Federal Reports

We determined that U.S Customs and Border Protection’s (CBP) mail inspection processes and physical security at the John F. Kennedy (JFK) International Airport International Mail Facility (IMF) are ineffective, showing limited progress since our prior audit. CBP inspected approximately [REDACTED} of the 1.3 million pieces of mail it received during our June 2019 site visit. CBP also did not timely inspect and process mail from high-risk countries, creating unmanageable backlogs. These deficiencies were largely because of inadequate resources and guidance. Consequently, more than [REDACTED] pieces of mail were sent out for delivery without physical inspection. We made eight recommendations aimed at improving international mail processes at JFK International Airport. CBP concurred with six, but non-concurred with two of the recommendations.

Statistics on employee integrity investigation cases closed during the semiannual reporting period for FY 2018, as well as summaries of the cases.

Statistics on employee integrity investigation cases closed during the semiannual reporting period for FY 2019, as well as summaries of the cases.

Statistics on employee integrity investigation cases closed during the semiannual reporting period for FY 2020, as well as summaries of the cases.

The VA Office of Inspector General (OIG) conducted a review to assess Veterans Health Administration’s (VHA) virtual primary care response to the COVID-19 pandemic, as well as the use of virtual care by primary care providers and their perceptions of VA Video Connect (VVC) between February 7 and June 16, 2020.The COVID-19 pandemic presented significant challenges to health care delivery worldwide. One strategy initiated by VHA, in accordance with the Centers for Disease Control and Prevention recommendation to social distance, included expanding the delivery of primary care via virtual care. In VHA, virtual care has had a long-standing presence as a modality of care. Virtual care options during the pandemic included video conferencing through VVC and third-party applications, such as Skype and FaceTime, as well as telephone appointments.The OIG found face-to-face primary care encounters decreased by 75 percent and virtual encounters increased, with contact by telephone representing 81 percent of all primary care encounters during the review period. Additionally, primary care providers reported via questionnaire that VVC training and support were lacking for veterans, as was technology equipment and internet connectivity. Providers also identified challenging scheduling processes related to virtual appointment scheduling as a concern.The OIG made two recommendations to the Under Secretary for Health related to access, equipment, and VVC application training and support.

This management advisory memo identifies potential risks associated with the Veterans Health Administration’s (VHA) efforts to expedite adding new staff to meet increased demand caused by the COVID-19 pandemic. The VA Office of Inspector General (OIG) recognizes the tremendous pressure to quickly hire staff to meet unprecedented needs. To achieve VHA’s goal of bringing all new employees on duty within three days of making a tentative offer, VHA has modified or deferred tasks such as fingerprinting, background investigations, drug testing, credentialing, and preplacement physicals.The potential risks identified by the OIG may threaten VHA’s ability to safeguard veterans’ sensitive information and ensure its workforce is suitable for serving patients at VA medical facilities. The OIG organized these potential risks into three categories: (1) employees who do not have a completed fingerprint-based criminal history check may gain access to sensitive information and controlled substances; (2) delays in processing fingerprints add to a backlog of investigations; and (3) onboarding tasks are deferred—such as drug testing and credentialing—that are not being centrally monitored to ensure completion.Because these risks, if realized, could damage the trust veterans have in VA keeping their information secure and meeting employee suitability standards, this memorandum raises issues for VHA to consider in determining whether vulnerabilities and related processes warrant further review. These include possible changes to centralize governance of deferred actions to improve oversight.

The VA Office of Inspector General (OIG) conducted an inspection in response to allegations that significant failures related to the management of view alert notifications placed patients at risk. Unaddressed view alerts do not necessarily correlate to unmanaged clinical results or administrative consults; however, they will continue to accumulate until they are addressed.The OIG conducted reviews of patients with unaddressed view alerts and referred a total of 33 patients who had clinical or treatment issues that had not been adequately managed by the system for follow-up. The OIG reviewed the system’s action plans and found all plans to be acceptable.The OIG did not substantiate that at least 12 providers had each accumulated more than 5,000 view alerts, or that the system excluded teleradiologists from the requirement to communicate abnormal and critical test results to ordering providers or their designees. However, the OIG confirmed that nine providers each had more than 5,000 view alerts at some point between July 23 and December 2, 2019.The OIG substantiated that of the patients reviewed, some patient care was being compromised because abnormal laboratory and imaging results were either not managed or not managed within the required timeframe. Some patients were at risk for delayed cancer diagnoses because of the lack of timely provider follow-up. The OIG also found that the ordering providers did not consistently take appropriate actions to edit and resubmit canceled consults.The OIG determined that system leaders did not give providers clear instructions or adequate training on the prioritization of view alerts for review and disposition, documentation of actions when clearing unaddressed view alerts, and designation of surrogates.The OIG made one recommendation to the Under Secretary for Health, one recommendation to the VA Southeast Network Director, and nine recommendations to the System Director.

The OIG found several potential partnership opportunities that would allow the Postal Service to play a role in health and wellness. These include assisting in the recovery from current or future national health emergencies, disseminating information about available healthcare services, and helping facilitate access to those services. Such initiatives would prove extremely valuable to the nation.

Statistics on employee integrity investigation cases closed during the semiannual reporting period for FY 2017, as well as summaries of the cases.

OIG issues an Immediate Release and Advisory alerting Lifeline, Emergency Broadband Benefit, and Affordable Connectivity Program providers and consumers to improper and abusive enrollment practices that are part of some providers’ online enrollment processes.

We determined that the Federal Emergency Management Agency’s (FEMA) process for recovering disallowed grant funds could be improved. First, FEMA justified allowing most of the costs we questioned for noncompliance with procurement regulations without addressing the procurement deficiencies. Second, although staff in FEMA regional offices generally followed internal guidance when recovering disallowed grant costs, they did not track debt collections by the FEMA Finance Center because FEMA guidance does not require them to do so. Finally, FEMA did not update its internal guidance to comply with revised time limits of the statute of limitations in the Robert T. Stafford Disaster Relief and Emergency Assistance Act. We made five recommendations for FEMA to address identified deficiencies and revise its guidance. FEMA concurred with all five of our recommendations.

The Agency needs to improve its oversight of long-standing contractors, like CGI Federal, to improve operations and be a better steward of taxpayer dollars.

Due to the COVID-19 pandemic and the November 2020 general election, the Postal Service’s Cleveland Processing and Distribution Center (P&DC) experienced earlier than normal Peak Season mail, including package volume. This management alert responds to media and mailer concerns indicating that drivers experienced excessive wait times for drop shipments at the Cleveland P&DC. Our objective was to assess the efficiency of processing drop shipments at the Cleveland P&DC in the Northern Ohio District.

What We Looked AtTo enhance safety, the Federal Aviation Administration (FAA) and the aviation industry use data to proactively detect risks and implement mitigation strategies before accidents and incidents occur. Since 2007, FAA’s Aviation Safety Information Analysis and Sharing (ASIAS) program has drawn together a wide variety of safety data and information across Government and industry to identify emerging, systemic safety issues. In 2013, we reported that FAA had made progress implementing ASIAS, but the system lacked advanced capabilities, and aviation safety inspectors’ access to ASIAS confidential data remained limited. The FAA Reauthorization Act of 2018 directed our office to perform a follow-up review to assess FAA’s progress in improving ASIAS. Our objectives were to assess FAA’s (1) progress with implementing ASIAS and plans to improve the system, including its predictive capabilities, and (2) efforts to more widely disseminate results of ASIAS data analyses. What We FoundFAA has made progress in implementing ASIAS since our 2013 review, but work remains to improve the program. For example, by September 2020, ASIAS grew to include data from 41 airlines, which according to FAA represents 99 percent of air carrier operations. However, FAA has not yet established a robust process for prioritizing analysis requests. Also, the Agency plans to make incremental enhancements to ASIAS, but the Agency does not expect to fully integrate predictive capabilities until 2025. In addition, while FAA provides some ASIAS information to aviation safety inspectors, the Agency does not provide access to national trend information that could improve their safety oversight. Further, inspectors do not widely use non-confidential ASIAS data for air carrier oversight due to the lack of guidance and the existing availability of similar data through other FAA databases. Our RecommendationsWe made three recommendations to improve FAA’s ability to better prioritize ASIAS efforts, provide improved data to aviation inspectors, and communicate the intended use and benefits of non-confidential ASIAS data. FAA concurred with all three recommendations and provided appropriate actions and completion dates.

A Senior Engineer was arrested on March 8, 2021, for theft of Amtrak property and terminated from employment the following day. From approximately August 2016 through July 2020, the employee is alleged to have stolen approximately 77 chainsaws, approximately 103 chainsaw replacement bars, and approximately 163 replacement chains. He sold the majority of the Amtrak chainsaws and parts using an online auction service. The investigation is ongoing and is being prosecuted by the U.S. Attorney’s Office, District of New Jersey.

EAC OIG, through the independent public accounting firm of McBride, Lock & Associates LLC, audited the election security funds received by the Kentucky State Board of Elections between July 13, 2018, and September 30, 2019.

Our objective was to evaluate the U.S. Postal Service’s service performance of Election and Political Mail during the November 2020 general election. We also evaluated the handling of mail for the Georgia Senate runoff election held on January 5, 2021.The Postal Service prioritized processing of Election Mail during the 2020 general election, significantly improving timeliness over the 2018 mid-term election even with significantly increased volumes of Election Mail in the mailstream. Although timeliness was slightly below goals, proper handling and timely delivery of all Election Mail, especially ballots, was the number one priority of the Postal Service. The Postal Service also leveraged high-cost efforts such as extra transportation and overtime to improve delivery performance. Further, while our site visits did identify some delayed Election Mail and compliance issues, the Postal Service took immediate corrective actions to address the identified issues. However, we did find opportunities for the Postal Service to increase the volume of ballots included in service performance and improve its internal communication on Election Mail guidance and processes.

We determined that the Federal Emergency Management (FEMA) Region II (Region II) and New York State’s Division of Homeland Security Emergency Services (DHSES) have not adequately monitored or timely closed hundreds of projects, awarded at $578.8 million, for 7 disasters we reviewed.  We recommended that Region II and DHSES address the procedural controls in the closeout process in order to be adequately prepared for the large number and complexity of the next wave of projects ready for closeout.  We made four recommendations that will help strengthen internal controls to improve oversight of the PA grant program.  FEMA concurred with all four of our recommendations.

The VA Office of Inspector General (OIG) conducted a national review to evaluate specific elements of colonoscope reprocessing at 10 multispecialty community-based outpatient clinics (CBOCs). The OIG reviewed training oversight and documentation, colonoscope reprocessing, and environmental monitoring in sterile processing areas.Colonoscopy carries some risk with the possibility of infection acquired from improperly cleaned medical devices. The Veterans Health Administration (VHA) requires specific training during initial orientation with monthly continuing education for Sterile Processing Services (SPS) staff to maintain technical knowledge. Facility SPS chiefs are responsible for oversight of staff training.The OIG determined that CBOC SPS staff reprocessed and tracked colonoscopes and monitored the environment according to VHA requirements.The OIG identified deficiencies in training and oversight of SPS staff. The OIG found that 50 percent of SPS employees who were required to complete initial training within 90 days did not complete it in the required time frame. Service chiefs at 70 percent of the CBOCs did not ensure that training documentation was complete. The OIG determined that SPS supervisors did not ensure that SPS staff received continuing education at 20 percent of the CBOCs.The OIG made two recommendations to the Under Secretary for Health related to initial SPS training and continuing education.

The VA Office of Inspector General (OIG) assessed VA’s oversight of the Medical/Surgical Prime Vendor-Next Generation (MSPV-NG) Program, under which prime vendors maintain inventories of medical and surgical supplies and restock medical facilities when needed. Specifically, the OIG examined whether medical facility-level staff verified the accuracy of distribution fees invoiced by the prime vendors, and national- and Veterans Integrated Service Network-level staff provided proper oversight of this activity.In February 2016, VA’s Strategic Acquisition Center awarded four MSPV-NG contracts with a cumulative value of about $4.6 billion to prime vendors for medical and surgical supplies. VA pays prime vendors for requested products plus a distribution fee to cover the costs associated with managing medical facilities’ inventories. Medical facilities paid approximately $25.4 million in MSPV-NG distribution fees during fiscal year 2018, according to an official from VHA’s Procurement and Logistics Office.The OIG found VA controls were not sufficient to ensure VA medical facility staff accurately reviewed, verified, or certified distribution fee invoices for the MSPV-NG program. VA also did not ensure staff at medical facilities accurately established and applied the on-site representative rates and paid fees based on annual facility purchases. The MSPV-NG pricing schedule establishes fee rates for on-site representatives based on annual facility purchase amounts. VA establishing a flat fee rate will help mitigate on-site representative fee rate disparities, but in the interim VA still needs to ensure facilities reconcile rate disparities that have occurred and continue to occur.The OIG made 10 recommendations designed to improve oversight of verification and certification of distribution fee invoices and ensure the accuracy of on-site representative fees.

The VA Office of Inspector General (OIG) conducted this review based on a confidential allegation received in March 2019 that employees at the Chicago, Illinois, VA regional benefits office were not following the Veterans Benefits Administration’s (VBA) procedures for correcting administrative errors.To correct administrative errors, employees must complete steps such as assigning numeric codes to identify types of claims or actions needed, making and approving decisions, correcting errors in VBA’s electronic system, properly notifying veterans, and ensuring debts were not improperly created.The OIG substantiated the allegation that Chicago employees did not follow VBA procedures, and based its conclusions on the procedures in place at the time each error was corrected. VBA modified its procedures for correcting administrative errors three times after the review team began work in October 2019.The OIG found claims processors did not properly correct administrative errors in 88 percent of cases reviewed. Errors resulted in improper underpayments of about $59,100 to six veterans, improper overpayments of $18,900 to two veterans, and $5,900 in debts VA had inappropriately collected from eight veterans through January 2020. VBA concurred with all the OIG-identified errors.Generally, errors occurred because claims processors did not sufficiently understand their responsibilities and procedures for correcting administrative errors. Beginning in January 2020, VBA updated its procedures manual with more detailed instructions for controlling administrative errors, determining when administrative decisions are required, preventing debts from being created, ensuring benefits are paid through the correct date, and removing erroneous benefit information from the electronic system. Chicago managers also increased oversight of administrative errors.The OIG recommended the director of the Chicago VA regional office ensure the errors identified by the review team are corrected, monitor the effectiveness of actions taken to improve the accuracy of corrections, and determine whether additional measures are needed.

This report presents the results of our self-initiated audit of Voyager Card Transactions - Brick, NJ, Post Office. The Brick, NJ, Post Office is in the South New Jersey District of the Atlantic Area. This audit was designed to provide U.S. Postal Service management with timely information on potential financial control risks at Postal Service locations.

This audit report is one of a series of OIG reports addressing the identification, reporting, and investigation of incidents of potential abuse or neglect of our Nation’s most vulnerable populations, including the elderly and individuals with developmental disabilities. Our objectives were to determine whether Florida: (1) ensured that nursing facilities reported potential abuse or neglect of Medicaid beneficiaries transferred from nursing facilities to hospital emergency departments; (2) complied with Federal requirements for assigning a priority level, initiating onsite surveys, and recording allegations of potential abuse and neglect; and (3) operated its incident report program effectively.

We audited $212.4 million of costs billed to the Tennessee Valley Authority (TVA) by G·UB·MK Constructors (GUBMK) under Contract No. 11514 to determine if costs billed to TVA were in compliance with contract's terms. We determined the costs billed by GUBMK generally complied with the contract except for $22,545. (Summary Only)

We determined that FEMA did not ensure procurements and costs for debris removal operations in Monroe County, Florida, met Federal requirements and FEMA guidelines.  Specifically, FEMA did not adequately review local entities’ procurements for debris removal projects and reimbursed local entities for questionable costs.  These deficiencies were due to weaknesses in FEMA training and its quality assurance process.  As a result, FEMA approved reimbursement to local entities for nearly $25.6 million (more than $23 million in Federal share) for debris removal projects, including contracts that may not have met Federal procurement requirements, and more than $2 million in questionable costs.  Without improvements to FEMA’s training and project review processes, FEMA risks continuing to expose millions of dollars in disaster relief funds to fraud, waste, and abuse.  We made three recommendations with which FEMA officials concurred.  Based on the information FEMA provided, we consider the three recommendations resolved and open.  

This review examined how effectively Veterans Benefits Administration (VBA) managers fulfilled the plan VA was required to submit to Congress for a skills certification program for claims processors. The program includes a required test to ensure staff have the skills, knowledge, and abilities needed to accurately carry out their tasks.The OIG found VBA did not meet the skills certification requirements for fiscal years (FYs) 2016 through 2019. Specifically, based on a statistical sample, the OIG estimated 4,700 of 10,800 individuals required to take the exam were not tested. The program also did not provide individual training plans to about 1,900 of the 2,500 employees who failed the test, or ensure that all staff who failed took the next scheduled test. Further, VBA did not take personnel actions against an estimated 98 percent of employees who failed consecutive tests after receiving remedial training.Several factors contributed to the identified issues, including an insufficient process for identifying and notifying those required to take the test and data limitations affecting tracking. In addition, VBA did not design tests for all employees cited in the plan. Testing was cancelled in FY 2018 because of intranet technical issues and in FY 2019 to assess the effectiveness of testing.The OIG made six recommendations regarding written guidelines for individuals required to or exempted from taking tests; a tracking mechanism for eligible test takers; updates to Congress on why not all claims-processing positions are subject to testing; plans to train staff who failed tests; an oversight plan to ensure individuals who failed consecutive tests were retrained; and notifying Congress of plans to take personnel actions against individuals who fail consecutive tests after remediation, as required by law.

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) 7: VA Southeast Network in Duluth, Georgia, 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 visit during concurrent inspections of VISN 7 facilities.In September 2019, VHA reassigned the Network Director and Chief Medical Officer, and appointed acting leaders to fill their roles following reports that a Community Living Center patient was bitten by hundreds of ants. The leadership team had worked together for almost five months at the time of the visit. Selected survey scores regarding employee satisfaction revealed opportunities for the acting Chief Medical Officer to improve attitudes toward leaders and for the Deputy Network Director and Quality Management Officer to improve feelings of moral distress at work. Patient experience survey scores were lower than VHA averages. The VISN leaders have an opportunity to improve employee and patient satisfaction. The leaders seemed to support efforts to improve and maintain patient safety, quality care, and other positive outcomes.The OIG issued seven recommendations for improvement in three areas:(1) Environment of Care• VISN comprehensive environment of care program policy• VISN Emergency Management Committee processes(2) Women’s Health• Quarterly program updates to executive leaders• Annual site visits at each facility• Staff education gap assessments(3) High-Risk Processes• VISN-led facility reusable medical equipment inspection results

We determined that the Federal Emergency Management Agency (FEMA) did not ensure state and local law enforcement agencies expended FEMA’s grant for protection of the President’s non-governmental residences in accordance with Federal regulations and Agency guidelines. Specifically, FEMA’s Grant Programs Directorate (GPD) reimbursed the New York City Police Department (NYPD) for unallowable overtime fringe benefits. Additionally, GPD did not provide effective oversight to manage the PRPA grant during its application review and verification process by assigning limited, inexperienced staff whose work received minimal supervisory review. We made four recommendations to FEMA that should improve the management of the program. FEMA concurred with three recommendations and nonconcurred with one recommendation.

This report provides a summary of our previous findings and recommendations, which may inform future disaster response efforts. Based on our prior work, we identified a pattern of internal control vulnerabilities that negatively affect both disaster survivors and disaster program effectiveness that may hinder future response efforts, including shortcomings in acquisition and contracting controls, interagency coordination challenges, and insufficient privacy safeguards that affect disaster survivors. Additionally, FEMA did not adequately oversee disaster grant recipients and subrecipients, manage disaster assistance funds, or oversee its information technology environment. This report discusses these vulnerabilities and the correlating recommendations we previously made that, if implemented, would better prepare FEMA to respond to future disasters. We made no new recommendations.

The objectives of our inspection were to determine (1) the U.S. Department of Education’s (Department) process for assessing the Accrediting Council for Independent Colleges and School’s (ACICS) compliance with Federal regulatory criteria for recognition, and (2) what evidence the Department considered in its review of selected recognition criteria and whether the Department’s conclusions were supported by evidence.We determined that the Department’s process for assessing ACICS’ compliance with Federal regulatory criteria for recognition followed applicable policies and regulations except during the 2016 recognition review. We determined that the Department did not comply with all regulatory requirements during its 2016 review of ACICS’ petition for recognition renewal because its process did not consider all available relevant information during its review as required.We determined that the Department implemented a process for assessing ACICS’ compliance with recognition criteria following a court remand in 2018 that was permitted under applicable policies and regulations as well as the court’s remand order.We determined that the conclusions of the SDO (DeVos) in the 2018 review regarding ACICS’ compliance with each of the six recognition criteria we reviewed were supported by the evidence cited.However, we found that the Office of Postsecondary Education’s (OPE) “Guidelines for Preparing and Reviewing Petitions and Compliance Reports” (Guidelines) allowed for areas of reviewer subjectivity.

In 2019, a confidential complainant alleged that employees of the contractor Signature Performance incorrectly processed claims for non VA care. The VA Office of Inspector General (OIG) conducted this audit to determine whether contractor employees accurately processed these claims.

Business Reply Mail (BRM) is a service offered by the Postal Service that enables a sender to provide a recipient with a convenient, prepaid method for replying to a mailing. Customers request refunds when postage has been applied to the prepaid mailing. To obtain a refund, customers must submit postage affixed BRM, and the required Postal Service (PS) Form 3533, Application for Refund of Fees, Products and Withdrawal of Customer Accounts. The Postal Service assesses fees to process the refunds and deducts them from the customer’s refund amount. OIG data analytics identified Hagerstown, MD, Post Office permit postage refunds totaling about $31,754 for fiscal year (FY) 2020, which is 51 percent of the district’s total. In addition, we identified several months with little or no refund activity. The objective of this audit was to determine whether postage affixed BRM refunds were properly issued, supported, and processed at the Hagerstown, MD, Post Office.

What We Looked AtThe Maritime Administration (MARAD) provides ships from the National Defense Reserve Fleet as training vessels for cadets at the State maritime academies to become licensed mariners. In fiscal year 2015, MARAD began the design of National Security Multi-Mission Vessels (NSMV) to replace five training ships nearing the end of useful life. Congress directed MARAD to use an entity other than itself to contract for NSMV construction using commercial design standards and construction practices and has thus far appropriated approximately $1.3 billion for the NSMV program. Given this significant investment and MARAD’s support of national security, we initiated this audit. Our objective was to assess MARAD’s management of the NSMV Program, including oversight of the vessel construction manager (VCM) contract and use of commercial design standards and commercial construction practices consistent with the best interests of the Federal Government. What We FoundVulnerabilities in MARAD’s NSMV program management may hinder achievement of program goals. Though it has taken some risk mitigation steps, MARAD’s program risk management is inadequate. Its risk assessment lacked complete analysis of important elements such as individual risk likelihood, consequences, and mitigation strategies. It also does not sufficiently update and monitor program risks. These deficiencies could affect the Agency’s ability to achieve timely and cost-effective vessels that meet its needs. Furthermore, MARAD has not reviewed complete versions of three required oversight plans that describe key areas of the VCM’s strategy for managing and overseeing NSMV design and construction. Incomplete plans impede MARAD’s ability to effectively oversee the VCM. Lastly, delays in the VCM contract and shipyard subcontract awards may increase MARAD’s exposure to program risks. Later-than-planned awards reduced the time between first vessel delivery and placement into service from 17 months to 1. This lost cushion increases the possibility that the VCM and shipyard will not have enough time to address issues and that contingency plans for late vessel delivery will be implemented, thus adding cost to the program’s billion-plus dollar investment. RecommendationsMARAD concurred with both recommendations to improve its management of the NSMV Program.

DHS’ Countering Weapons of Mass Destruction’s (CWMD)BioWatch has information sharing challenges that reducenationwide readiness to respond to biological terrorismthreats. According to its mission statement, BioWatch isdesigned to operate a nationwide aerosol detection system.The system is intended to detect potential biological threatagents, identify the agent used, and share information withstakeholders, serving as an early warning system.However, BioWatch does not operate a nationwide earlywarning system. Its biological detection equipment is locatedin just 22 of 50 states (44 percent), which leaves 28 stateswithout coverage. This occurred because BioWatch has notreassessed its strategic posture and designated locationsneeding coverage since 2003. Moreover, BioWatch equipmentin 34 of 35 jurisdictions could not always collect air samplesto test for biological threats because the equipment was notsecured to prevent unplugging or security breaches.Further, BioWatch monitors and detects just 6 of 14(approximately 43 percent) biological agents known to bethreats because it has not updated its biological agentdetection capabilities with the 2017 threat assessmentresults. Also, as of 2018, BioWatch stopped conductingroutine full-scale exercises with its jurisdictions inpreparation for a potential bioterrorism attack. According toBioWatch officials, this occurred because CWMD leadershipdirected BioWatch to no longer conduct these exercises,leaving each jurisdiction discretion to perform its ownexercises.Without implementing changes to address BioWatch’schallenges, the United States’ ability to prepare for, detect,and respond to a potential bioterrorism attack is impeded,which could result in significant loss of human life.

The Patient Protection and Affordable Care Act established health insurance marketplaces in all 50 States and the District of Columbia. The Centers for Medicare & Medicaid Services (CMS) operates the Federal marketplace and is responsible for generating advanced premium tax credits (APTCs) made to qualified health plans (QHPs). We previously audited CMS's interim process for approving financial assistance payments on an aggregate basis for the 2014 benefit year. We determined that CMS did not ensure that payments were made only for confirmed enrollees and in the correct amounts. This audit reviewed CMS's permanent process for authorizing APTCs to QHP issuers on a policy-level basis for the 2018 calendar year.The objectives of this audit were to determine whether CMS: (1) ensured APTCs were allowable; and (2) reported accurate enrollment data to the Department of the Treasury's Internal Revenue Service (IRS) for the IRS to use when reconciling APTCs.

OIG Investigations Newsletter Volume XXXII for the period of December 1, 2020 - January 31, 2021

We found that Ohio generally had sufficient internal controls to ensure that LEAs developed IEPs in accordance with Federal and State requirements for children with disabilities who attend virtual charter schools and that these students were provided with the services described in their IEPs. These internal controls included developing model policies and procedures; monitoring LEAs; and providing technical assistance, guidance, and training. However, we found that Ohio could strengthen its monitoring process to ensure that LEAs also have written procedures on how they implemented the model policies for IEP development and how they provided and documented service delivery for students with disabilities, and by requiring sponsors1 to timely report significant compliance issues found during their LEA monitoring reviews.

This investigation was initiated based on a Postal Service employee's allegations of voter fraud in a video.

The objective of our inspection was to determine (1) whether selected institutions receiving funds under the Institutional Portion of Higher Education Emergency Relief Fund (HEERF) met public reporting requirements and (2) the reported usage of the Institutional Portion of HEERF by selected institutions.We determined that 81 of the 100 institutions included in our sample complied with Institutional Portion reporting requirements.We were unable to locate Institutional Portion reports anywhere on the websites associated with 19 of the 100 (19 percent) institutions included in our sample.

The OIG investigated allegations that a U.S. Fish and Wildlife Service (FWS) employee working at a refuge stole copper wiring and a bulldozer.We found that the employee removed copper from the former military facilities at the refuge and sold it for less than $5,000 during the last 10 years. We did not find evidence that the employee converted a Government-owned bulldozer for personal use or financial gain.We presented our interim findings to the FWS, and the employee was subsequently removed from Federal service. The U.S. Attorney’s Office declined prosecution.

In accordance with our statutory authority Public Law (P.L.) 109-SS, the USCP Office of Inspector General (OIG) began a review of the events surrounding the takeover of the U.S. Capitol on January 6, 2021. Our objectives for this review were to determine if the Department (1) established adequate measures for ensuring the safety and security of the Capitol Complex as well as Members of Congress, (2) established adequate internal controls and processes for ensuring compliance with Department policies, and (3) complied with applicable policies and procedures as well as applicable laws and regulations. The scope included controls, processes, and operations surrounding the security measures prior to the planned demonstrations and response during the takeover of the Capitol building.

This report contains information about recommendations from the OIG's audits, evaluations, reviews, and other reports that the OIG had not closed as of the specified date because it had not determined that the Department of Justice had fully implemented them. The list omits information that the Department of Justice determined to be limited official use or classified, and therefore unsuitable for public release.The status of each recommendation was accurate as of the specified date and is subject to change. Specifically, a recommendation identified as not closed as of the specified date may subsequently have been closed.

The OIG examined whether the VHA had effective procedures for (1) purchasing, (2) inventorying, and (3) tracking biologic implants such as skin substitutes and corneal or dental implants. The OIG found deficiencies in all three areas at four medical facilities it visited.The audit team determined that purchasing agents did not always record implant purchases properly or use the appropriate funds. The purchasing agents did not record 2,931 of 10,305 purchased biologic implants in the appropriate system. Instead, agents documented the implants in various local spreadsheets, databases, and third party systems. Purchasing agents sometimes improperly used logistics funds instead of prosthetic funds, which makes it difficult for VHA to fully account for biologic implant spending and effectively budget or use funds for other purposes.The OIG found that due to inadequate guidance, the facilities visited had an inaccurate inventory of biologic implants, did not use a standardized system, and did not consistently review inventory on hand. At the four facilities visited, staff could not locate 714 biologic implants in inventory, valued at almost $1.1 million. The audit team also found 288 unrecorded additional items, valued at almost $433,000, in storage locations. Poor inventory management can jeopardize prompt care, as medical providers may need to delay or cancel procedures if implants are unavailable.Finally, the facilities visited failed to track at least 45 percent of implants reported as used from October 2017 through March 2019. Further, VHA did not designate responsibility for overseeing tracking, develop a national policy on how facilities should track biologic implants, or have a standard tracking system that meets accreditation requirements. Effective tracking is needed for facilities to notify veterans if their implants are recalled by the manufacturers.VHA concurred with the OIG’s 11 recommendations to improve how it purchases, inventories, and tracks biologic implants.

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Washington DC VA Medical Center (facility) pursuant to a request by several members of Congress. The members had learned that the facility was not in compliance with the Veterans Health Administration (VHA) policy on communicating exam results and letters had not been appropriately mailed to patients who had breast imaging studies.After discovery of the unsent letters, facility staff completed reviews and all patients were notified of abnormal findings. The OIG identified nine additional mammography exams not included in the facility’s reviews due to errors in diagnostic coding. The facility reviewed and determined the exams were not abnormal.The facility identified two patients and the OIG identified two additional patients who had clinically significant mammography exams (breast cancer). Though the four patients did not receive timely letters, all four breast cancer patients received timely notification by the ordering provider. The OIG found that ordering providers did not consistently document patient notification of abnormal mammography results as required.At the time of the OIG review, the facility did not have a functional mammography program due to loss of staff. The facility had not fully implemented the September 2019 National Radiology Program Office (NRPO) site visit recommendations.The NRPO did not cite the facility for lack of a program standard operating procedure manual.The facility did not fully implement program procedural changes including oversight of staff duties and training, appropriate oversight and quality controls in delegating the task of mailing patient lay summary letters, and development of a formalized training program for mammography staff to ensure monitoring and tracking of patients.The OIG made seven recommendations related to documentation and notification processes, action plans, standard operating procedures, staff training, and NRPO reviews and requirements.

The Barrington Station is located in the Los Angeles District of the West Pac Area. OIG data analytics identified the Barrington Station as having four consecutive floor stamp inventory count shortages totaling about $8,781 for fiscal year (FY) 2020. We determined the Barrington Station properly accounted for money orders but did not always properly account for stamps and cash.

The Postal Service’s Peak Season lasts about eight weeks, starting on or around Thanksgiving Day in November and ending on or around Martin Luther King, Jr. Day in January. Since FY 2018, the average cost of the Postal Service’s air network per day during Peak Season increased from $8.7 million to $9.8 million (12.6 percent increase). The highest Peak Season average volume per day was [redacted] million pounds in FY 2019. Despite less volume during the FY 2020 Peak Season (November 28, 2019 – January 20, 2020), the cost per pound to transport mail by air continued to rise – from [redacted] in FY 2018 to [redacted] in FY 2020 (10.9 percent increase). Our objective was to assess the Postal Service’s efforts to reduce Peak Season air transportation operational costs while maintaining service during fiscal year (FY) 2019 and FY 2020.