Federal Reports

We reviewed the U.S. Department of Housing and Urban Development’s (HUD) information technology (IT) modernization roadmap. A significant number of HUD’s mission-essential applications have not been modernized, which presents multiple sources of risk. These applications are hosted on legacy information systems and mainframe platforms, which are operationally inefficient, increasingly difficult to secure, and costly to maintain. Historically, HUD has failed to successfully implement multiple modernization plans and projects. Leadership changes with shifting priorities and insufficient funding pose potential risk to modernization. As a result, hundreds of millions of dollars in potential savings from modernization have not been realized, and security risks have remained. Our objectives were to (1) determine the extent to which HUD has developed an IT modernization roadmap and to report on its current and future state, (2) gain an understanding of HUD’s IT modernization strategy and priorities, and (3) assess the effectiveness of the roadmap and strategy.HUD’s recent efforts to modernize key IT systems that support its programs has been well managed and resulted in positive outcomes. HUD made significant progress with implementing its multiyear modernization roadmap; formalizing its strategy for converting to modern technology; and delivering improved information systems. HUD reported that these modernization efforts result in long-term cost savings and industry efficiencies. Prior IT modernization efforts often failed, costing millions of dollars and lost resources. HUD’s Office of the Chief Information Officer (OCIO) developed an enterprisewide IT modernization roadmap in April 2020. This roadmap includes initiatives within HUD program offices, enterprise capabilities, and improving technologies, such as migrating legacy mainframe platforms to modernized cloud technologies. The roadmap includes initiatives and timelines based on an agile approach, which allows HUD to deliver new functionality incrementally, maximize flexibility, and adjust to shifting program office modernization priorities. The Federal Housing Administration (FHA), Office of Public and Indian Housing (PIH), and mainframe modernization were identified as priority modernization initiatives. This evaluation report contains two recommendations and five opportunities for improvement to assist in continued successes for future modernization efforts.

OIG data analytics identified that the Ft. Lauderdale Main Post Office had issued $126,196 in refunds for spoiled/unused postage meter stamps and customers postage and fees paid for special services from February 1, 2020, to January 1, 2021. The Ft. Lauderdale Main Post Office was the ninth largest in the nation for refunds in these categories. The objective of this audit was to determine whether postage, fees, and meter revenue refunds are valid and properly supported and processed at the Ft. Lauderdale Main Post Office.

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

We evaluated NRCS’ controls over the EWP Program relating to hurricane disaster assistance provided for Hurricanes Harvey, Irma, and Maria.

This audit is part of a series of hospital compliance audits. Using computer matching, data mining, and data analysis techniques, we identified hospital claims that were at risk for noncompliance with Medicare billing requirements. For calendar year 2017, Medicare paid hospitals $206 billion, which represents 55 percent of all fee-for-service payments; accordingly, it is important to ensure that hospital payments comply with requirements.Our objective was to determine whether Staten Island University Hospital (the Hospital) complied with Medicare requirements for billing inpatient and outpatient services on selected types of claims.

Hospitals that cannot control the spread of emerging infectious diseases within their facilities risk spreading a disease such as COVID-19 to patients and staff. OIG therefore developed a plan to assess the Centers for Medicare & Medicaid Services’ (CMS’s) controls related to hospital preparedness for emerging infectious diseases.The objective of this audit was to determine whether CMS designed and implemented effective internal controls related to hospital preparedness for emerging infectious diseases such as COVID-19.

In prior audits of school-based administrative and health services costs that States allocated to Medicaid using random moment sampling (RMS), we identified significant overpayments. After conducting a risk assessment ofKentucky’s Medicaid AdministrativeClaiming program, we determined that Kentucky claimed significant Medicaid school-based administrative costs based on its RMS. We conducted this audit because of the significant amount claimed and our prior findings related to costs that States allocated to Medicaid using RMS.Our objective was to determine whether Kentucky claimed school-based Medicaid administrative costs in accordance with Federal requirements.

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 VA Office of Inspector General (OIG) conducted a review of 58 Veterans Health Administration (VHA) outpatient clinics’ emergency preparedness for the delivery of telemental health care as of November 1, 2019. The review focused on clinic-specific emergency procedures, emergency procedure roles and responsibilities, emergency contact information of staff, and patient safety reporting methods. The review excluded telemental health care provided to patients in their homes, which was a preferred setting for pandemic telemental health care, and non-VA clinic settings.OIG staff interviewed VHA leaders from the Office of Connected Care and the Office of Mental Health and Suicide Prevention, as well as facility telehealth coordinators and mental health service chiefs or representatives from 58 patient-clinic locations. OIG distributed questionnaires to 333 telepresenters and remote providers to evaluate knowledge of the patient-clinic locations’ emergency preparedness of those 187 staff-completed questionnaires.The OIG identified the following findings that could lead to delays in patient intervention and missed opportunities for patient safety:1. Missing telehealth emergency plans and procedures2. Emergency procedures not specific to telehealth care or the patient-clinic location3. Lack of a process for annual updates to telehealth emergency procedures4. Undefined emergency procedure roles and responsibilities for telehealth staff5. Missing or insufficient emergency contact information6. Lack of a process to verify and communicate emergency contact information7. Lack of a consistent process to designate the telehealth setting in patient safety reporting methodsThe OIG made five recommendations to VHA.

Through the Veterans Cemetery Grants Program, the National Cemetery Administration (NCA) offers grants to states, US territories, and tribes to help provide final resting places for eligible veterans and family members where VA’s national cemeteries cannot meet burial needs. Grants may be used to establish, expand, or improve veterans cemeteries.The VA Office of Inspector General (OIG) audited the program to assess NCA’s governance and oversight. The audit team also assessed whether critical noncompliance issues at two cemeteries in Hawaii were addressed.The OIG found grants program staff did not rank and award some cemetery grants as regulations required. After grants were awarded, program staff generally ensured cemeteries used grants for their intended purpose. However, NCA did not ensure cemeteries with grants met all national shrine standards for installation of permanent markers, maintenance, and safety. The audit team observed noncompliance issues at eight state cemeteries, including critical issues at the Hilo and Makawao cemeteries in Hawaii. As a result, NCA lacks assurance that veterans and family members buried in state veterans cemeteries have been appropriately honored with timely and accurate grave markings, burial locations, and maintenance.The OIG made 11 recommendations to the under secretary for memorial affairs to ensure state cemetery grants are prioritized and awarded in accordance with federal regulations. The OIG also recommended NCA continue to seek an increase in cemetery grant funding.NCA should also evaluate current headstone and niche cover contracts for timeliness and quality issues, require cemeteries to submit annual performance assessments, and provide remote training options for cemetery employees. The OIG also recommended NCA work with Hawaii’s government to correct longstanding problems at its eight state veterans cemeteries.

In 2019, Congress enacted the Payment Integrity Information Act (PIIA) to update required reporting on agencies’ improper payments. PIIA requires agencies to review and identify programs and activities that may be susceptible to significant improper payments, to estimate the rate and amount of improper payments in agency programs, and to report on their actions to reduce and recover those payments. The Inspector General of each agency assesses compliance with these requirements annually.Despite continuing work to improve its compliance with PIIA and preceding improper payment legislation, AmeriCorps remains non-compliant and did not meet four of the six PIIA requirements. Specifically, three of the four programs reported that more than ten percent of their payments were improper. AmeriCorps did not appropriately establish its published reduction targets, nor did it publish a complete and appropriate corrective action plan to reduce improper payments. Furthermore, AmeriCorps did not estimate reliably the amount and the rate of improper payments made in the AmeriCorps State and National Program, Foster Grandparent Program (FGP), Senior Companion Program (SCP), and Retired and Senior Volunteer Program (RSVP), due to AmeriCorps’ sampling methodology and statistical projections.AmeriCorps attributes the decreases in the improper payments rates to the implementation of an approved third-party vendor solution that grantees may use to perform required criminal history checks, previously the primary root cause of AmeriCorps’ improper payments. Although this corrective action reduced the improper payment rates in FY 2020, AmeriCorps continued to report improper payment rates equal to or above the ten percent threshold for the FGP, SCP, and RSVP programs.AmeriCorps agreed to implement our recommendations to update its improper payment standard operating procedures, strengthen supervision and oversight of the sample selection, testing, and statistical projection procedures, and develop and implement actions to reduce the improper payment rates below ten percent for FY 2021. AmeriCorps Management’s Response can be found in Appendix C of the report.

The purpose of this flash report is to apprise the U.S. Department of Education (Department) of the risk that the Puerto Rico Department of Education (Puerto Rico DOE) used Department program funds for payroll costs related to inactive employees1 from 2007 to 2020.We found that the Puerto Rico DOE may have charged up to $1.3 million in unallowable payroll costs to the Emergency Impact Aid program.

Our audit covered 6,864 claims for which NW Hospice (located in Tigard, Oregon) received Medicare reimbursement of $31.5 million for hospice services provided from June 1, 2016, through May 31, 2018. We reviewed a random sample of 100 claims. We evaluated compliance with selected Medicare billing requirements and submitted these sampled claims and the associated medical records to an independent medical review contractor to determine whether the services met coverage, medical necessity, and coding requirements.

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 John D. Dingell VA Medical Center in Detroit, which includes multiple outpatient clinics in Michigan. 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.The medical center’s executive leadership team appeared stable, with one of the five positions permanently filled for four months at the time of the OIG’s virtual review. Employee survey results revealed opportunities for the Associate Director for Patient Care Services to improve staff satisfaction and reduce moral distress. Patient experience surveys revealed opportunities for leaders to improve patient satisfaction. The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any significant concerns. Leaders were knowledgeable selected data used in Strategic Analytics for Improvement and Learning models and should continue to sustain and improve performance.The OIG issued five recommendations for improvement in three areas:(1) Medical Staff Privileging• Provider exit review process(2) Mental Health• Suicide prevention training completion(3) Women’s Health• Women veterans health committee membership• Women veterans program manager responsibilities• Designated maternity care coordinator

The VA Office of Inspector General (OIG) determined whether Veterans Health Administration (VHA) emergency department oversight ensured patients received emergency care services in a timely manner and whether facilities made any needed improvements to the patient flow process, which is how patients move through a facility from arrival to discharge or admission. Emergency departments measure timeliness using software that records this process. Some 2.3 million patients visit VHA’s 110 emergency departments each year.The data is necessary for VHA to determine how long patients waited to be seen, treated, and discharged. The OIG found data were inconsistently entered and contained inaccuracies. The OIG recognizes that emergency department staff may provide care first out of necessity before documenting it. However, data problems hindered identification of needed improvements in the patient flow process and the effectiveness of corrective action plans.The OIG found VHA’s data and evidence in patients’ electronic health records indicated that some patients with the most critical needs did not always receive emergency care within VHA timeliness thresholds. While the patients assessed in this audit were not found to have experienced clinically significant adverse outcomes due to their wait, VHA can improve its monitoring of the data for the patients most at risk.The OIG also identified possible data manipulation by the Baltimore VA Medical Center emergency department director that made it appear patient discharge or admission times were shorter than actual wait times. The director has since been replaced.The OIG made five recommendations to improve VHA’s emergency department oversight, including ensuring the Baltimore VA Medical Center reevaluates its corrective action plan, training staff on how to accurately record triage times, strengthening reliability reviews to improve data accuracy, establishing routine oversight for data reliability, and monitoring data of patients with the most severe needs receiving emergency care.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate an allegation that improper feeding by a registered nurse (RN) at the New York Harbor Health Care System’s Community Living Center (CLC) contributed to the death of a patient. The OIG identified concerns related to inaccurate electronic health record (EHR) documentation and an inadequate facility review of the patient’s care.The OIG substantiated that improper feeding during lunch by a CLC RN contributed to the death of a patient. Approximately five hours after being fed lunch when the patient was intubated, a piece of chicken was removed from the patient’s airway. A code team physician documented two EHR notes indicating a dimension of the chicken as .8 cm in one note and 8 cm in the second note. The OIG was unable to determine the exact size of the chicken but based on the information available, concluded that the chicken did not have a dimension of 8 cm but was larger than an appropriate size to feed to the patient.CLC nursing staff did not include accurate meal consumption documentation on the day at issue. Two staff members entered an EHR note which contained differing amounts of food the patient ate at breakfast. There was no documentation the patient ate lunch.The OIG determined that facility leaders did not complete a comprehensive review of the event. The Cardiopulmonary Resuscitation Subcommittee completed an insufficient review of the code by not determining the accuracy of the EHR documentation. No staff member submitted an incident report of the adverse clinical outcome. A clinical disclosure was completed but not an institutional disclosure.The OIG made seven recommendations to the Facility Director related to nursing competencies and training, feeding documentation, review of the patient’s care, committee oversight, incident reports, and institutional disclosure.

Information technology controls protect VA systems and data from unauthorized access, use, modification, or destruction. The VA Outpatient Clinic in Austin, Texas, is VA’s largest freestanding outpatient clinic— conducting almost 300,000 outpatient visits annually. The OIG inspected this clinic to determine whether it was meeting federal guidance in four security control areas related to configuration management, physical security, security management, and access controls.The team identified security deficiencies in the clinic’s configuration management controls related to component inventory and vulnerability and patch management. Although the inspection team and VA’s Office of Information and Technology (OIT) both used the same vulnerability scanning tools, OIT did not detect 150 of the 246 vulnerabilities the team identified. OIT’s standard vulnerability identification process and scans were ineffective. The poor component inventories and vulnerability management contributed to inadequate patch management. Without these controls, VA may be placing critical systems at unnecessary risk of unauthorized access, alteration, or destruction.The team also discovered three hard drives that potentially held personally identifiable information and personal health information that were not labeled or processed for sanitization. Media protection deficiencies like these increase the risk of unauthorized disclosure of veterans’ information.The team did not identify deficiencies with the maintenance, physical, and environmental security controls or security management and access controls. The clinic’s existing policies and procedures addressed these areas, and no recommendations were made for them.The OIG recommended maintaining an accurate inventory, implementing a more effective patch and vulnerability management program, distributing the media protection standard operating procedure, and ensuring compliance with the procedure’s labeling and sanitization provisions.

Due to the importance of switching and clearances being performed safely to avoid injuries and to minimize the possibility of unscheduled outages or equipment damage, we performed an evaluation to determine if switching and clearances, required training, and audits were performed in compliance with Transmission and Power Supply’s switching and clearance procedures. We determined the selected procedural requirements for requesting and tracking of switching and clearances were generally performed in accordance with procedures. We could not assess most procedural requirements related to preparation and performance of switching orders because field personnel performing the work do not always submit the completed switching order. However, we identified several instances where switching order steps were not performed in sequence as required. We also determined employees who performed key functions received required training; however, tracking of training could be improved. In addition, while clearance audits were completed by the appropriate personnel within the required time frames, their effectiveness could be increased.

We confirmed that 15 high-risk disaster relief purchases made by the BLM and the NPS were allowable and supported by DOI and bureau policy.

The North Royalton, Willoughby, and Jesse C. Owens Post Offices are in the Ohio 1 District. The Postal Service is required to maintain a safe and healthy environment for both employees and customers in accordance with its internal policies and procedures and Occupational Safety and Health Administration (OSHA) safety laws. Our objective was to determine if Postal Service management is adhering to building maintenance, safety and security standards, and employee working condition requirements at post offices.

Contract Delivery Service (CDS) is a contractual agreement between the Postal Service and an individual or firm for the delivery and collection of mail to and from homes and businesses. The Postal Service considers CDS to be one of its three primary delivery types, in addition to city carriers and rural carriers. CDS suppliers are not Postal Service employees, but independent contractors who provide delivery on specific routes not serviced by Postal Service mail carriers. The Postal Service manages CDS contracts within the transportation functional area, which consists of a wide variety of different contracts related to transportation. In fiscal year (FY) 2020, the Postal Service had more than 7,900 active CDS contracts, which cost a total of about $447 million. Our objective was to assess whether all CDS costs are accurately captured and reliably attributed to mail products and services.

We audited the City of Houston’s Community Development Block Grant Disaster Recovery (CDBG-DR) 2015 program. Under this program, the Consolidated Appropriations Acts of 2016 and 2017 made funds available for necessary expenses related to disaster relief, long-term recovery, restoration of infrastructure and housing, and economic revitalization. We audited this program based upon the U.S. Department of Housing and Urban Development, Office of Inspector General’s (HUD OIG) 2019 audit plan priority to review disaster assistance programs. Our objective was to determine whether the City ensured that it maintained adequate supporting documentation for disbursements and its program complied with procurement requirements.We found that the City generally ensured that it maintained adequate supporting documentation for disbursements; however, it did not always ensure that its program complied with procurement requirements. Specifically, the City did not always ensure that (1) it procured its master contractor agreements in accordance with competition and other procurement requirements for its home repair program; (2) it and its subrecipients maintained documentation to support that it performed independent cost estimates and cost analyses for its home repair and housing buyout programs; or (3) it and its subrecipients included all contract provisions in awarded contracts for its home repair, housing buyout, and infrastructure programs. This condition occurred because the City did not always understand procurement requirements and ensure that its subrecipients understood and followed requirements and had adequate controls and procedures. As a result, the City could not (1) show that it awarded 12 contracts worth more than $10 million in a manner that allowed for unrestricted competition and provided the most advantage to it and HUD, (2) support the cost reasonableness of more than $1.2 million in contract disbursements, and (3) provide reasonable assurance to HUD that it had adequate procurement control systems to ensure the proper administration and expenditure of disaster funds.We recommend that HUD require the City to (1) support that it awarded contracts without restriction and in a manner advantageous to it and HUD or put the more than $9.7 million in contract awards to better use, (2) support or repay more than $1.2 million in contract disbursements, and (3) develop and implement written procedures and take actions to better ensure that it and its subrecipients meet all program procurement requirements.

Quality Review of FLRA OIG Audit Operations For The Period April 1, 2020 Through March 31, 2021

An Amtrak sheet metal worker/mechanic based in Chicago, Illinois, was terminated from employment on June 18, 2021, following his administrative hearing. Our investigation found that the former employee violated company policy by failing to disclose a conviction to the company during his employment and by using sick leave while serving time in jail and while confined to his home on electronic monitoring.

An Amtrak Foreman was terminated from employment on June 18, 2021, for misusing a General Services Administration (GSA) fuel card in violation of Amtrak policy. The employee admitted to using the fuel card from July 2019 to June 2021 to make over $7,400 in fuel purchases for his personal vehicle and vehicles belonging to other family members. The investigation was conducted with the GSA OIG.

The Office of Inspector General (OIG) evaluated whether VA’s community care staff accurately uploaded records for non-VA medical care to veterans’ electronic health records. Veterans receive non-VA care based on certain criteria, such as the distance from the veteran to the nearest VA facility or the wait time for a VA facility appointment. Records for non-VA care enable continuity of care by Veterans Health Administration (VHA) providers and inform treatment decisions.The audit team found that staff at six of the seven VA medical facilities reviewed did not always index, or categorize, these records accurately. Inaccurate indexing of medical records poses a risk to veteran care and increases the burden on the VHA staff who locate and correct the errors, reducing their time for other tasks. The team reviewed 209 veterans’ mental health medical records that VHA community care staff indexed between April 1, 2019, and September 30, 2019, and found 108 indexing errors for 92 veterans. (Some veterans’ records had more than one error.) Errors included using ambiguous or incorrect document titles, indexing records for non-VA care to the wrong referral or veteran, and entering duplicate records. These errors occurred, in part, due to inadequate procedures, training, quality checks, and quality assurance monitoring, and a lack of local facility-level policies.The OIG recommended the under secretary for health improve non VA medical records scanning and indexing by ensuring VHA facilities create and fully implement standard operating procedures. These procedures should clearly define responsibilities for Health Information Management and community care staff and the procedures for accurately scanning, importing, and indexing non-VA medical records. The OIG also recommended the under secretary ensure that Health Information Management leaders provide or formally delegate training, quality checks, and quality assurance monitoring for facility community care staff responsible for medical record management.

The Cochituate, Winchester, and John F. Kennedy Post Offices are in the Massachusetts-Rhode Island District. The Postal Service is required to maintain a safe and healthy environment for both employees and customers in accordance with its internal policies and procedures and Occupational Safety and Health Administration (OSHA) safety laws. Our objective was to determine if Postal Service management is adhering to building maintenance, safety and security standards, and employee working condition requirements at post offices.

Robert Barrows, a former Amtrak Assistant Conductor, pleaded guilty in U.S. District Court, District of Massachusetts, on June 17, 2021, to making a false statement to obtain federal employee’s compensation in 2016. Barrows falsely claimed on his unemployment benefits claim form that he had no income during the claim period when he applied for Railroad Retirement Board unemployment benefits. Our investigation was conducted jointly with the RRB Office of Inspector General.

We prepared this memorandum to provide the Office of Housing at the U.S. Department of Housing and Urban Development (HUD) information regarding the opportunity to promote a homeless waitlist preference at Multifamily Housing rental assistance properties. HUD has an opportunity to revisit the promotion and marketing of its homeless waitlist preference and the importance of partnering with a homeless service provider. Additionally, HUD can take this opportunity to make any changes to the program or adopt additional incentives to increase the likelihood of owner and agent participation. Lastly, HUD should also consider updating its public website to make it more liket that someone with limited resources and knowledge of its site can successfully identify Multifamily Housing rental assistance properties in his or her area.

Our objective was to assess the Postal Service’s management of its employees’ use of novel coronavirus disease (COVID-19) leave under the Families First Coronavirus Response Act (FFCRA). Although the FFCRA expired on December 31, 2020, the Postal Service continued to allow liberal leave usage for employees who had a sickness related to COVID‑19. On March 11, 2021, the American Rescue Plan Act was signed into law. This Act is similar to the FFCRA in that it created a new type of leave. Effective March 12, 2021, and continuing through September 30, 2021, the American Rescue Plan Act provides employees with up to 600 hours of paid leave. The OPM issued guidance on using the new leave authority on April 29, 2021.

Sound financial management practices at VA facilities are critical to ensure funds are used appropriately, effectively, and efficiently. For that reason, the VA Office of Inspector General (OIG) conducted a review to examine whether VA’s Maryland Health Care System appropriately managed purchases and payments for medical equipment and supplies. Fiscal oversight of purchase cards and internal controls governing the use of overtime were also reviewed.The OIG found ineffective processes, internal control weaknesses, and inadequate oversight in five areas:1. The healthcare system and the Enterprise Equipment Request (EER) portal need improved controls for approving equipment purchases.2. Healthcare system staff and the prime vendor should prepare timely and accurate planning information to ensure adequate supplies are on hand to fill orders.3. Even though no inaccurate inventory payments were identified, VA’s inventory system needs controls to ensure correct recording of supply units and costs.4. The healthcare system purchase card program requires closer monitoring to ensure purchases are authorized and supported by documentation.5. The healthcare system should strengthen its overtime payment controls to ensure supervisors verify overtime hours were completed before approving timecards for payment.VA concurred with all eight OIG recommendations. The OIG team also identified more than $5 million in questioned costs related to identified issues such as undocumented or unapproved purchases.

Veterans may apply for an annual clothing allowance benefit if they have a service-connected disability and use a prosthetic or orthopedic appliance or use a prescription skin medication that damages clothing. For fiscal year 2019, about 92,000 veterans received about $98 million in payments. The VA Office of Inspector General (OIG) determined whether entitled veterans received their annual clothing allowance benefit.The Veterans Benefits Administration (VBA) jointly administers the benefit with the Veterans Health Administration (VHA). VHA is responsible for administering and awarding benefits. VBA’s role is to inform veterans of potential entitlement, budget for the benefit, and provide data management and information technology support.VA generally ensured entitled veterans received their annual clothing allowance benefit. However, the OIG found that the VHA handbook needs detailed guidance on administering the benefit, including the roles, responsibilities, and functions of all staff involved.The OIG also found that some veterans may no longer meet entitlement requirements. Although most veterans are required to apply each year for benefits, those given “recurring status” are automatically renewed. To prevent overpayment errors, recurring status was eliminated in August 2012. If those cases were reevaluated, an estimated 31,200 veterans may not qualify based on changes in device design or technology. Reevaluation could save about $129.7 million over the next five years.The OIG recommended the under secretary for health revise the VHA clothing allowance handbook to include detailed procedures for determining and monitoring benefit entitlement. The OIG also recommended the under secretary, in collaboration with VBA, reevaluate veterans’ entitlement to recurring clothing allowance benefits.

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 Northern Indiana Health Care System, which includes a campus in Fort Wayne and Marion, and multiple outpatient clinics in Indiana. 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.The leaders had worked together for nine months at the time of the OIG’s virtual review. Employee survey data indicated that leaders had created a positive workplace environment where employees felt safe bringing forth issues and concerns. Patient experience surveys highlighted opportunities to improve satisfaction in the inpatient and outpatient settings. The OIG’s review of the system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. However, the healthcare system had disclosed 114 adverse events to patients and their families. Leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to sustain and improve performance.The OIG issued 20 recommendations for improvement in five areas:(1) Medical Staff Privileging• Ongoing professional practice evaluations• Provider exit review forms• State licensing board reporting(2) Medication Management• Aberrant behavior risk assessments• Urine drug testing• Informed consent(3) Mental Health• Follow-up visits• Suicide prevention safety plans• Suicide prevention training(4) Women’s Health• Gynecological care coverage• Women veterans health committee attendance(5) High-Risk Processes• Annual risk analysis• Daily cleaning schedule• Staff training and continuing education• Competency assessments

The Office of the Inspector General conducted a review of the Commercial Energy Solutions Fuels and Hedging (F&H) organization to identify factors that could impact F&H’s organizational effectiveness. During the course of our evaluation, we identified behaviors that had a positive impact on F&H. These included relationships with team members and most management. However, we also identified a behavioral risk related to relationships with a manager in one group. In addition, we identified risks to operations that could hinder F&H’s effectiveness. These risks were related to inaccurate coal burn forecasts and interactions with business partners.

We audited costs claimed by the Utah Department of Natural Resources, Division of Wildlife Resources (Division) under grants awarded by the U.S. Fish and Wildlife Service (FWS) through the Wildlife and Sport Fish Restoration Program. We conducted this audit to determine whether the Division used grant funds and State hunting and fishing license revenue for allowable fish and wildlife activities and complied with applicable laws and regulations, FWS guidelines, and grant agreements. The audit period included claims totaling $66.1 million on 76 grants that were open during the State fiscal years that ended June 30, 2018, and June 30, 2019.We found that the State generally ensured that grant funds and hunting and fishing license revenue were used for allowable fish and wildlife activities and complied with applicable laws and regulations, FWS guidelines, and grant agreements. We noted, however, issues with subawards. We found control deficiencies with the Division’s subrecipient determination, subaward reporting, and subaward agreement elements.The FWS concurred with the six recommendations and will work with the Division to implement corrective actions.

We reviewed the actions the BLM has taken to protect its employees, volunteers, and the visiting public during the COVID-19 pandemic.

Jonathan Lasko, a resident of Hollywood, Florida, pleaded guilty in the Circuit Court ofthe Fifteenth Judicial Circuit for Palm Beach County on June 15, 2021, to charges relatedto a health care fraud scheme. Lasko, who owned addiction treatment facilities inFlorida and California, engaged in a scheme where he paid kickbacks to marketers, alsoknown as “patient brokers,” for the referral of patients to his facilities. Lasko pleadedguilty to First Degree Felony Organized Scheme to Defraud and was sentenced to fiveyears of probation. He admitted to defrauding insurance companies, includingAmtrak’s insurance administrator, Aetna, in an aggregate amount exceeding $50,000.Criminal judicial proceedings for other defendants in this case are pending.

The objective of our review was to evaluate the results of Federal Student Aid’s (FSA) process for suspending involuntary collection and refunding payments involuntarily collected on defaulted Department-held loans in response to the Coronavirus pandemic.We found that FSA suspended administrative wage garnishments and the U.S. Department of Treasury (Treasury) offsets for over 96 percent of the borrowers that FSA collected payments for within 90 days of March 13, 2020, the start of the suspension period. However, as of October 23, 2020, we found that FSA continued to receive administrative wage garnishments for 1,930 borrowers.We also found that FSA refunded most administrative wage garnishments and Treasury offsets collected from March 13, 2020, through September 30, 2020, and issued refunds for $576.65 million (99 percent) of the $582.48 million collected for the same period. FSA also refunded 1,063,984 of the 1,094,507 administrative wage garnishments and 221,436 of the 244,080 Treasury offsets within 60 days from the date the payments were received. However, we found that FSA did not reprocess refunds for $21.25 million of the $576.65 million FSA refunded that were subsequently returned to Treasury and did not refund $5.83 million (1 percent) of the $582.48 million wage garnishments and Treasury offsets collected.Finally, we found that FSA did not develop procedures to obtain and track the U.S. Department of Justice’s (Justice) progress on suspending involuntary collections and refunding payments involuntarily collected on defaulted Department-held loans from March 13, 2020, through September 30, 2020.

Delays in EPA SIP actions increase the risk that state or local air agencies are not implementing plans sufficient to achieve or maintain the NAAQS.

VA medical facilities’ demand for personal protective equipment (PPE) increased dramatically during the COVID-19 pandemic. The VA Office of Inspector General (OIG) reviewed how the Veterans Health Administration (VHA) ensured the Medical/Surgical Prime Vendor-Next Generation (MSPV-NG) program and its prime vendors met contract requirements by offering medical facilities a no-cost option to develop advance-order supply lists tailored to catastrophic events and contingency plans. The OIG also assessed whether facilities took advantage of those options and strategies and relied on the contracts to obtain PPE during the pandemic.All four MSPV-NG prime vendors developed contingency plans that included the advance-order list. Three of the four vendors also offered options to purchase and store medical supplies in advance. Though the prime vendors fulfilled their contract requirements, the OIG found none of 16 medical facilities assessed took advantage of those emergency strategies before the pandemic. Most facility leaders did not know those plans existed. Most medical facilities reported maintaining their own contingency stocks, which were at risk of quickly depleting. That risk increased when prime vendors were unable to fulfill orders, leading staff to purchase medical supplies on the open market where VHA’s data showed they paid higher prices.By not asking prime vendors to provide services established in contingency plans, VA medical facilities missed opportunities to receive certain needed medical supplies. VA can apply lessons learned during the pandemic by continuing to refine its contract requirements for prime vendors to address catastrophes.The OIG recommended educating chief logistics officers on the supply strategies offered in prime vendors’ contingency plans, and ensure they understand how those strategies can help mitigate supply shortages. The OIG also recommended clarifying for local facilities the intent of the emergency and continuous supply contract provisions.

The objective was to (1) determine whether the Social Security Administration (SSA) made payments to beneficiaries and/or representative payees who were deceased according to Alabama, Georgia, or Illinois records and (2) identify non-beneficiaries in the States’ files whose death information did not appear in Agency records.

The objective was to determine whether the Social Security Administration (SSA) complied with its policies and procedures for allegations of misuse by individual representative payees (payee) who served 14 or fewer beneficiaries. Specifically, we examined SSA’s negligence determinations and whether it reimbursed beneficiaries and obtained restitution of misused funds from payees.

Jean Francois Picard, a medical marketer based in Los Angeles, was sentenced in United States District Court, Southern District of California, on June 14, 2021, to 10 months in prison and three years of probation for payment of illegal remunerations. Our investigation found that Picard paid kickbacks to other marketers for facilitating the referral of prescriptions for medically unnecessary compounded drugs and other items reimbursed by health care benefit programs. As a result of the scheme, Amtrak’s insurance providers were fraudulently charged approximately $22,000. Criminal judicial proceedings for other defendants in this case are pending.

Our objective was to determine whether actions the Social Security Administration has taken since our March 2011 report, Follow-up: Personally Identifiable Information Made Available to the Public Via the Death Master File (A-06-10-20173), effectively mitigated PII breaches.

The objective was to review six demonstration projects the Social Security Administration (SSA) has conducted since 2010 under section 234 of the Social Security Act to (1) summarize information on the demonstration projects’ work rules tested and/or services offered, costs, savings, and participant use of incentives and/or services; (2) report any resulting changes that affected SSA’s policy or program; and (3) determine whether SSA reported project results to Congress.

The Federal Emergency Management (FEMA) followed applicable laws, regulations, and guidance in its efforts to provide funding for reconstruction of the Vieques’ Community Health Center. FEMA’s assessment of the funding needs for the project is complete and $39,569,695 (Federal share) was obligated on January 21, 2020 for a full facility replacement. We did not make any recommendations but announced an audit to assess FEMA’s Public Assistance Program Alternative Procedures process for all permanent work projects.