Federal Reports

AmeriCorps, Office of Inspector General presents its Spring 2021 Semiannual Report, covering the six-month period of October 1, 2020 – March 31, 2021.

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

The VA Office of Inspector General (OIG) audited the Veterans Benefits Administration’s (VBA) handling of “proceeds” to determine whether they are completed accurately and timely. A proceed is an actionable item in the veteran’s or beneficiary’s record that is created when benefits payments are returned to VA instead of being paid, including reasons such as a change of bank account number, a change of address, or a veteran’s death.On December 18, 2019, VBA had more than 7,500 open proceeds totaling about $13 million. At that time, veterans service centers at each regional office handled compensation proceeds. Some veterans and beneficiaries had to wait months to have their funds returned to them, potentially causing financial hardship.The OIG determined that VBA generally handled proceeds accurately but did not always close them within 90 days, a benchmark the OIG used for this audit. The team reviewed 150 closed sample proceeds and determined that 96 percent were handled correctly. However, VBA took more than 90 days to close some proceeds, which totaled an estimated $2.1 million.Service and pension center staff do not have timeliness measures for proceeds incorporated in their performance standards. Setting a timeliness standard would help encourage the closing of these proceeds. The OIG also found that ineffective monitoring contributed to delays in handling proceeds. The Debt Management Center had only limited internal monitoring but instituted new practices for monitoring proceeds in February 2020, shortly after this audit began. VA concurred with the OIG’s recommendations that VBA set a standard time for closing proceeds and develop oversight and monitoring procedures to ensure proceeds are closed promptly.

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 Chillicothe VA Medical Center and multiple outpatient clinics in Ohio. 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. At the time of the virtual site visit, leaders had worked together for almost two months, while some had served in their roles for more than a year. Employee survey data revealed opportunities for the Chief of Staff to improve satisfaction in the workplace. Patients generally appeared happy with their care. The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Executive leaders were able to speak in depth about actions taken during the previous 12 months to maintain or improve employee satisfaction and patient experiences. Leaders were knowledgeable within their scope of responsibilities about data and/or factors contributing to specific poorly performing Strategic Analytics for Improvement and Learning measures.The OIG issued 12 recommendations for improvement in six areas:(1) Quality, Safety, and Value• Peer review summary reports• Root cause analysis processes(2) Medical Staff Privileging• Ongoing professional practice evaluations• Provider exit review forms(3) Medication Management• Pain management committee processes(4) Mental Health• Suicide prevention training(5) Women’s Health• Women veterans health committee membership and attendance(6) High-Risk Processes• Standard operating procedures• Airflow directional devices• Staff training and competency

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

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

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

Amtrak (the company) contracted with the independent public accounting firm of Ernst & Young LLP to audit its consolidated financial statements as of and for the fiscal year then ended, September 30, 2020, and to provide a report on internal control over financial reporting and compliance with certain provisions of laws, regulations, contracts and grant agreements, and other matters, which they issued on December 17, 2020.1 Because the company receives federal financial assistance, it must obtain an audit performed in accordance with U.S. generally accepted government auditing standards. The contract also required Ernst & Young to perform a Single Audit of the company’s federal financial assistance for the fiscal year ended September 30, 2020, in accordance with the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). The objective of the Single Audit was to test internal control over compliance with major federal program award requirements and determine whether the company complied with the laws, regulations, and provisions of contracts or grant agreements that may have a direct and material effect on its major federal programs. As required by the Inspector General Act of 1978, we monitored the audit activities of Ernst & Young to help ensure audit quality and compliance with auditing standards. Our review disclosed no instances in which Ernst & Young did not comply, in all material respects, with U.S. generally accepted government auditing standards and Uniform Guidance requirements.

The objective of our audit was to determine whether Federal Student Aid (FSA) designed and implemented processes that provided reasonable assurance that it reallocated unexpended award year 2016–2017 campus-based student financial assistance program funds in accordance with the Hurricanes Harvey, Irma, and Maria Education Relief Act of 2017.First, FSA did not design and implement processes that provided reasonable assurance that it identified all schools participating in the campus-based student financial assistance programs that were affected by or enrolled students affected by a qualifying disaster before reallocating unexpended award year 2016–2017 FSEOG and FWS funds. Second, FSA did not design and implement processes that provided reasonable assurance that it would give preference to schools located in affected areas when reallocating FWS funds.

As part of its oversight activities, OIG is conducting a series of audits of recipients of multiple HHS grants. We selected Gateway Community Action Partnership (Gateway) for this audit because it received multiple HHS Administration for Children and Families (ACF) grants, including Hurricane Sandy Disaster Relief Act grants totaling $19.7 million, and grants to operate childcare programs at more than 50 locations.Our objective was to determine whether Gateway claimed and accounted for HHS grant funds in accordance with Federal requirements.

DOL-OIG Semiannual Report to Congress Vol. 85 for the period of October 1, 2020 - March 31, 2021

This report details the Office of Inspector General's Spring 2021 Semiannual Report to Congress. The following topics are included:• Overview of the SBA and the OIG• Pandemic Response Oversight• Small Business Access to Capital• Disaster Loan Program• Procurement Assistance• Agency Management• Other Significant OIG Activities• Statistical Highlights• Appendices

The Semiannual Report to Congress summarizes the results of VA OIG oversight, provides statistical information, and lists all reports issued from October 1, 2020 to March 31, 2021. During this reporting period, VA OIG audits, evaluations, investigations, inspections, and other reviews identified more than $1.9 billion in monetary impact for a return on investment of $21 for every dollar spent on oversight. During this reporting period, the VA OIG issued 124 reports and publications on VA programs and operations, made 389 recommendations, and conducted investigations that led to 109 arrests.

What We Looked AtWe queried and downloaded 88 single audit reports prepared by non-Federal auditors and submitted to the Federal Audit Clearinghouse between January 1, 2021 and March 31, 2021, to identify significant findings related to programs directly funded by the Department of Transportation (DOT).What We FoundWe found that reports contained a range of findings that impacted DOT programs. The auditors reported significant noncompliance with Federal guidelines related to 16 grantees that require prompt action from DOT's Operating Administrations (OA). The auditors also identified questioned costs totaling $8,008,786 for nine grantees.RecommendationsWe recommend that DOT coordinate with the impacted OAs to develop a corrective action plan to resolve and close the findings identified in this report. We also recommend that DOT determine the allowability of the questioned transactions and recover $8,008,786, if applicable.

Semiannual Report to Congress of the Denali Commission Office of Inspector General for the period October 1, 2020, through March 31, 2021.

The April 2021 Semiannual Report to Congress summarizes the Office of Inspector General’s successful work completed from October 1, 2020, through March 31, 2021, to promote excellence, integrity, and accountability within the programs, operations, and management of the U.S. Department of the Interior. Our audit-related activities resulted in total monetary impacts of $2,174,176 with 246 recommendations made and 107 recommendations closed. Our investigative activities resulted in 3 indictments, 16 criminal and civil referrals, and $7,462,808 in civil settlements or recoveries.

During our review of the events surrounding the January 6, 2021, takeover of the United States Capitol, we became aware of a contractor, utilized by the Containment Emergency Response Team (CERT), who had questionable content on their website.

To promote compatibility with the Department of Defense’s electronic health record system, VA is replacing its aging record system. This requires VA medical facilities to upgrade their physical infrastructure, including electrical and cabling. The OIG determined from its audit that the Veterans Health Administration’s (VHA) cost estimates for these upgrades were not reliable. VHA’s estimates did not fully meet VA standards for being comprehensive, well-documented, accurate, and credible. The audit team projected that VHA’s June and November 2019 cost estimates were potentially underestimated by as much as $1 billion and $2.6 billion, respectively. This was due in part to facility needs not being well-defined early on. The estimates also omitted escalation and cabling upgrade costs and were based on low estimates at the initial operating sites. Because cost estimates support funding requests, there is risk that funds intended for other medical facility improvements would need to be diverted to cover program shortfalls.

This report presents the results of our self-initiated audit of Mail Delivery and Customer Service Operations at the East Stroudsburg Post Office, in East Stroudsburg, PA. The East Stroudsburg Post Office is in the Delaware-Pennsylvania 2 District of the Atlantic Area. This audit was designed to provide U.S. Postal Service management with timely information on potential scanning, mail delivery, and customer service operations risks at the East Stroudsburg Post Office.

Administrative review of a former employee's purchase of a government issued cell phone.

For our final report on the evaluation of NOAA OMAO’s Ship Fleet Recapitalization Program, our overall objective was to determine the extent to which NOAA OMAO’s acquisition fleet lifecycle processes were followed throughout the development, operation, maintenance, and sustainment of the program to meet mission requirements, with a focus on OMAO’s requirements management processes.We contracted with The MITRE Corporation (MITRE)—an independent firm—to perform this evaluation of NOAA. Our office oversaw the progress of this evaluation to ensure that MITRE performed the evaluation in accordance with the Council of the Inspectors General on Integrity and Efficiency’s Quality Standards for Inspection and Evaluation (January 2012) and contract terms. However, MITRE is solely responsible for the attached report and conclusions expressed in it.

Medicare contractors are required to separately account for Medicare segment pension plan assets based on the requirements of Cost Accounting Standards (CAS) 412 and 413.The HHS, OIG, Office of Audit Services, Region VII pension audit team reviews Medicare segment pension assets to ensure compliance with Federal regulations. Previous OIG audits found that Medicare contractors did not always correctly identify and update the segmented pension assets.Our objective was to determine whether Blue Cross Blue Shield of South Carolina (BCBS South Carolina) complied with Federal requirements and its established cost accounting practice when updating its Excess Plan Partial Medicare segment pension assets from January 1, 2015, to January 1, 2017.

Semiannual Report summarizing the activities of the Office of Inspector General

To see our report, click on the link below

Our Semiannual Report to Congress presents a snapshot of the work we did to fulfill our mission for the six-month period ending March 31, 2021. Our dynamic report format provides readers with easy access to facts and information, as well as succinct summaries of the work by area. Links are provided to the full reports featured in this report, as well as to the appendices.

Summary of accomplishments and activities the U.S. Department of Education OIG completed from October 1, 2020, through March 31, 2021

In this semiannual period, our audit, evaluation, and investigative activities identified more than $7.1 million in questioned costs, funds put to better use, and recoveries and opportunities for TVA to improve its programs and operations.

DHS needs to improve the collection and management of data across its multiple components to better serve and safeguard the public. The data access, availability, accuracy, completeness, and relevance issues we identified presented numerous obstacles for DHS personnel who did not have essential information they needed for decision making or to effectively and efficiently carry out day-to-day mission operations. Although DHS has improved its information security program and developed plans to improve quality and management of its data, follow through and continued improvement will be essential to address the internal control issues underlying the data deficiencies highlighted in the report. We made no recommendations in the summary report.

The U.S. Postal Service considers mail to be delayed when it is not processed in time to meet the established delivery day. Delayed mail can adversely affect Postal Service customers and harm the organization’s brand.The Postal Service launched the Mail Condition Visualization (MCV) system in January 2019. The application’s intent is to provide near real-time visibility of a facility’s on-hand volume, delayed inventory volume, delayed dispatch volume, and oldest mail date by mail category and processing operation. MCV receives data from handheld devices used in mail processing operations, Surface Visibility scans, and mailer documentation. The MCV application calculates delayed mail inventory daily by determining the number of mailpieces that have not received their next expected processing operation scan by 6:59 a.m. for destinating final processing operations and by 6:00 a.m. for all other operations.

Physicians managing center-based ESRD patients can be paid an MCP that covers most outpatient dialysis-related physician services provided to each Medicare beneficiary who is being treated for ESRD. , The MCP varies based on the beneficiary’s age and the number of visits during each calendar month in which the beneficiary receives ESRD-related services. Physicians report (to Medicare contractors) separate Current Procedural Terminology (CPT) codes based on the beneficiary’s age and whether they provide ESRD-related services to the beneficiary on one visit per month, two to three visits per month, or four or more visits per month. A physician who provides ESRD-related services to a beneficiary during one visit per month receives Medicare payment at a lower payment rate. A physician receives Medicare payment at a relatively higher payment rate when services are provided during two to three visits per month. To receive the highest payment amount, a physician has to provide services during at least four ESRD-related services’ visits per month. Physicians managing ESRD patients who dialyze at home are paid a single monthly rate based solely on the age of the beneficiary. Physicians must furnish at least one face-to-face patient visit per month for the home dialysis MCP service; however, Medicare contractors may waive the monthly face-to-face requirement on a case-by-case basis.

The EPA needs to document and follow established procedures to ensure scientifically sound decisions regarding pesticides.

A procurement manager was terminated from employment on May 21, 2021, after our investigation found she violated Amtrak policies by repeatedly mischaracterizing the relationship with and misrepresenting actions by our office to intimidate and coerce Amtrak employees and vendors from taking certain actions or into conducting certain actions on multiple occasions. Although the employee admitted to her misconduct, she was also evasive and provided inconsistent responses to our agents during her interview with us.

Under the Medicare Advantage (MA) program, the Centers for Medicare & Medicaid Services (CMS) makes monthly payments to MA organizations based in part on the characteristics of the enrollees being covered. Using a system of risk adjustment, CMS pays MA organizations the anticipated cost of providing Medicare benefits to a given enrollee, depending on such risk factors as the age, sex, and health status of that individual. Accordingly, MA organizations are paid more for providing benefits to enrollees with diagnoses associated with more intensive use of health care resources relative to healthier enrollees, who would be expected to require fewer health care resources. To determine the health status of enrollees, CMS relies on MA organizations to collect diagnosis codes from their providers and submit these codes to CMS. We are auditing MA organizations because some diagnoses are at higher risk for being miscoded, which may result in overpayments from CMS.This audit is part of a series of audits in which we are reviewing the accuracy of diagnosis codes that MA organizations submitted to CMS. Using data mining techniques and considering discussions with medical professionals, we identified diagnoses that were at higher risk for being miscoded and consolidated those diagnoses into specific groups. (For example, we consolidated 28 major depressive disorder diagnoses into 1 group.) This audit covered Anthem Community Insurance Company, Inc. (Anthem), for contract number H3655 and focused on seven groups of high-risk diagnosis codes. Our objective was to determine whether selected diagnosis codes that Anthem submitted to CMS for use in CMS’s risk adjustment program complied with Federal requirements.

As part of our annual audit plan, we audited costs billed to the Tennessee Valley Authority (TVA) by Stantec Consulting Services, Inc. (Stantec) to provide coal combustion residual engineering services under Contract No. 13051. The contract provided for TVA to compensate Stantec for work on either a cost reimbursable, time and material (T&M), unit rate, or fixed price basis. Our audit objectives were to determine if (1) costs were billed in accordance with the terms and conditions of the contract and <br> (2) tasks were issued using the most cost efficient pricing methodology. Our audit scope included about $55.3 million in costs billed to TVA from January 5, 2018, through February 29, 2020, of which over 99.9 percent was billed using T&M compensation terms. In summary, we determined:Stantec overbilled TVA $93,916, including (1) $73,099 for mileage rates not specified in the contract and (2) $20,817 for ineligible travel costs.The use of T&M terms on projects caused TVA to pay at least $1.65 million more than it would have if cost reimbursable payment terms had been used for those projects. Additionally, if TVA utilized cost reimbursable pricing for the remaining contract spend, they could potentially avoid $1.01 million in future costs.(Summary Only)

During this semiannual reporting period, we issued five audit reports which included $3,340,428 in questioned costs and 48 recommendations to improve agency operations and award recipient’s stewardship of Federal funds. Through our audit follow-up process, we assisted the National Endowment for the Arts (Arts Endowment) staff and award recipients in clearing 32 recommendations based on corrective actions taken. In addition, we resolved a total of 19 hotline complaints -- 16 new complaints and three from prior reporting periods. I applaud the Arts Endowment and OIG staff for pressing forward and working together when needed to avoid unreasonable and unnecessary work delays during the Pandemic. This enabled staff to continue delivering the missions of the Agency and OIG in a high quality and timely manner in spite of COVID-19, which required staff to work virtually during this period. The value-added work that we accomplished this period is due to my staff’s commitment toexcellence, continued growth, and dedicated work effort; along with the support of the Arts Endowment Acting Chairman and her staff. I look forward to continuously working with my staff, the Chairman, and her staff in promoting economy, efficiency, and effectiveness while helping to ensure integrity, excellence, and value in the delivery of the Arts Endowment mission.

Pivotal Stage – the future: Semiannual Report to Congress for October 1, 2020 – March 31, 2021.

Our objective was to assess the Postal Inspection Service’s response to mail fraud and mail theft during the COVID-19 pandemic. After we began the audit, we received a congressional request from seven members of Congress asking us to identify what actions, if any, the Postal Inspection Service had taken to address the increase in mail theft during the COVID-19 pandemic.

The objective of our inspection was to describe Federal Student Aid’s (FSA) control activities over institutional processes for completing verification and reporting verification results in accordance with Federal requirements.We found that FSA implemented control activities over institutional processes for completing verification procedures and reporting verification results. Specifically, we identified five significant control activities over these processes: (1) annual compliance audits, (2) program reviews, (3) W code reports, (4) management information system (MIS) reports, and (5) verification guidance.We found that FSA performed ongoing monitoring of the verification guidance control activity; but FSA did not monitor the other control activities on a regular basis. However, in September 2018, FSA’s Enterprise Risk Management (ERM) group issued a document titled “Verification Internal Review Report” (ERM Report) that described its separate evaluation of the processes FSA had in place to ensure institutions performed verification. We found that FSA did not address all of the control issues identified in the ERM Report and did not always determine the appropriate corrective actions or complete or document the corrective actions taken.

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Marion VA Medical Center in Illinois (facility) to review an allegation that a patient died due to complications from high cholesterol.The OIG substantiated that high cholesterol contributed to the patient’s death; however, the death certificate indicated that the primary cause of death was accidental acute multi-drug intoxication.The psychiatrist and staff failed to document providing the patient with education during a telephone encounter regarding potential side effects or adverse drug-drug interactions of medication changes.Contrary to clinical guidance, the psychiatrist prescribed long-term benzodiazepine use for a patient diagnosed with posttraumatic stress disorder. The psychiatrist also failed to address the patient’s two negative urine drug screens for a prescribed medication, and failed to address a positive urine drug screen for cannabis.Due to COVID-19, the facility failed to launch the Psychotropic Drug Safety Initiative Phase Four Plan.The primary care provider did not comply with facility policy by failing to enter a return-to-clinic order following an appointment but could not determine if this affected the patient. Primary care and behaviorial health staff did not comply with facility policy to telephone the patient or send a letter after the patient missed appointments.The OIG made five recommendations related to ensuring behavioral health staff provide and document patient education regarding possible side effects of medications and adverse drug-drug interactions; timely communicating test results; monitoring implementation of Phase Four of the Psychotropic Drug Safety Initiative; ensuring primary care staff comply with entering return-to-clinic orders; and ensuring primary care and behavioral health staff document contacts, attempted contacts, and letters sent when a patient misses an appointment.

To see our report, click on the link below

To see the report, please click the link below

To see the report, please click the link below

Why OIG Did This Audit A previous OIG review found that medical equipment suppliers could bill Medicare for a noninvasive home ventilator (NHV) as if it were being used as a ventilator, when use of a lower cost respiratory assist device or basic continuous positive airway pressure device was indicated by the patient’s medical condition.Sleep Management, LLC (Sleep Management), was among the top three suppliers of NHVs in calendar years (CYs) 2016 and 2017. Medicare paid Sleep Management $36.8 million for NHVs during our audit period. Our objective was to determine whether Medicare claims submitted by Sleep Management for the monthly rental of NHVs complied with Medicare requirements.How OIG Did This AuditWe selected a random sample of 100 claim lines for the monthly rental of NHVs submitted by Sleep Management that Medicare paid in CYs 2016 and 2017 (audit period). An independent medical review contractor reviewed supporting documentation to determine whether the claim lines complied with Medicare coverage and payment requirements.

The investigation substantiated that a TVA employee negotiated employment with a contractor for whom he approved invoices; however, he did so with the knowledge and apparent support of TVA management. After becoming an employee of the contractor, he continued to approve invoices for the contractor (now his employer) as he had done while employed by TVA. While working for the Contractor, the subject potentially had direct access to the sensitive business information of vendors in direct competition with the employing contractor.The employee did not consult TVA Ethics for guidance on this matter while still employed by TVA.

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 Cincinnati VA Medical Center and multiple outpatient clinics in Kentucky, Indiana, and Ohio. 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.Three of the medical center’s four executive leadership positions were occupied by acting staff. The Associate Director, the only permanently assigned leader, had been in the position for less than one year at the time of the OIG virtual review. Survey results revealed opportunities for the acting Chief of Staff to improve employee attitudes toward the workplace. Survey data also indicated that patients were generally satisfied with the care provided. However, gender-specific results highlighted opportunities to improve experiences in the inpatient and patient-centered medical home settings. The OIG identified concerns related to the identification of sentinel events and institutional disclosures. 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 16 recommendations for improvement in five areas:(1) Quality, Safety, and Value• Committee processes• Peer review processes• Root cause analyses(2) Medical Staff Privileging• Professional practice evaluations• Provider exit reviews(3) Mental Health• Suicide safety plans(4) Women’s Health• Designated women’s health providers• Women veterans health committee membership(5) High-Risk Processes• Standard operating procedures• CensiTrac® instrument tracking system• Eyewash station testing• Staff training

Our objective was to determine mailer compliance with Negotiated Service Agreement (NSA) provisions and evaluate the Postal Service’s oversight of NSA Contract [redacted]. We selected the NSA based on the mailer’s fiscal years (FY) 2019 and 2020 volume and revenue.