018 report, the VA Office of Inspector General (OIG) found that about half of the military sexual trauma claims denied between April 1 and September 30, 2017, were not properly processed under VBA procedures, resulting in premature denial. These premature denials could have resulted in veterans not receiving the benefits they deserved. The OIG made six recommendations intended to help VBA review and correct all prematurely denied claims since October 1, 2016, and to better process them in the future.This report examined whether VBA effectively implemented the OIG’s 2018 recommendations and found that processors did not always follow the updated policies and procedures. VBA leaders did not effectively implement the OIG’s recommendations and did not ensure adequate governance over military sexual trauma claims processing. The OIG concluded that VBA was not properly implementing the recommended changes.The OIG recommended the acting under secretary for benefits should establish a formal procedure to correct all claims processing errors identified by the OIG. The OIG also recommended the acting under secretary fix continuing military sexual trauma claims processing deficiencies and strengthen controls to effectively implement and promote compliance with the OIG’s 2018 recommendations. Lastly, the acting under secretary should ensure VBA strengthen communication, oversight, and accountability for the processing of military sexual trauma claims.

The VA Office of Inspector General (OIG) conducted a review of select activities and challenges of Military Sexual Trauma (MST) Coordinators and Veterans Integrated Service Network Points of Contact in response to a request from Congressman Chris Pappas, Chairman of the House Veterans’ Affairs’ Subcommittee on Oversight and Investigations, and Congresswoman Julia Brownley, Chairwoman of the Women Veterans Task Force. The OIG also reviewed the culture of safety for patients requesting MST-related care.Sexual trauma experienced while serving in the military affects both women and men with potentially serious and long-term consequences. Psychological trauma, such as MST, also increases risk of physical health conditions such as cardiovascular disease, stroke, and diabetes. The Veterans Health Administration requires that each facility has a designated MST Coordinator with at least 20 percent of their time dedicated to protected administrative time.The OIG conducted a national survey and interviews to evaluate MST Coordinators duties and perceived challenges. Approximately 80 percent of the respondents reported having been assigned at least 20 percent or more of protected time. Thirty-nine percent reported inadequate resources to fulfill MST Coordinator administrative responsibilities. Based on analysis of survey results and interview information, the OIG found that insufficient protected administrative time, role demands, insufficient support staff, and inadequate funding and outreach materials challenged MST Coordinators’ ability to fulfill role responsibilities.Additionally, the OIG found that MST Coordinators who reported more dedicated time than other MST Coordinators did not necessarily serve at facilities with higher numbers of patients in MST related care.The OIG made one recommendation to the Under Secretary for Health to evaluate the sufficiency of current guidance and operational status regarding protected administrative time, administrative staff support, and funding for outreach, education, and special project resources, with consideration of MST Coordinators’ responsibilities, and take action as warranted.

The Transportation Security Administration (TSA) partially complied with the Act by establishing operational processes for routine activities within its Explosives Detection Canine Team (EDCT) program for surface transportation. Specifically, TSA has a national training program for canines and handlers, uses canine assets to meet urgent security needs, and monitors and tracks canine assets. However, TSA did not comply with the Act’s requirements to evaluate the entire EDCT program for alignment with its risk-based security strategy or develop a unified deployment strategy for its EDCTs for surface transportation. We recommended that TSA coordinate with its law enforcement agency partners to conduct an evaluation of the EDCT program and develop an agency-wide deployment strategy for surface transportation consistent with TSA's Surface Transportation Risk-Based Security Strategy. TSA concurred with both recommendations.

The Office of the Inspector General conducted a review of the Generation Services, Field Services organization to identify factors that could impact Field Services' organizational effectiveness. During the course of our evaluation, we identified many positive behaviors for engagement; however, we also identified needed improvements in behaviors in relation to first-line supervisors in three departments. We also identified risks to business operations, including experience, resource needs, such as funding, and staffing, and concerns related to reorganization efforts involving engineering. In addition, business partners discussed concerns, including areas for improvement related to support and collaboration.

The Veteran-Directed Care (VDC) program provides veterans with a budget to hire caregivers and purchase the goods and services that will best meet their needs and allow them to remain in their homes longer. The Veterans Health Administration (VHA) administers the program to maximize veterans’ functional independence and prevent or lessen the burden of disability on older, frail, and chronically ill patients, as well as their families and caregivers.Since fiscal year (FY) 2017, the VDC program has grown significantly. The number of veterans in the program has more than doubled to 4,400 in FY 2020. During this time, VDC program expenditures have increased by about 97 percent. The VA Office of Inspector General (OIG) audited the program to determine if VHA budgets and manages resources to ensure veterans in the program receive authorized goods and services to help them remain in their homes.The OIG found that VHA provided VDC services to veterans that addressed their care needs. However, due to weaknesses in program management, VHA lacks assurance that veterans are safe, provider agencies are paid correctly, and taxpayer dollars are properly spent. The OIG also identified opportunities for VHA to improve VDC policies and funding to ensure medical facilities can effectively implement and manage the program to help veterans stay in their homes.The OIG recommended the under secretary for health ensure program coordinators document their quarterly monitoring of the services veterans receive, improve the provider agency billing and payment process, and establish guidance to ensure veterans do not receive the same personal care services through the VDC program and the Family Caregiver Program. The OIG also recommended establishing procedures to assist in identifying staffing needs and tracking demand for program services.

The PRAC’s objective was to review pandemic-related federal contracts and identify first-time contractors and contracts awarded without competitive bidding. We found that first-time federal contractors received $4.4 billion worth of pandemic contracts in Fiscal Year 2020 and that $128 million was deobligated from contracts with first-time federal contractors during the same period. Additionally, we identified the four most common flexibilities identified to justify limited competition were urgency, only one source, simplified acquisition procedures, and authorized by statute. Of these, we found that 11% of non-competitive contracts used the “only one responsible source” authority, which is defined to be used when supplies and services are available from only one source in certain conditions. A limited sample revealed that 10 of 14 contracts either shouldn’t have selected that authority or had data entry errors within the Federal Procurement Data System.

This compendium analyzes currently open and unresolved recommendations. From March 2017 through March 2021, the EPA OIG issued nine semiannual reports to Congress that identified an average of 99 open recommendations and 18 unresolved recommendations issued by the OIG to the EPA. The total potential monetary benefit was, on average, $167 million for the open recommendations and $7.5 million for the unresolved recommendations.

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 Mann-Grandstaff VA Medical Center and multiple clinics in Idaho, Montana, and Washington. The inspection covers 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; Medical Staff Privileging; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment.At the time of the OIG site visit, the leadership team had worked together for about one month and had vacancies in two of four positions. Employee satisfaction survey results for the medical center and leaders were similar to or higher than Veterans Health Administration averages. Patients generally appeared satisfied with the care provided, but indicated opportunities to improve appointment scheduling for female veterans. The OIG’s review of accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors, but the OIG noted potential risks with the medical center’s expected electronic health record system implementation. 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 13 recommendations for improvement in five areas:(1) Quality, Safety, and Value• Protected peer reviews• Root cause analyses(2) Medical Staff Privileging• Focused professional practice evaluations(3) Mental Health• Patient follow-up• Suicide prevention safety plans• Community outreach activities• Suicide risk training(4) Women’s Health• Gynecologic care coverage• Women veterans health committee• Quality assurance data collection and tracking• Women veterans program manager duties(5) High-Risk Processes• Annual risk analysis• Competency assessments

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the leadership performance and oversight by Veterans Integrated Service Network (VISN) 20: VA Northwest Health Network in Vancouver, Washington, covering leadership and organizational risks and key processes associated with promoting quality care. This inspection focused on Quality, Safety, and Value; Medical Staff Credentialing; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. The OIG conducted this unannounced review during concurrent virtual site visits of VISN 20 facilities.The executive leaders had worked together for approximately one month at the time of the OIG virtual review. The VISN office and leaders’ selected employee satisfaction survey averages were generally better than VHA averages, with the exception of the Deputy Network Director and Chief Medical Officer’s scores. Overall, VISN leaders appeared to maintain an environment where employees felt safe bringing forth issues and concerns. Patient experience survey scores were similar to or better than VHA averages. Leaders were knowledgeable within their scope of responsibilities about selected data used in Strategic Analytics for Improvement and Learning models and should continue to sustain and improve performance.The OIG issued four recommendations for improvement in two areas:(1) Medical Staff Credentialing• Credentials file review and approval for physicians with potentially disqualifying licensure actions(2) High-Risk Processes• Sharing of VISN-led facility reusable medical equipment inspection results with executive leaders• Posting of inspection results to the reusable medical equipment SharePoint site• Oversight of facility corrective action plan development and action item tracking

Over the past 20 years, digital diversion of communication, growth in ecommerce, changing customer needs and expectations, and new sources of competition have transformed the mail and parcel industry. In this white paper, the OIG researched public and private organizations with similarities to the Postal Service that managed to adapt and succeed in other disrupted markets. We highlighted specific insights from these case studies that can be informative for the Postal Service as it sets its strategies for the future.

We conducted a performance audit of two National Endowment for the Arts (Arts Endowment) Partnership awards issued to the Washington State Arts Commission (ArtsWA). Based on our review, we determined ArtsWA generally met the financial and compliance requirements in the award documents. However, we identified some areas requiring improvement. For instance, we found that ArtsWA: included $31,000 in unallowable cost share on its Federal Financial Reports (FFRs); included $19,458 in unallowable entertainment costs on its FFRs; did not notify all subrecipients of Federal subaward management requirements; and did not verify potential vendors were eligible to receive Federal funds. We believe the evidence obtained during the audit provides a reasonable basis for our findings and conclusions based on our audit objectives. We are questioning $50,458 ($31,000 plus $19,458) in unallowable costs. We also made six recommendations to address the audit findings -- four to ArtsWA and two to the Arts Endowment.

The VA Office of Inspector General (OIG) reviewed allegations referred by Chairman Mark Takano, House Committee on Veterans’ Affairs, regarding deficiencies in the mental health care provided at the Ralph H. Johnson VA Medical Center (facility) to a high risk for suicide patient who died by suicide.The OIG did not substantiate that service agreement procedures resulted in inadequate psychiatric monitoring or delayed psychiatric care or that facility staff delayed placement of the patient’s high risk for suicide patient record flag.The OIG found that staff did not adequately evaluate the patient’s condition when reviewing the patient’s high-risk status. Facility staff did not assign a Mental Health Treatment Coordinator (MHTC) prior to discharge or establish a facility MHTC policy, as required. The Recovery Engagement and Coordination for Health – Veterans Enhanced Treatment (REACH VET) provider did not outreach the patient, as required.Facility staff did not comply with Veterans Health Administration suicide risk assessment procedures and did not notify facility leaders or suicide prevention staff of the patient’s death by suicide.The OIG made five recommendations to the Facility Director related to high risk for suicide patient record flag reviews, MHTC assignment, REACH VET program requirements, suicide risk assessment, and staff notification of patients’ death by suicide.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate concerns related to Ralph H. Johnson VA Medical Center (facility) staff’s management of a patient’s reported perpetration of intimate partner violence (IPV). The OIG also evaluated concerns related to the IPV Assistance Program (IPVAP) implementation at the facility.The OIG found that despite the patient’s and spouse’s IPV reports, inpatient mental health unit staff did not consult with the IPVAP point of contact or ensure the spouse felt safe with the patient returning home upon discharge. The inpatient psychiatry resident did not timely complete a progress note addendum, which resulted in other clinicians not having access to critical IPV related information for 34 days. Facility staff failed to consider consultation with the Office of Chief Counsel although the Veterans Health Administration (VHA) advises employees to “work with your Office of Chief Counsel” regarding state reporting requirements for victims of IPV. Outpatient mental health staff did not consult with the IPVAP point of contact or document discussion of IPV resources or treatment options, as the OIG would have expected. The Facility Director did not ensure development of an IPVAP protocol, as required, and although a licensed independent provider was appointed as the IPVAP coordinator, facility staff and leaders did not identify the assigned IPVAP coordinator as a resource at the time of the patient’s care in 2019. The OIG also found that VHA guidance about IPV training responsibilities was unclear.The OIG made one recommendation to the Under Secretary for Health related to IPV training guidance and three recommendations to the Facility Director related to staff consultation with the IPVAP coordinator, timely clinical documentation, and consultation with the Office of General Counsel to determine reporting requirements.

We found that NPS employees did not follow compliance and protection requirements for archeological resources in Virgin Islands National Park.

Every Postal Service-owned vehicle is assigned a Voyager credit card to pay for its commercially purchased fuel, oil, and routine maintenance. OIG data analytics identified offices with potentially fraudulent Voyager card activity. The Wilmington, NC, Magnolia Station had 1,713 transactions at risk from October 1, 2020, through March 31, 2021, totaling $41,211. This included 282 Voyager card fuel purchases conducted with one employee’s PIN and valued at $6,084 and 60 transactions flagged as high-risk in FAMS. The objective of this audit was to determine whether Voyager card PINs were properly managed, and Voyager card transactions were properly reconciled at the Wilmington, NC, Magnolia Station.

Final Management Letter: Review of the SEC's Compliance With CISA ED 21-01 and Initial Response to the SolarWinds Compromise

John Pangelinan, a medical marketer based in Los Angeles was sentenced on August 2, 2021, to time served and two years’ probation for conspiracy to commit honest services mail fraud and health care fraud. Pangelinan brokered kickbacks and bribe payments to doctors in exchange for their referrals of compounded medications, durable medical equipment, and other health care goods to certain providers.Our investigation found that Pharmacy Acquisition LLC provided medically unnecessary compounded drug prescriptions to Precise Compounding Pharmacy that were reimbursed by health care benefit programs, including Amtrak’s plan. As a result of the scheme, Amtrak’s insurance providers were fraudulently charged approximately $22,000.

The OIG determined whether VA complied with the requirements of the Payment Integrity Information Act of 2019 (PIIA) for fiscal year 2020. Several requirements focus on improper payments, or any payment that should not have been made or was made in an incorrect amount under statutory, contractual, administrative, or other legally applicable requirements.The review team found that VA did not comply with PIIA because it did not satisfy two of six requirements:• to meet reduction targets for two programs assessed to be at risk for improper payments, and• report an improper payment rate of less than 10 percent for five VA programs and activities that had improper payment estimates in the materials accompanying the annual financial statement.VA satisfied the other four requirements:• to post the annual financial statement for the most recent fiscal year and accompanying materials on PaymentAccuracy,• publish improper payment estimates for programs susceptible to significant improper payments in these materials,• publish corrective action plans for each program for which an estimate above the statutory threshold was published in these materials, and• conduct improper payment risk assessments for each program with annual outlays greater than $10 million at least once in the last three years.In fiscal year 2020, VA reported improper payment estimates totaling $11.37 billion for 12 programs and activities. To VA’s credit, it noted a decrease in improper payment estimates two years in a row and a decrease in its improper payment rates for nine programs and activities.The OIG recommended the under secretary for benefits ensure the Pension Program meets its reduction target. The OIG also recommended the acting deputy under secretary for health ensure the Purchased Long-Term Services and Supports Program meets its reduction target and reduce improper payments for five VA programs to below 10 percent.

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 Roseburg VA Health Care System, which includes the Roseburg VA Medical Center and three outpatient clinics in Oregon. The inspection covers 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; Medical Staff Privileging; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment.When the team conducted this inspection, the healthcare system’s leaders had worked together for 16 months, with the most tenured leader permanently assigned in 2016. Survey results revealed opportunities to improve staff feelings of “moral distress” in the workplace. Patients appeared generally satisfied, but there were opportunities to improve the experiences of women veterans.The OIG identified concerns with root cause analysis action implementation and outcomes measurement. Leaders were knowledgeable about employee satisfaction and patient experiences. However, they had opportunities to improve their knowledge of VHA data and/or system-level factors contributing to specific poorly performing Strategic Analytics for Improvement and Learning measures.The OIG issued 13 recommendations for improvement in six areas:(1) Quality, Safety, and Value• Root cause analyses(2) Medical Staff Privileging• Ongoing professional practice evaluations• Provider exit reviews(3) Mental Health• Staff training(4) Care Coordination• Goals of care conversations(5) Women’s Health• Designated women’s health providers• Women veterans health committee(6) High-Risk Processes• Standard operating procedures• Staff training• Monthly staff continuing education

The Office of the Inspector General determined some requirements of the Tennessee Valley Authority’s procedures related to arc flash protection and engineering calculations were not performed. Specifically, (1) some arc flash hazard analyses were not performed, (2) arc flash hazard analyses were not periodically reviewed, (3) some arc flash hazard analyses were incomplete or inaccurate, and (4) some hazards were not accurately communicated on warning labels as required. In addition, we found arc flash hazard calculations were not formatted, approved, or maintained as required. We also determined personal protective equipment was maintained and most training was completed as required by the arc flash procedure; however, we identified a few individuals who had not completed the assigned curriculum. Lastly, we identified an opportunity for improvement related to developing a Transmission and Power Supply specific arc flash procedure. Based on issues identified during the course of our evaluation, Transmission and Power Supply performed an assessment of its arc flash program and developed an action plan to address identified gaps.

The Peace Corps Office of Inspector General (OIG) reviewed the Peace Corps’ medicalevacuation and care of Volunteer Ezeani to determine if the agency was sufficiently prepared torespond to this medical emergency and assess whether the medical evacuation of VolunteerEzeani was appropriately managed.

While some of HUD’s efforts to improve its hiring and human capital functions and reduce its average time-to-hire have been successful, HUD’s hiring process overall was not efficient. HUD’s Office of the Chief Human Capital Officer (OCHCO), which is responsible for developing and implementing policies and procedures associated with human capital management, set a goal to reduce the average time-to-hire but did not meet this goal. OCHCO must implement efforts to improve HUD’s hiring and human capital functions and increase hiring efficiency, as defined in its own human capital operating plans.Hiring process owners, including program office hiring managers and administrative staff, received limited and inconsistent training on the hiring process and were not aware of the roles or responsibilities in the hiring process. The unclear roles and responsibilities, along with the inconsistent training, impacted HUD’s ability to hire efficiently.Additionally, OCHCO had inconsistent and unreliable hiring data due to the manual nature of the data input and the lack of interaction among the various data-tracking tools. As a result, OCHCO may not fully understand how well HUD’s hiring process is operating or where its shortcomings exist. The unreliable hiring data impede OCHCO’s and the program offices’ ability to properly identify when to take actions for improvement.We offer 11 recommendations to improve HUD’s hiring process. Six of the recommendations are aimed at process reform, and five recommendations are designed to support data improvement. The status of each recommendation is “unresolved-open.”

What We Looked AtAs the Federal Aviation Administration’s (FAA) operational arm, Air Traffic Organization (ATO) is responsible for providing safe and efficient air navigation services in U.S. controlled airspace. ATO provides air navigation services in over 17 percent of the world’s airspace and includes large portions of international airspace over the Atlantic and Pacific Oceans and the Gulf of Mexico. Until recently, FAA ATO had never applied the high-impact security categorization rating to any of its information systems. While many of these systems provide safety-critical services and would have adverse high impact to FAA’s mission in the event of system failure, and on the safety and efficiency of the National Airspace System (NAS), FAA categorized all of them as low or moderate. Given the importance of ATO’s information systems to air traffic control security and traveler safety, we initiated this audit. Our audit objectives were to assess (1) FAA’s information system categorization process and (2) the security controls that FAA has selected for the systems it recently re-categorized as high impact. Our RecommendationsFAA concurred with all six of our recommendations to enhance FAA’s categorization process, and mitigate security risks until the Agency selects and implements high security controls for its re-categorized high-impact systems. THE DEPARTMENT HAS DETERMINED THAT THIS REPORT CONTAINS SENSITIVE SECUITY INFORMATION (SSI) that is controlled under 49 CFR parts 15 and 1520 to protect Sensitive Security Information exempt from public disclosure. For U.S. Government agencies, public disclosure is governed by 5 U.S.C. § 552 and 49 CFR parts 15 and 1520. SSI will be redacted from the report version posted on our website.

The objective of the performance audit was to determine whether the Procurement List (PL) addition process was transparent and performed efficiently, effectively, and in compliance with applicable laws, regulations, and policies.To answer the audit objective, the auditors interviewed key officials and reviewed all PL additions and PL transaction data during fiscal years (FY) 2018, 2019, and 2020. The team also assessed 1) the effectiveness of the policies, procedures, and practices employed when approving the addition or removal of products and services to or from the PL, 2) Central Nonprofit Agency (CNA) processes for producing and providing PL addition packages, and 3) how the Procurement List Information Management System (PLIMS) supports the processing of additions to and deletions from the PL.Overall, the performance audit concluded that, in general, the PL additions process complied with applicable laws and regulations, and that the Commission has improved its guidance to the CNAs regarding the submission of transaction packages to PLIMS, which led to improvements in the approval rates of PL addition packages and reduced overall PL addition cycle time. There were also improvement opportunities in four areas of the Commission’s process for completing PL additions.The report offers 13 recommendations to help the Commission improve its controls over the PL additions process as well as improve the efficiency and effectiveness of the process in helping the Commission achieve its policy goals.

This report presents the results of our audit of the Vehicle, Fuel, and Oil Expenses – Birmingham, AL, Woodlawn Station Post Office. The Woodlawn Station Post Office is in the Alabama-Mississippi District of the Southern 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 objectives were to (1) identify Old-Age, Survivors and Disability Insurance beneficiaries whose benefits may have been affected by State or local government pensions and (2) determine whether the Agency implemented recommendations from our 2011 report.

Allegations of Bias Against FEC Personnel Reviewing 58Th Presidential Inaugural Committee Reports

The VA Office of Inspector General (OIG) conducted an inspection at the VA Salt Lake City Healthcare System (facility) in Utah to assess allegations of lack of care coordination and a delay in a patient receiving an anticoagulant medication, refusal to hire a community-based outpatient clinic (CBOC) pharmacist, delays in relocating the Orem CBOC, and that the Facility Director ordered patients to be bussed to the facility for care.The OIG did not substantiate a lack of care coordination. A non-VA hospital provided the patient with a discharge summary, a prescription and savings card for a one-month supply of medication, education, and a follow-up call. The non-VA hospital also provided the facility with the discharge summary and prescription.The OIG substantiated the patient’s nurse delayed care by not returning the patient’s call for assistance with obtaining the medication, and by not informing the covering provider of the patient’s request and that the patient had been off of the medication for four days. The patient died the following day.The facility conducted an internal review of the patient’s care. The OIG found that the review was incomplete and included inaccurate information and leaders were unable to determine if an institutional disclosure was warranted.The OIG did not substantiate the Chief of Pharmacy refused to hire a CBOC pharmacist, that having a pharmacist would have allowed the patient to obtain the medication, or that the Facility Director ordered patients to be bussed from the Orem CBOC to the facility for care.The OIG substantiated the Orem CBOC relocation was delayed, but the facility developed and implemented a contingency plan to address the delay.The OIG made three recommendations related to a clinical care review of the patient, root cause analysis processes, and determining the need for an institutional disclosure.

This interim report presents preliminary findings related to two Office of Audit reviews, A-08-21-51036 & A-15-21-51015. The objectives of these audits are to evaluate SSA’s management of mail and controls over its processing of Social Security card applications during the COVID-19 pandemic.

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.

Postal Service Supply Management is responsible for important components of the contract invoice payment process, which includes invoice submission, certification, and approval for payment. Suppliers can submit invoices manually or electronically as specified in the contract. Prior to payment, invoices must adhere to submission requirements and be certified. If the invoice does not meet submission requirements, the invoice certifier is required to reject it.The Postal Service is subject to the Prompt Payment Act, which requires payment of an invoice subject to the contract payment terms after receipt of goods and services. Payment terms specifying the timeframe for making payments are included in Postal Service contracts.

The Medicaid Management Information Systems (MMIS) is an integrated group of procedures and computer processing operations designed to meet principal objectives, such as processing medical claims. States report costs related to private MMIS contract services as administrative costs.Generally, the Federal Government reimburses States 50 percent of their administrative costs; however, for certain approved MMIS costs, the Federal Government reimburses 90 percent or 75 percent. States are required to obtain prior approval in an Advanced Planning Document (APD) to receive the higher reimbursement rates.For Federal fiscal years 2013 through 2017, 10 States claimed more than 50 percent of the total costs related to private MMIS contract services. Arkansas ranked 8th highest.

We investigated whether a BIA employee improperly received gifts, influenced a nonprofit’s operations, and awarded funds to a university.

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 Puget Sound Health Care System, which includes the Seattle and American Lake (Tacoma) divisions and multiple outpatient clinics in Washington. The inspection covers key clinical and administrative processes associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Medical Staff Privileging; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment.At the time of the OIG virtual review, the executive team had worked together for 16 months. The Director and the Chief of Staff had served since 2017, the Deputy Director for Patient Care Services and Associate Director had been in their positions since 2018, and the Deputy Director had served since 2019. Survey data indicated opportunities to improve employee satisfaction and reduce feelings of moral distress. Patient survey results showed that individuals were generally less satisfied with their care compared to VHA averages. Leaders were knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and actions taken during the previous 12 months to maintain and improve performance.The OIG issued 21 recommendations for improvement in six areas:(1) Quality, Safety, and Value• Committee processes• Protected peer review• Patient safety• Root cause analyses(2) Medical Staff Privileging• Focused and ongoing professional practice evaluations• Provider exit reviews(3) Medication Management• Aberrant behavior risk assessment• Urine drug testing• Informed consent• Patient follow-up(4) Care Coordination• Goals of care conversations• Life sustaining treatment decisions progress notes(5) High-Risk Processes• Climate control• Staff training and competencies• Monthly continuing education

The U.S. Department of Housing and Urban Development (HUD), Office of Inspector General, audited HUD’s Office of Multifamily Housing Programs’ health and safety complaint process. We conducted this audit due to a July 2019 explosion that occurred at the Calloway Cove Apartments, a Multifamily housing property in Jacksonville, FL, which resulted in a fire that injured several people. HUD’s Real Estate Assessment Center had identified life-threatening health and safety deficiencies at the property for several years, and there had been separate concerns related to health and safety issues at this complex, which appear to have gone unaddressed and may have led to the fire. Our audit objective was to determine whether HUD ensured that health and safety complaints associated with Multifamily Section 8-assisted housing were resolved in a timely manner.HUD’s complaint process did not ensure that health and safety complaints were resolved in a timely manner. On average, it took 2.5 days to resolve the life-threatening health and safety issues reviewed, including 3 days to resolve a gas leak issue. It took an average of 17 days to resolve the non-life-threatening health and safety issues, including 175 days to resolve an infestation problem. For the purpose of this audit, we determined reasonable benchmark resolution times to be 24 hours for resolving life-threatening health and safety issues and 72 hours for non-life-threatening health and safety issues. This condition occurred because HUD did not have a standardized, effective process for monitoring, tracking, and resolving complaints in a timely manner. As a result, Multifamily housing tenants were, in some instances, faced with unhealthy and dangerous living environments for extended periods.We recommend that the Deputy Assistant Secretary for the Office of Multifamily Housing Programs (1) develop a comprehensive process to ensure that complaints received by the Multifamily Housing Clearinghouse are resolved in a timely manner; (2) develop agencywide policies and procedures for the intake, monitoring, and tracking of health and safety complaints; (3) develop an automated real-time system for receiving, tracking, and resolving health and safety issues; and (4) revise the annual contributions contract to more clearly define contractor and property management responsibilities and deadlines for resolving health and safety issues.

Without the required testing and an effective system of internal controls, the EPA cannot make measurable progress toward complying with statutory requirements or safeguarding human health and the environment against risks from endocrine-disrupting chemicals.

From January 1, 2020, through April 30, 2021, the West Valley, AZ, Processing and Distribution Center reported 7,034 late arriving containers, about 270.9 million pieces of delayed inventory, and 180,161 delayed dispatch containers. This site was selected based on the high number of delayed dispatch containers during this time period.