Federal Reports

The Office of the Inspector General identified several issues with the use and oversight of the U.S. Nuclear Regulatory Commission’s telework program, including missing telework agreements and inaccurate telework records, both of which are required by law for proper program administration.  Additionally, we found inadequate compliance with documentation standards, which could result in inconsistent adherence to policies and inaccuracies in employee records. Finally, we identified discrepancies in some official duty stations and failure to comply with telework agreement terms, potentially resulting in incorrect locality pay.
This report makes seven recommendations to strengthen the telework program’s document management and oversight processes to ensure full compliance with federal laws and regulations.

A passenger conductor based in Raleigh, North Carolina, was terminated from employment on April 26, 2025, following an administrative hearing. Our investigation found that the former employee violated company policy by allowing an unknown and un-ticketed individual to proceed to the train platform and put an unidentified package onto the train without knowing its contents. The package was subsequently found to contain illegal narcotics. The former employee is not eligible for rehire.

At the request of the Tennessee Valley Authority’s (TVA) Supply Chain, we examined the cost proposal submitted by a company for designing, fabricating, and delivering hydraulic turbine runners and components as specified by TVA.  Our examination objective was to determine if the company’s cost proposal was fairly stated for a contract with expenditures up to $175 million.

In our opinion, the company’s proposed (1) hourly manufacturing and labor rates and (2) markup factors for recovery of indirect costs were fairly stated. However, the company’s proposed billing rates for craft labor were overstated.  Specifically, the proposed craft billing rates in the example project included (1) an ineligible sick leave markup, (2) overstated state unemployment insurance markup, and (3) duplicated workers’ compensation insurance markup.  We estimated TVA could avoid about $1.2 million over the potential $175 million contract by negotiating appropriate reductions to the craft labor billing rates.  In addition, we suggest TVA negotiate to include craft labor billing rates in the contract’s rate schedule, including craft markups and cost adders.  

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess an allegation that a physician (subject physician), who was not privileged at the Overton Brooks VA Medical Center (facility) in Shreveport, Louisiana, provided care to intensive care unit (ICU) patients. The OIG also identified concerns with a quality review completed after facility leaders’ awareness of the event.

The OIG substantiated that the subject physician, a fellow in training at an academic affiliate, provided patient care for three hours in the ICU with attending physician oversight. Failure to follow the trainee Veterans Health Administration (VHA) onboarding process and lack of oversight of physician coverage for the ICU contributed to the event. The resident student coordinator facilitated the VHA trainee onboarding process before receiving the required verification letter, resulting in the improper onboarding of the subject physician. Additionally, the chief of medicine failed to ensure a process was implemented to verify ICU coverage-pool physicians were credentialed and privileged at the facility.

The Facility Director chartered a root cause analysis (RCA); however, the RCA team’s application of the RCA process left patient safety risks unresolved and did not explore how the subject physician was onboarded as a trainee or provided care in the facility’s ICU. The RCA team’s failure to follow VHA required guidelines affected the reliability of the RCA team’s assessment and conclusion. The OIG also identified a facility practice involving an additional concurrence step, which created vulnerabilities related to breaching RCA confidentiality and service line leaders influence on RCA findings. 

The OIG made one recommendation to the Under Secretary for Health to evaluate VHA using an additional RCA concurrence step and three recommendations to the Facility Director related to trainee onboarding requirements, oversight of intensive care unit physician credentialing and privileging, and completing root cause analyses as required. 

After previous failed attempts, VA is modernizing its finance and acquisition systems by implementing the Integrated Financial and Acquisition Management System (iFAMS). The system is being deployed by the Financial Management Business Transformation Service (FMBTS) in waves across VA. The six waves that had been carried out as of June 2023 represent only about 3.6 percent of all projected iFAMS users. One remaining wave is for the Veterans Health Administration, which represents more than 92 percent of iFAMS users. As of fiscal year 2024, the life cycle cost estimate to deploy and sustain the system across VA is anticipated to be about $8.6 billion through 2050.

Interfaces, which are created and tested during the iFAMS software development process, facilitate the flow of data between systems to automatically complete business processes. Therefore, interface development is critical for iFAMS to meet users’ needs. The VA OIG conducted this audit to assess whether the interface development process aligned with stated goals to enhance iFAMS implementation. The OIG examined FMBTS’s planning, communication, and monitoring of success metrics for the process. This audit focuses on the Consolidated Wave Stack, the first wave that deployed both finance and acquisition functions simultaneously.

The OIG found that during the Consolidated Wave Stack, validation sessions lacked essential details and FMBTS missed opportunities to fully confirm the system functioned properly. If functionality issues are not identified or corrected before deployment, user productivity and efficiency can decrease while the risk of errors increases. Consequently, FMBTS should test essential functions for both real-world application and technical assessment moving forward. The OIG made four recommendations for FMBTS to improve the interface development process for future implementation waves.

Each year, the U.S. Department of Housing and Urban Development (HUD or Department) Office of Inspector General (OIG) provides the Department with a memorandum of priority open recommendations the OIG issued in its reports. The OIG designated these recommendations as“priority” because, if implemented, the recommendations will have the most significant impact on increasing efficiency in HUD programs, reducing fraud and wasteful spending, and assisting HUD with addressing its top management challenges.

A management official based in Chicago, Illinois, was terminated from employment on April 24, 2025, as the result of our investigation. We found that the former employee violated company policies by engaging in outside employment while on a medical leave of absence and conducting outside business activities while on company time. The former employee is not eligible for rehire.

An Amtrak Supervisor based in Philadelphia violated company policy between 2022 and 2023 by not swiping out on a Time Entry Device after his shifts and, subsequently, swiping out and immediately back in when he returned to work. In addition, our investigation revealed that the supervisor directed multiple subordinates to follow this same swiping protocol. The scheme allowed recording of significant consecutive hours for each employee. The employees used this swiping protocol to inaccurately claim a full eight hours of regular pay in Amtrak’s timekeeping system, instead of correctly recording seven hours of regular pay and one hour of Code 29 pay (hours paid but not worked), thereby creating inaccurate financial accounting records and hiding Code 29 hours from management.

The supervisor was terminated after his disciplinary hearing in April 2025 and is not eligible for rehire.

Our Objective(s)To evaluate FMCSA Motor Carrier Safety Assistance Program (MCSAP) grant oversight activities. Specifically, we reviewed FMCSAs (1) policies and procedures for monitoring MCSAP grant recipients, (2) annual risk assessments and monitoring plans for MCSAP recipients, and (3) tracking of recipients achievement of safety goals.
Why This AuditThe Federal Motor Carriers Safety Administration (FMCSA) reported that 5,176 fatalities involving large trucks and buses occurred in 2023. To reduce these incidents, FMCSA provides MCSAP formula grants to State agencies. The Infrastructure Investment and Jobs Act of 2021 (IIJA) authorized over $2 billion in appropriations for MCSAP grants and up to $400 million in supplemental funds.
What We FoundFMCSAs Division Offices do not always follow the Agencys MCSAP monitoring policies and procedures.

FMCSAs guidelines on Division Offices reviews of grantees MCSAP reimbursement requests are insufficient and outdated.

Why We Did This Report

The U.S. Environmental Protection Agency Office of Inspector General initiated this project to determine whether Bacon & Company, CPAs, LLC performed the fiscal year 2022 single audit of the Narragansett Bay Commission in Rhode Island in accordance with applicable auditing standards and federal requirements for single audits.

Summary of Findings

We determined that Bacon & Company complied with the applicable auditing standards and federal requirements when it performed the FY 2022 single audit of the Narragansett Bay Commission. As a result, we assign Bacon & Company a pass rating. During our review, we also identified an error in Bacon & Company’s major program determination for compliance testing. However, this error did not impact the overall quality or our assigned rating.

We reviewed the Office of Contracting and Procurement’s controls over Contractor Performance Assessment Reporting System requirements.

This report presents the results of our management advisory bringing the Small Business Administration’s (SBA) attention to concerns regarding forgiven Paycheck Protection Program (PPP) loans subsequently flagged as potentially ineligible using hold code 70 (potential clawback) for which the agency has not completed its review to facilitate recovery of improper payments for ineligible loans. A hold code is an identifier placed on a loan in the agency’s system indicating a potential issue needs to be resolved. SBA uses hold code 70 to flag forgiven PPP loans for which it subsequently suspects the borrower is potentially ineligible for the loan or for loan forgiveness. It is imperative that SBA completes its review to promote program integrity and mitigate financial loss by seeking recovery of improper payments for ineligible loans.

The unprecedented demand for PPP funds and the need to quickly award loans gave way to a pay and chase environment that relied heavily on post-payment reviews and resolving subsequent hold codes to ensure program integrity. SBA was required to issue PPP regulations no later than 15 days from the date the CARES Act was enacted (March 27, 2020) and lenders were to disburse loans within 10 days of approving applications and SBA reduced or eliminated key upfront controls as it sought to expedite aid.

As of May 24, 2024, SBA had forgiven over 10.5 million PPP loans, totaling over $750 billion, 37,938 of which (totaling approximately $4.6 billion) had an open hold code 70 (potential clawback). SBA’s guidance stipulates that all loans for which a forgiveness payment has been made and later determined to be potentially ineligible will be flagged using hold code 70 regardless of size; however, it also stipulates that if a forgiven loan is less than or equal to the $25,000 de minimis threshold, it may be considered immaterial, and recovery may not be prioritized. Of the 37,938 PPP loans subsequently flagged with a hold code 70, there were 26,234 loans, totaling $454 million, that were less than or equal to $25,000.

We found SBA did not complete its review process for the 37,938 PPP loans, totaling approximately $4.6 billion, that were flagged with a hold code 70 (potential clawback). Specifically, SBA only completed the first two steps of its four-step review process for loan and/or forgiveness amounts in which the reviewer and approver recommended the amount be denied in part or in full or for loans in which the approver disagreed with the reviewer’s loan review recommendation.

Management agreed with our recommendations to complete reviews for the 37,938 potentially ineligible PPP flagged with hold code 70 and to develop criteria to formalize policies and procedures for recovering improper payments for all loans subsequently flagged with hold code 70 and later deemed ineligible.

This report provides information on the U.S. Fish and Wildlife Service’s use of Inflation Reduction Act funding for listed species recovery efforts.

The OIG received a hotline allegation from a VA medical center employee regarding the improper sharing of sensitive information on VA’s internal network. The complainant reported that an employee could search for fellow employees on the internal network and find documents and emails that contained sensitive personal information. Among these documents were human resources paperwork, such as interview questions and reference checks, performance awards, and personally identifiable information for veterans getting surgery.

The OIG confirmed sensitive personal information was accessible by VA users who had no business need to access it. Furthermore, the OIG noted that the type of sensitive personal information accessible should not have been hosted on the systems it was found on, as the information exceeded the systems’ security authorizations. The OIG determined this was a national issue because the hosting systems are cloud based and the information was observable by any authorized VA employee, regardless of location.

To address the reasons for the improper sharing, the OIG recommended that the assistant secretary for information and technology 
   •    ensure facilities and programs remove unauthorized sensitive personal information from collaborative application sites such as SharePoint; 
   •    direct facilities and programs to standardize SharePoint administration, inventory and consolidate their SharePoint sites; 
   •    implement enforcement mechanisms such as recommended architecture to allow greater control of permissions and content; 
   •    expand roles and responsibilities for privacy officers and information system security officers; 
   •    implement automated tools to detect and correct improper sharing agencywide; and 
   •    mandate standardized training for SharePoint administrators and owners. 

The assistant secretary concurred with all recommendations, and the OIG agreed to close two recommendations after VA provided sufficient evidence of implementation. The four other recommendations remain open.

Our audit objective was to determine whether USPTO had an effective governance structure and processes in place to manage its AI tools. To meet our objective, we tested two of the six AI tools USPTO had in use when we began our audit. 

Overall, we found that USPTO has begun developing its AI workforce but should strengthen key organizational and system-level governance practices needed to effectively manage and oversee its AI tools. Specifically, USPTO:

• Has a governance structure that defines roles and responsibilities for key personnel, but should improve internal stakeholder involvement
• Should promote transparency on its AI tools to external stakeholders
• Does not have the specific, measurable objectives needed to define system success 
• Did not trace requirements or technical specifications to system objectives
• Does not have an AI-specific risk management plan

Together, these weaknesses increase the risk that USPTO will develop unreliable, untrustworthy AI systems. 
 

The Office of Inspector General performed an evaluation of an Agricultural Research Service (ARS) facility’s physical condition and security.

The Office of Inspector General is issuing this management advisory to bring to the U.S. Small Business Administration’s (SBA) attention possible security threats from personally owned devices accessing the agency’s information technology network from national and international locations with only a username and password.

We identified in our fiscal years 2023 and 2024 Federal Information Security Modernization Act assessments that SBA did not have multifactor authentication enabled for users to access the agency’s secure network. Relying on usernames and passwords alone greatly increases the risk of SBA data being accessed and exploited by cyber criminals and other bad actors. We also determined personally owned devices could access the SBA network from foreign locations, which is prohibited by SBA information technology policy.

We made five recommendations, and SBA management agreed with all five. All of the recommendations have been closed or resolved.

Our investigation determined that, between 2022 and 2023, an Amtrak Supervisor based in Philadelphia and several other employees violated company policy by not swiping out on a Time Entry Device (TED) after their shifts and, subsequently, swiping out and immediately back in when they returned to work. This resulted in the recording of significant consecutive TED hours. The employees used this swiping protocol to inaccurately claim a full eight hours of regular pay in Maximo, Amtrak’s timekeeping system, instead of correctly recording seven hours of regular pay and one hour of Code 29 pay (hours paid but not worked) to which they were actually entitled.

We also found that the supervisor collected additional Code 29 hours to which he was not entitled, in violation of the Infrastructure Management and Construction Services’ (IMCS) internal hours‐of‐service policy, which limits the number of hours an IMCS employee can work to 16 hours in a 24‐hour period. We further found that a Division Engineer, based in Philadelphia, violated the internal hours‐of‐service policy by allowing and encouraging these employees to claim Code 29 pay after working only 14 hours, which resulted in the company paying for hundreds of unnecessary Code 29 hours. The supervisor was terminated and is no longer eligible for rehire, and the Engineer was reprimanded.

The Office of the Inspector General performed an audit of TVA’s transmission network cybersecurity.  The audit scope was limited to a specific type of connectivity within TVA’s transmission network.  The audit objective was to determine the level of cybersecurity in place for this type of connectivity.

We determined the connectivity within TVA’s transmission network had a high level of cybersecurity in place commensurate with the level of associated risk.  In addition, our testing of internal controls identified process improvements related to configuration management.  We recommend the Senior Vice President, Grid, update configuration management processes to improve periodic reviews. 

The U.S. Postal Service is responsible for processing, transporting, and delivering the nation’s Election and Political Mail. The Postal Service has specific policies and procedures on the proper acceptance, processing, delivery, and documentation of Election and Political Mail.

Our objective was to evaluate the service performance and visibility of Election and Political Mail during the 2024 general election. For this audit, we reviewed Election and Political Mail policies and mail tracking methods, analyzed service performance data, and judgmentally selected and conducted observations at 68 mail processing facilities and 947 delivery units during the 2024 general election season.

Overall, the Postal Service significantly exceeded service performance goals for Election and most Political Mail, but opportunities existed for the Postal Service to improve tracking of Ballot Mail within its network. The Postal Service applied its “extraordinary measures” to expedite handling of Ballot Mail. In fact, we found the Postal Service provided service above rates charged for certain ballots and late arriving Political Mail. The Postal Service could have potentially received $15.4 million more in revenue if it charged rates in line with the service provided on these ballots. When we observed non-compliance with Election and Political Mail policies and procedures, we found it was caused by confusion in the field over new, electronic processes or temporary changes in the mail flow due to the election. We did not see widespread instances of delayed Election or Political Mail in delivery units before or after the election, but better controls could lead to more accurate daily reporting on the status of Election and Political Mail from delivery operations.

In addition, the Postal Service estimated that just under 40 million ballots mailed to and from voters did not have performance tracking data. The Postal Service’s inability to track ballots negatively impacts its and other interested parties’ visibility into the status of ballots in the postal network.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate allegations related to a patient’s care and the lung cancer screening (LCS) program at the VA Eastern Kansas Healthcare System (system) in Topeka and Leavenworth.

The OIG substantiated that a patient experienced a delay in the diagnosis of and treatment for lung cancer. Neither the patient aligned care team (PACT) provider nor the system pulmonologist took the necessary steps to ensure a bronchoscopy was ordered and completed. The PACT provider ordered, but failed to track, a positron emission tomography (PET) scan completed by a community provider; and failed to communicate the abnormal results to the patient and initiate clinical actions as indicated. System leaders conducted an institutional disclosure to the patient; however, the institutional disclosure documentation did not include required details.

The OIG identified concerns related to the absence of an established process for community care providers to communicate abnormal test results directly to the system’s ordering providers.

Community care staff did not make timely, sufficient efforts to retrieve the patient’s PET scan results. The OIG found a broad system failure of community care staff not making three attempts to retrieve patient records within 90 days of completed appointments, which leaders partially attributed to metrics that prioritized receiving and scheduling community care appointments.

System and program leaders failed to develop the LCS program infrastructure prior to implementation. The LCS program lacked oversight, multidisciplinary engagement, policy, and adequate primary care training and engagement.

The OIG made one recommendation to the Under Secretary for Health related to the communication of patients’ abnormal test results and one recommendation to the Veterans Integrated Service Network Director regarding the system’s LCS program. The OIG made four recommendations to the System Director related to test results, institutional disclosures, and community care records. 

FSA’s launch of the 2024–2025 FAFSA was plagued by multiple system implementation issues that prevented students and families from successfully applying for financial aid within critical timeframes. As a result, FSA developed actions to improve the 2025–2026 FAFSA process and increase transparency and communication. The objective of our review was to describe FSA’s plans to solicit, analyze, and incorporate feedback from students, families, institutions of higher education, and other stakeholders for the completion, submission, and processing of the 2025–2026 FAFSA. We found that although FSA did not have a formal plan with specific details about how it would solicit, analyze, and incorporate the feedback it received regarding the completion, submission, and processing of the 2025–2026 FAFSA, FSA and the Department established multiple channels of communication for receiving feedback. On November 14, 2024, FSA announced that since the start of beta testing on October 1, 2024, more than 14,000 students successfully submitted their 2025–2026 FAFSAs and that the Department had successfully processed their applications, sending over 81,000 records to more than 1,850 schools and 43 States.

We contracted with the Joachim Group CPAs & Consultants (Joachim Group) to examine the management of government issued purchase and travel cards. The Joachim Group conducted the audit in accordance with Generally Accepted Government Auditing Standards (GAGAS) and is responsible for the attached audit report and the conclusions expressed therein. The OIG monitored the auditor’s progress throughout the compliance audit and reviewed the respective audit report and related documentation.

This report presents the results of our audits of delivery operations and property conditions in the Georgia District in the Southern Area.

The U.S. Postal Service’s mission is to provide timely, reliable, secure, and affordable mail and package delivery to more than 160 million residential and business addresses across the country. To fulfill this role, the Postal Service is committed to ensuring its delivery platform and services are always a trusted, visible, and valued part of America’s social and economic infrastructure. This includes leveraging people, technology, and systems to provide worldclass visibility of mail and packages as they move through the Postal Service’s integrated system. The U.S. Postal Service Office of Inspector General (OIG) reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission.

This report presents a summary of the results of our self-initiated audits of delivery operations and property conditions at four delivery units, as well as district-wide delivery operations in the Georgia District in the Southern Area (Project Number 25-015). The delivery units included the Gray Main Post Office (MPO), Perry Administrative Post Office (APO), Warner Robins MPO, and Zebulon Branch in Georgia.

Why We Did This Report

The Pesticide Registration Improvement Act requires the U.S. Environmental Protection Agency Office of Inspector General to perform an annual audit of the financial statements for the Pesticide Registration Fund.

Summary of Findings

We rendered an unmodified opinion on the EPA’s fiscal years 2023 and 2022 (Restated) Pesticide Registration Fund—also known as the Pesticide Registration Improvement Act, or PRIA, Fund—financial statements, meaning that the statements were fairly presented and free of material misstatement. We noted the following material weakness: the EPA materially misstated the on-top adjustment involving the PRIA income and expenses from other appropriations, which is the PRIA 23-02A on-top adjustment, in its fiscal year 2023 draft financial statements by over $2.6 million. An on-top adjustment is a journal entry that is made at the end of an accounting period to adjust the accounts to accurately reflect revenues and expenses of the current period.

Our investigation determined that an Amtrak Engineer based in Philadelphia, Pennsylvania, violated company policies by misusing his company-issued computer to conduct personal business on company time and failing to report three outside businesses on his annual Certificates of Compliance. He was terminated on April 16, 2025, and he is not eligible for rehire.

The expansion of benefits under the PACT Act of 2022 necessitated VBA increasing capacity to process the influx of claims. By September 2023, VBA had sought to hire 2,520 claims processors—veterans service representatives and rating veterans service representatives—and reported exceeding its goal by hiring 3,279 claims processors. The OIG conducted this audit to determine whether VBA followed required steps to hire qualified claims processors using PACT Act funds. In addition, the OIG calculated the attrition rates for claims processors and evaluated measures VBA implemented to retain these staff.

The OIG found VBA’s human resources staff generally followed the required steps to hire qualified claims processors using PACT Act funds from October 1, 2022, through September 30, 2023. In just 2 percent of hires, applicants received an official job offer before their screening results were available; nevertheless, rushing official job offers puts VBA at risk of hiring someone who may not be suitable for federal service. Also, although overall time frames were met, the time to onboard—from acceptance of a tentative offer to starting work—exceeded the guidelines.

As for attrition, the OIG determined the median tenure of claims processors who resigned from VBA during the period in question was about 10 to 12 months, just when they have gained proficiency. Consequently, VBA may not recoup the considerable resources invested in recruiting, hiring, and training staff for this critical position. VBA’s Office of Human Capital Services developed a retention program in July 2022, but participation was voluntary and the program also lacked measurable performance indicators, preventing the OIG team from assessing its success.

The OIG made no recommendations as VBA’s existing controls appeared to ensure human resources staff follow the procedures, but the OIG reported ways to improve those procedures and ongoing retention efforts.

In January 2023, the Tennessee Valley Authority (TVA) issued a record of decision to retire and demolish its Cumberland Fossil Plant and replace one of its two units with a natural gas plant.  Subsequently, TVA implemented the Cumberland Energy Solution (CES) project to construct a 1,450-megawatt natural gas-fueled combined cycle (CC) plant.  In August 2023, Major Projects obtained approval from the TVA Board of Directors for all related CES project funding (including transmission) totaling $2.1 billion.  Due to the importance of completing the transmission modifications to support the CC plant, we initiated an evaluation of the Cumberland CC transmission project.  Our evaluation objective was to determine if the project followed TVA’s (1) scope and (2) risk management guidelines. 

We determined the Cumberland CC transmission project complied with most elements of scope and risk management.  For example, (1) the project had completed required scoping documentation, including a project charter, work breakdown structure, and supporting schedules; (2) funds were appropriately allocated for a change in the project scope; and (3) the risk register contained required elements.  However, documentation reflected inadequate collaboration and estimating related to project cost.  In addition, risk register development did not adequately include joint project team members and some risk response owners were not aware of their monitoring responsibilities. 

Review of the Federal Labor Relations Authority’s Privacy and Data Security Policies, Procedures, and
Practices for Fiscal Year 2025

The VA Office of Inspector General (OIG) conducted this review to determine whether claims processors are properly assigning effective dates when considering PACT Act–related claims. After reviewing a statistical sample of 100 PACT Act–related claims completed from August 10, 2022, through August 9, 2023, the OIG estimated that incorrect effective dates were assigned for about 31,400 of 131,000 (24 percent). In an estimated 26,100 of those claims, the assigned effective date was incorrect, resulting in at least $6.8 million in improper payments. At least 2,300 additional claims had date errors, but the review team could not determine their monetary impact, as claims processors prematurely decided them without enough evidence to definitively establish correct dates.

Although determining correct effective dates for PACT Act–related claims is inherently complicated for claims processors—requiring mastery of numerous sections of the United States Code, the Code of Federal Regulations, and VBA guidance—VBA failed to effectively prepare them. VBA did not provide detailed guidance in its PACT Act–related standard operating procedure, its two automated tools were unreliable for determining effective dates, and it did not initially provide the necessary training.

When granting benefits, claims processors must determine and apply the most advantageous effective date allowed by law for each claim or benefit awarded. The proper assignment of effective dates for disability compensation benefits is vital because an incorrect effective date can have a substantial financial effect on veterans.

The OIG recommended the under secretary for benefits create a job aid for claims processors on how to determine the correct effective date for PACT Act–related claims, remove the older tool and update the newer one, assess training effectiveness by monitoring the results to assess its effectiveness, and correct all errors on cases identified by the review team.

Our objective was to assess the company’s efforts to identify and manage its risk of train strikes—incidents in which a train hits people or vehicles.

Train strikes have resulted in hundreds of fatalities and injuries in recent years and can take a heavy toll on the crew members involved—by our estimate, in fiscal year 2023, one in five of the company’s passenger engineers may have been involved in a strike.

We found that, like other railroads, the company faces inherent challenges to reducing train strikes because of factors that are difficult to control, such as suicide attempts and motorists who ignore crossing signals. Nonetheless, the company can better identify and manage train-strike related risks. It began new initiatives to do so during our audit; however, embedding ongoing initiatives into a more comprehensive, proactive risk management process could help the company better identify all major risks and make informed decisions about where to allocate its limited resources. We identified a list of key practices to aid this effort, such as collecting input from train crews about specific hazards and doing a cost-benefit analysis of different mitigation steps. The company already has many positive efforts underway that align with each of these practices. In addition, we found the data Amtrak collects on train strikes and reports to the Federal Railroad Administration had some discrepancies, which the company corrected during our audit.

We recommended that Amtrak develop a comprehensive, proactive process to identify and manage the risk of train strikes. As it institutes this process, the company should consider expanding implementation of the key practices we identified, as appropriate. We also recommend that it implement a process to regularly review and reconcile its train strike data to ensure its accuracy.
 

As part of the Office of Inspector General’s (OIG) oversight responsibility, we reviewed the results of prior OIG engagements that were relevant to the funded trade programs. We identified areas with reported past weaknesses and recommendations that may provide the Foreign Agricultural Service (FAS) insight when disbursing funds under these programs.

This report provides information about the processes that the Food and Nutrition Service uses to disburse Supplemental Nutrition Assistance Program benefits using the EBT system, as well as the related oversight activities.

The U.S. Postal Service selected the Terre Haute Sorting & Delivery Center (S&DC) as one of the first facilities for fleet modernization and electrification. It contracted for the design and installation of 76 parking spaces with charging ports to support the electrical vehicle (EV) rollout. An external contractor performed the commissioning, including the electrical, network, charging, and safety testing in early February 2024. The Terre Haute S&DC was commissioned on February 8, 2024, and carriers began using 21 EVs for delivery in May 2024.

Our objective was to assess whether the Terre Haute S&DC was prepared to utilize EVs in delivery operations and the functionality of the EV infrastructure and vehicles. Our audit work, which included conducting observations and using a contractor to perform tests at the facility, was substantially completed before the issuance of the Executive Order, Unleashing American Energy, January 20, 2025.

The Terre Haute S&DC infrastructure was sufficiently prepared to support EV use for delivery operations, and all 21 EVs at the facility were being used on local routes. We, however, identified some infrastructure implementation issues related to parking space sizes and electrical panels that hindered operational efficiency and posed safety risks. We also identified other opportunities to enhance charger functionality and facility and equipment security. For example, we found instances of chargers not functioning on a consistent basis — one for 132 consecutive days — as service request requirements were not communicated to local staff and the Postal Service lacked oversight mechanisms for notifying key parties of functionality issues. We also found that the related infrastructure was not secured properly and had insufficient signage. For example, the parking lot gate to the facility and key electrical panels were unlocked, putting nearly $1.6 million in assets at risk.

This inaugural disaster recovery biannual report and subsequent reports will provide curated information regarding the U.S. Department of Housing and Urban Development (HUD) and its grantees’ use of the more than $109 billion in disaster recovery funds approved by Congress since the 2001 World Trade Center attack, as well as information on new or completed HUD OIG oversight work related to HUD’s disaster recovery program.

HUD’s grantees use these essential funds to assist impacted communities and low- and moderate-income families in recovering from disasters and to mitigate damages from future disasters, including damage from water, wind, and fire. For our first report, we have benchmarked disaster recovery funding, grantee spending, and spending by activity type to help our stakeholders better understand HUD’s disaster recovery portfolio.

Click here for a fully accessible file.

The Tennessee Valley Authority's (TVA) transmission planning process includes assessing the capacity of the transmission system to reliably deliver power from generation resources to customer loads.  Due to the importance of ensuring TVA’s transmission system can accommodate its generation strategy and ensure adequate system margins to allow for reliable customer supply, we performed an evaluation to determine if TVA’s plans for transmission capacity support (1) planned generation additions and (2) demand growth.  We determined TVA’s plans for transmission capacity account for generation additions and demand growth; however, we identified an increased risk to Transmission Planning and Projects’ ability to execute these plans.  These included (1) gaps between budgeted funding levels and forecasted spending needed to support TVA’s planned generation and demand growth through fiscal year 2029 and (2) some transmission projects that were forecast to exceed approved cost and/or time frames, which could impact the ability of Transmission Planning and Projects to support generation additions or demand growth. 

The overall objective is to identify AbilityOne Program data generated or maintained by Central Nonprofit Agencies (CNA) and/or Nonprofit Agencies (NPA), that is not currently available to the Commission.  

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Western Colorado Healthcare System in Grand Junction. 

This evaluation focused on five key content domains:
   •    Culture
   •    Environment of care
   •    Patient safety
   •    Primary care
   •    Veteran-centered safety net

The OIG issued eight recommendations for improvement in two domains:
  1.    Environment of care
   •    Toxic exposure screenings
   •    Fire extinguisher inspections
   •    Preventive maintenance inspections 
   •    Wheelchair disinfection, ceiling vent dust removal, and wall repair
   •    Equipment and supply access and storage 
   •    Video monitoring
   •    Veterans Integrated Service Network oversight of the environment of care program
  2.    Patient Safety
   •    Patient test result notification process

The OIG conducted this review to assess the merits of two hotline complaints—one in March 2024 and one in April 2024—alleging Omaha VA Medical Center leaders manipulated the clinically indicated date for consults, thereby limiting veterans’ access to community care. The OIG substantiated the allegations, determining that from March 7, 2024, through April 11, 2024, facility leaders implemented a prohibited 29-day default for the clinically indicated date field that applied to referrals for specialty care and for some primary and mental health care. The default was implemented because clinically indicated dates for many specialty care consults were, in the chief of staff’s and medical facility director’s opinion, sooner than the patient’s condition warranted.

Before implementing the default, both the medical facility director and the chief of staff were made aware that there should not be a default. After implementing, they were also notified by an Omaha VA Medical Center employee that the default was not allowed and should be removed, but facility leaders took 19 days to remove the default. Furthermore, the OIG found providers were not given training on clinically indicated dates. In early November 2024—more than six months after the default was removed—training was provided.

The OIG made four recommendations: to clarify that automatically prepopulating the clinically indicated date field is prohibited; to determine whether any administrative action should be taken; to direct the medical facility director to provide education and training on the consult process; and to assess the actions the medical facility has taken to review consults potentially affected by the default and ensure veterans received the care they needed.

This report presents the results of our audit of the Postal Automated Redirection System. 

The Postal Automated Redirection System (PARS) was deployed in 2007 to handle letter mail that cannot be delivered to the name and address on the mailpiece. Mail sorting equipment can automatically intercept mail with an active Change of Address (COA), and PARS sorting equipment can forward it to the new destination, reducing additional mail handling. If mail that is undeliverable as addressed is not intercepted during the automated process, a carrier at the delivery unit can identify it as either forwardable — with a valid COA — or as return to sender and send it back to the plant for further processing. With the average American moving 11.7 times in their lifetime, the Postal Service must effectively handle PARS mail to ensure timely delivery of essential communications, such as bills, checks, and court documents. 

Our objective was to assess the effectiveness of procedures for processing and handling PARS mail. To accomplish our objective, we conducted interviews with U.S. Postal Service Headquarters management, obtained and analyzed PARS related data for fiscal years (FY) 2023 and 2024, and determined avoidable costs incurred due to identified issues. 

This report presents the results of our audit of Efforts to Reduce Workhours in Mail Processing.

The U.S. Postal Service’s mail processing function involves the sortation and distribution of mail for dispatch and delivery. During fiscal year (FY) 2024, more than 107,000 employees worked in the mail processing function. Based on workhour plans, which the Postal Service develops as part of its annual budget process, the Postal Service planned to reduce mail processing workhours by more than 28 million hours between FYs 2022 and 2024.

Our objective was to assess the Postal Service’s efforts to reduce workhours in mail processing. We analyzed trends in mail processing workhours, volume, and productivity, and we compared actual workhours to workhour plans during FYs 2022 through 2024. Also, we interviewed headquarters personnel to gain an understanding of the workhour planning process and workhour reduction efforts. Further, we interviewed personnel at nine judgmentally selected mail processing plants, and 10 judgmentally selected processing divisions regarding mail processing workhour management.

Although management reduced workhours in mail processing facilities by more than 17 million hours during FYs 2022 through 2024, there may be opportunities to further reduce workhours by stabilizing or improving productivity. The workhour reductions included a 5 percent decrease in overtime hours; however, mail processing facilities used 10.8 million more hours than planned, which resulted in at least $174.8 million in additional cost. While productivity slightly increased during FY 2024, some mail processing facilities still saw declines in productivity during that year. Opportunities exist for management to more effectively plan for workload shifts and operational challenges during initial workhour planning and to improve mail processing productivity. The Postal Service spent an additional $63.6 million in FY 2024 to cover the additional workhours.

A lead service attendant based in Chicago, Illinois, resigned from his position on April 10, 2025, as a result of our investigation. We found that the former employee violated company policies by consuming alcohol while staying in company-supplied lodging and allowing his girlfriend to stay in his hotel room. We also found that the former employee failed to disclose a conviction on his background questionnaire form during the company’s hiring process. The former employee is not eligible for rehire.

Our Objective(s)To determine (1) whether Bowman & Company, LLPs work complied with the Single Audit Act of 1984, as amended, and the Office of Management and Budget's Uniform Guidance, and the extent to which we could rely on the auditor's work on the U.S. Department of Transportations (DOT) major programs, and (2) whether the Delaware River Port Authoritys reporting package complied with the reporting requirements of the Uniform Guidance.
Why This AuditDuring the fiscal year that ended on December 31, 2022, the Delaware River Port Authority expended approximately $32 million from DOT programs. Bowman & Company determined DOTs major programs were FTAs Federal Transit Cluster, FHWAs Highway Planning and Construction Cluster, and OSTs National Infrastructure Investments Discretionary Grant Program. We performed a quality control review on the single audit conducted by Bowman & Company to ensure compliance with all Federal laws and regulations.
What We FoundReview of Audit Work

Bowman & Company complied with the requirements of the Single Audit Act, the Office of Management and Budget's Uniform Guidance, and DOTs major programs.
We found nothing to indicate that Bowman & Companys opinion on DOT's major programs was inappropriate or unreliable.

Review of Reporting Package

We did not identify any deficiencies that required correction and resubmission of the Port Authoritys reporting package.

RatingWe assigned Bowman & Company an overall rating of Pass.