Federal Reports

What We Looked AtThe Pipeline and Hazardous Materials Safety Administration (PHMSA) aims to protect people and the environment by advancing the safe transportation of energy and other hazardous materials. An essential element of PHMSA’s safety mission is its underlying safety culture—the organization’s safety-related values and behaviors. A positive safety culture is essential to any organization that directly or indirectly addresses high-hazard risks, such as the regulatory agencies of DOT. We initiated this audit to help Agency leaders make informed decisions about their organizational safety culture and focused on PHMSA because it had publicly identified fostering a positive safety culture as a strategic goal. The first part of this report is an assessment of PHMSA’s safety culture. The second part evaluates PHMSA’s efforts to foster a positive safety culture as it carries out its mission and other responsibilities. What We FoundWhile PHMSA exhibits several indicators of a positive safety culture, we also found opportunities to further enhance its efforts. For example, many employees have positive perceptions of their immediate supervisors and the Agency’s impact on industry safety. However, some non-supervisors indicated that they do not trust management to share information and perceive that industry and PHMSA are not sufficiently separate, which may impact the way employees share concerns with management. PHMSA also developed a number of safety culture–related initiatives but did not always complete or document its actions. For example, in 2015, PHMSA allocated $1.5 million for safety culture planning and, over the next 4 years, expended one-third of that amount. Additionally, no one individual is focused wholly on fostering a positive safety culture at all times, including during changes of administrations. While most employees believe PHMSA’s leadership is committed to safety, some express doubt about the leadership’s commitment to fostering a positive safety culture. Our RecommendationsPHMSA concurred with our two recommendations to enhance its efforts to foster a positive safety culture. Accordingly, we consider them resolved but open pending completion of the planned actions.

To view a set of interactive dashboards with up-to-date data on COVID-19 cases in this facility, click here: https://experience.arcgis.com/experience/ab22fb4c564e4f4b986e257c685190…

To view a set of interactive dashboards with up-to-date data on COVID-19 cases in this facility, click here: https://experience.arcgis.com/experience/ab22fb4c564e4f4b986e257c685190…

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the facility to evaluate allegations related to a thoracic surgeon’s surgical complications including patient deaths and misrepresentations of operative note documentation and the facility’s inappropriate reporting of the thoracic surgeon’s complication rate.The surgeon, board certified in thoracic and cardiac surgery, began clinical practice in 2009, started working at the facility in 2013 as a staff thoracic surgeon, and was selected to become Chief of Surgery in July 2014.On November 9, 2017, the OIG received a complaint about the surgeon’s competency and quality of care in five patient cases. The OIG consulted with a non-VA thoracic surgeon, who reviewed the care of the five patients as well as 19 patient cases from a previous OIG evaluation.The non-VA consultant identified quality of care concerns with 16 of the 24 patient cases. The facility completed external management reviews and found five cases of concern. In February 2019, the surgeon was reassigned to a nonclinical care setting. Veterans Health Administration (VHA) and Veterans Integrated Service Network leaders established a panel of VHA cardiothoracic surgeons who reviewed 22 of the 24 cases evaluated by the non-VA consultant as well as other, additional cases. In December 2019, the panel determined that the surgeon delivered thoracic surgical care within quality expectations and the surgeon resumed patient care.The OIG did not substantiate that the facility failed to appropriately report surgical errors and complications. The OIG made five recommendations to the Under Secretary for Health related to a thoracic specialty leader, operative documentation, the National Surgery Office’s surgery assessments, and peer review processes. The OIG made an additional five recommendations to the Facility Director related to operative documentation, professional communications, Surgical Work Group oversight, privileging, and institutional disclosures.

Marc Hoang, a Pharmacist based in West Covina, California, pleaded guilty in United States District Court, Central District of California, on October 26, 2020, to making a false statement related to a health care fraud investigation. Our investigation found that Hoang knowingly and willfully made a materially false and fraudulent statement on a Drug Enforcement Administration (DEA) form. Hoang submitted the form to the DEA to renew the controlled substances registration for his former pharmacy. On the form, Hoang represented that he was the person who distributed the controlled substances and was the officer and point of contact for the pharmacy, when in fact, he was not.In this same investigation, Navanjun Grewal, a Plastic and Reconstructive Surgeon based in Beverly Hills, California, pleaded guilty in United States District Court, Central District of California, on January 13, 2021, to making and using a false document and to obstruction of a federal audit. Our investigation found that Grewal created false and fraudulent patient files in response to an audit request regarding prescriptions for compounded medications that were submitted for reimbursement.Both defendants will be sentenced at a future date.

Under the home health prospective payment system (PPS), the Centers for Medicare & Medicaid Services pays home health agencies (HHAs) a standardized payment for each 60-day episode of care that a beneficiary receives. The PPS payment covers part-time or intermittent skilled nursing care and home health aide visits, therapy (physical, occupational, and speech-language pathology), medical social services, and medical supplies.Our prior audits of home health services identified significant overpayments to HHAs. These overpayments were largely the result of HHAs improperly billing for services to beneficiaries who were not confined to the home (homebound) or were not in need of skilled services.Our objective was to determine whether Southeastern Home Health Services (Southeastern) complied with Medicare requirements for billing home health services on selected types of claims.

What We Looked AtIn the last 5 years, fatalities in crashes involving large trucks or buses increased by 10.6 percent. As part of its mission, the Federal Motor Carrier Safety Administration (FMCSA) oversees its medical certification program and promotes safety through regulations, policies, and monitoring of certified medical examiners and driver examinations. In May 2014, FMCSA initiated the National Registry of Certified Medical Examiners (National Registry) to assist in verifying that medical examiners can effectively determine if interstate commercial drivers meet FMCSA’s physical qualification standards. We initiated this audit given the significant safety risk posed by drivers who do not meet physical qualification requirements. Our audit objectives were to evaluate FMCSA’s procedures for overseeing its medical certificate program. Specifically, we analyzed FMCSA’s procedures for (1) validating and maintaining data quality in the National Registry and (2) monitoring medical examiner eligibility and performance and reviewing driver examinations.What We FoundFMCSA’s ability to oversee whether drivers meet physical qualification standards to safely operate a commercial vehicle is limited because of a lengthy outage of the National Registry and a resulting backlog of driver examination reports that were not entered into the Registry. In addition, weaknesses associated with the accuracy and completeness of data in the National Registry limit the effectiveness of FMCSA’s oversight. Furthermore, FMCSA has not fully implemented requirements for random periodic monitoring of medical examiners’ eligibility and performance. While FMCSA has conducted initial certification reviews of medical examiners’ eligibility qualifications, the Agency is not yet conducting annual eligibility audits after initial certification. Without these oversight reviews, FMCSA may be missing fraud indicators or other risks that may require mitigation and has less assurance that drivers are physically qualified to safely operate a commercial vehicle.Our RecommendationsWe conducted our audit of FMCSA’s medical certification program during a transition period while the Agency is working to design and deploy a new National Registry. FMCSA concurred with our four recommendations to improve FMCSA’s oversight of its medical certification program once the Agency deploys its new National Registry. 

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA Central Iowa Health Care System (facility) in Des Moines in response to an OIG Office of Investigations referral regarding a facility report that a urologist practiced, was privileged, and ordered controlled substances without a Drug Enforcement Administration (DEA) registration.The OIG confirmed the facility’s report regarding the urologist and assessed facility medical staff management processes. The OIG found that the urologist was able to practice and was privileged without DEA credentials because facility leaders did not timely implement a Veterans Health Administration (VHA) directive requiring providers who ordered controlled substances to possess an individual DEA registration. Upon recognizing that the urologist verbally ordered controlled substances in the operating room without a DEA registration, facility leaders took action by notifying the OIG Office of Investigations of the urologist’s unauthorized ordering, suspending the urologist’s privileges for one month, and implementing a process to ensure all controlled substance ordering providers, including the urologist, hold an active DEA registration. The failure of the urologist to timely obtain a DEA registration was not related to clinical competency.The OIG was concerned, however, that the facility’s operating room practice permitted surgeons to issue verbal orders for nonurgent medications without subsequently entering the medication orders in the computer. The practice bypassed quality controls and prevented pharmacists and controlled substance inspectors from reviewing medication orders. The OIG made five recommendations to the Facility Director related to monitoring compliance with VHA and facility policies to maintain DEA registrations and management of medications in the operating room.

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A Pennsylvania man pleaded guilty in U.S. District Court, Northern District of Illinois, to theft of government funds on January 12, 2021. Our investigation disclosed that Ryan Kane, a resident of Philadelphia, participated in a scheme to defraud Amtrak and others by using stolen credit card information from more than 10 credit cards to purchase Amtrak tickets online. Kane then cancelled the Amtrak tickets and received vouchers for the value of those tickets from Amtrak. Kane sold the Amtrak vouchers on eBay at a fraction of their face value. As a result, Kane fraudulently caused Amtrak to issue more than $35,000 in ticket vouchers.In addition, Kane conspired with Christian Newby by showing him how to execute the scheme. Newby, a resident of Milan, Michigan, defrauded Amtrak of more than $540,000 and was sentenced to 72 months in federal prison in September 2020.Kane will be sentenced at a future date.

This report presents the results of our self-initiated audit of property conditions at the Smithville (owned), Leander (owned), and Kyle (leased) post offices in the Rio Grande District. This audit was designed to provide Postal Service management with timely information on potential risks related to property conditions. The Postal Service is required to maintain a safe and healthy environment for both employees and customers in accordance with its internal policies and procedures and Occupational Safety and Health Administration (OSHA) safety laws. Our objective was to determine if Postal Service management is adhering to building maintenance, safety and security standards, and employee working condition requirements at post offices.

Late trips occur when various conditions cause a delay in the arrival or departure of transportation beyond the scheduled times. When mail processing operations do not process mail timely or mail volume is above normal or expected levels, managers may have to call extra trips to transport this mail. Late and extra trips to delivery units can cause disruptions and increase the number of carriers returning after 6 p.m. When carriers return after 6 p.m., customer service can suffer and mail collected by the carriers may be late to the Processing and Distribution Center (P&DC). In addition, late returning carriers can cause increased overtime and penalty overtime costs. We conducted this audit of late and extra trips at the Richmond P&DC in Sandston, VA, to provide Postal Service management with timely information on operational risks.

The Los Angeles P&DC is in the Southern California Division of the Logistics and Processing Operations Western Region. The P&DC processes letters, flats, and parcels. From July 1 to September 30, 2020, it reported 4,637 late trips (highest among P&DCs) and 1,535 extra trips (second highest among P&DCs) from the plant to delivery units. Our objective was to assess the causes of late and extra trips.

Inspection and Evaluation of CFTC’s Compliance with E.O. 13950, Combating Race and Sex Stereotyping (September 22, 2020) (CFTC OIG 2021-IE-1)

An Amtrak carman based in Beech Grove, Indiana, was terminated from employment on January 9, 2021, following his administrative hearing. Our investigation found the former employee violated company policy when he failed to report multiple drug or alcohol related convictions on his initial background investigation questionnaire.

The objective of this audit was to determine the effectiveness of security measures for select IT systems that support the 2020 Census. Our audit scope included the Bureau’s risk management program, security operations center (SOC) capabilities, security of Active Directory, and implementation of multi-factor authentication. We found the following: (1) The Bureau’s inadequate risk management program left significant risks present in decennial IT systems. (2) The Bureau’s Decennial security operations center lacked fundamental capabilities during periods of decennial census data collection. (3) The Bureau inadequately managed its Active Directory that supports decennial census operations. (4) The Bureau had not fully enforced personal identity verification in accordance with federal and Department requirements.

We reviewed the U.S. Department of the Interior’s (DOI’s) compliance with four requirements from Executive Order 13950, Combating Race and Sex Stereotyping. The DOI met two of the requirements we reviewed and made progress toward compliance in the other two.This report was issued to the Secretary of the Interior for his information. We did not offer recommendations or require any further action.

Our objective was to evaluate the Contract Delivery Service (CDS) renewal process for compliance with Postal Service policies and procedures. Our scope included all CDS contract renewals for fiscal years (FY) 2018 and 2019. The Postal Service has statutory authority to contract for surface mail transportation services from any carrier or person carried out via Highway Contract Routes, which include transporting mail and CDS routes. CDS routes are contract agreements between the Postal Service and private individuals or firms to deliver and collect mail nationwide.

The OIG completed an audit to identify the extent to which the EPA's Office of Research and Development research initiatives address threats and risks to public health and the environment from plastic pollution within the waters of the United States.

EAC OIG, through the independent public accounting firm of McBride, Lock, & Associates, LLC, audited $3.7 million in funds received by the New Mexico Secretary of State under the Help America Vote Act. The objectives of the audit were to determine whether the Office: 1) used funds for authorized purposes in accordance with Section 101 of HAVA and other applicable requirements; 2) properly accounted for and controlled property purchased with HAVA payments; and 3) used the funds in a manner consistent with the budget plan provided to EAC.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to determine the validity of an allegation regarding a patient’s mental health care at the Harry S. Truman Memorial Veterans’ Hospital (facility) in Columbia, Missouri, prior to death by suicide. The OIG reviewed the patient’s mental health care coordination, discharge planning, suicide risk screening and evaluation, administrative actions, and Mental Health Treatment Coordinator (MHTC) assignment. The OIG substantiated that the patient died by suicide within three days of discharge from the facility’s Inpatient Mental Health Unit. The OIG also substantiated that an inpatient psychiatry resident initiated antidepressant medication, and a registered nurse provided discharge instructions that included suicide prevention materials, consistent with Veterans Health Administration (VHA) guidance. Inpatient staff did not include Columbia Vet Center staff in discharge planning and failed to complete the VHA-required comprehensive suicide risk evaluation prior to the patient’s discharge, which may have contributed to missed information to adequately establish acute and chronic suicide risk factors and a risk mitigation plan. Facility leaders did not establish an MHTC policy and staff did not assign the patient’s MHTC while awaiting transfer to another level of care. Staff failed to comprehensively report a positive suicide risk screening result in an issue brief related to the patient’s death, and facility leaders, in part based on the issue brief, did not make an institutional disclosure to the patient’s next of kin.Veterans Integrated Service Network and National Center for Patient Safety leaders did not have knowledge of a memorandum of understanding that required Vet Center representation for shared patients during VHA root cause analyses. The OIG made one recommendation to the Under Secretary for Health and six recommendations to the Facility Director.

The Columbia Main Post Office is located in the Gateway District of the Central Area. This audit was designed to provide U.S. Postal Service management with timely information on potential scanning and mail delivery risks at the Columbia Main Post Office. The delivery unit has 38 city routes which are delivered by 47 full-time carriers and 12 City Carrier Assistants. The unit also has nine rural routes delivered by eight full-time, seven Replacement Carriers, and six Assistant Rural Carriers. We chose the Columbia Main Post Office based on the number of stop-the-clock scans occurring at the delivery unit. Our objective was to evaluate select mail delivery and customer service operations and determine whether internal controls were effective at the Columbia Main Post Office. We found issues related to package scanning and also the safeguarding of assets.

This memorandum provides the results of our evaluation of the Economic Development Administration’s (EDA’s) plan for the implementation of Coronavirus Aid, Relief, and Economic Security Act (CARES Act)1 funding. Our objective was to determine whether EDA implemented and followed the requirements of the CARES Act. Specifically, we determined (1) what steps EDA took in implementing the CARES Act, (2) challenges EDA faced during implementation, and (3) EDA’s ongoing efforts in awarding funds under the CARES Act. Overall, we found that EDA implemented and followed the requirements of the CARES Act. EDA has put in place measures to mitigate challenges resulting from employees working from home due to the COVID-19 pandemic, and it is on track to obligate all CARES Act funds before September 30, 2022. EDA, however, still faces challenges in its workforce planning for emergency and disaster relief efforts.

The U.S. Department of Housing and Urban Development, Office of Inspector General, has completed its audit of Federal Housing Administration (FHA)-insured loans originated in calendar year 2019. Our audit objective was to determine whether FHA insured loans that were not eligible for insurance because they did not have the required flood insurance coverage. We found FHA insured at least 3,870 loans that closed in 2019, totaling $940 million, which were not eligible for insurance because they were made for properties in flood zones without the required flood insurance coverage. We found loans that had private flood insurance instead of the required national flood insurance program coverage, coverage that did not meet the minimum required amount, or no coverage at the time the loan was closed and endorsed. We recommend that FHA require lenders to provide evidence of sufficient flood insurance or execute indemnification agreements for the 43 loans in our statistical sample that did not have sufficient flood insurance at the time of our audit. We also recommend that FHA add to HUD databases the information necessary to ensure that the required flood insurance is in place at loan origination, including flood zone, flood insurance type, flood insurance amount, and site value of the property, and include system checks that prevent endorsement of loans without the required flood insurance.

See the additional details link below for the full report, report summary, multimedia or any agency follow-up.

To gain insight on the effects and impact of COVID-19 on law enforcement investigative operations, the DOJ Office of the Inspector General (OIG) surveyed law enforcement personnel within the DOJ during July and early August of 2020. Specifically, the OIG deployed an anonymous online survey to Special Agents; Criminal Investigators; General Inspection, Investigation, Enforcement, and Compliance personnel; and U.S. Marshals and Deputy U.S. Marshals. Results from this survey are available at the following link: https://experience.arcgis.com/experience/891259547d994573a314acf7927ac6…

For our evaluation of the First Responder Network Authority’s (FirstNet Authority’s) actions following our August 2019 management alert, FirstNet Management Altered Contract Requirements Without Authorization -- which was a result of a hotline complaint -- our objective was to assess whether FirstNet Authority management took steps to address the concerns noted in our August 2019 management alert and whether continued concerns still existed.We observed that FirstNet Authority management took several actions consistent with the corrective steps proposed in the management alert. However, FirstNet Authority’s actions have not fully mitigated issues included in the management alert. Continued management attention is warranted to strengthen the underlying control environment, which continues to allow inappropriate management actions.

We audited Neighborhood Housing Services of Los Angeles County’s (NHSLA) Neighborhood Stabilization Program 2 (NSP2). The audit was based on a complaint alleging questionable NSP2 financial activity, double payments to contractors, and payments to contractors for incomplete work. Our Office of Audit received the referred complaint in late 2018. However, because the complaint included concerns regarding activities and auditee actions from at least 5 years before, we did not address the specific complaint issues but instead reviewed more recent program activities. The objective of the audit was to determine whether NHSLA administered its NSP2 in accordance with program requirements, focusing on procurement and contracting, expenditures of program income, and tracking and accounting of program income.NHSLA did not always follow program requirements in administering its NSP2. Specifically, it (1) could not support NSP2 activities in its interfund account and revolving loan fund, (2) borrowed NSP2 program income and deposited those funds into its non-NSP2 accounts, (3) could not support administrative and project delivery costs, and (4) did not have proper documentation to support the procurement of its construction contract. As a result, the U.S. Department of Housing and Urban Development (HUD) did not have assurance that more than $5.1 million in program income was used for its NSP2, $1.7 million in salary expenditures was in accordance with program requirements, and $856,692 in construction costs was reasonable.We recommend that the Director of the Los Angeles Office of Community Planning and Development require NHSLA to (1) support the eligibility of interfund activities or repay the program $3.4 million from non-Federal funds, (2) return $529,745 in program income funds to its NSP2 account, (3) support the use of its loan proceeds or repay the program $658,261 from non-Federal funds, (4) support transfers of NSP2 funds or repay the program $500,000 from non-Federal funds, (5) support its administrative and project delivery costs or repay the program more than $1,388,545 from non-Federal funds and not reimburse another $324,478, (6) support the reasonableness of the construction contract or repay the program $856,692 from non-Federal funds, and (7) develop and implement procedures and controls for its procurement.

DOL-OIG Investigations Newsletter Volume XXXI for the period of October 1 - November 30, 2020

Memorandum for Department of Defense Lead Inspector General

During the COVID-19 pandemic, the Postal Service provided vital service, including the delivery of critical items such as medications, stimulus payments, and Social Security checks. Further, the Postal Service is the leading delivery service provider for online purchases. A May 2020 Harris Poll survey on America’s 100 essential companies’ responses to the COVID-19 pandemic, ranked the Postal Service as number one, based on its resolve, integrity, responsiveness, and permanence. Our objective was to evaluate mail service during the early stages of the novel coronavirus (COVID-19) disease pandemic.

On 27 March 2020, Congress passed the Coronavirus Aid, Relief, and Economic Security (CARES) Act, which provided emergency assistance and healthcare response for individuals, families, and businesses affected by the Coronavirus disease. Section 3610 of the CARES Act provided agencies discretionary authority to reimburse costs of paid leave to federal contractors and subcontractors using existing appropriations to keep these individuals in a ready state and to protect the life and safety of government and contractor personnel. Given the unprecedented circumstances surrounding these Section 3610 authorities, including the potential risk to National Reconnaissance Office (NRO) programs as well as substantial funding outlays, the NRO Office of Inspector General conducted this evaluation. The objectives were to evaluate the NRO's implementation of Section 3610 of the CARES Act and to identify preliminary impacts to the NRO's mission. The OIG determined that the NRO used a multifaceted strategy consistent with Section 3610 and Office of Management and Budget guidance to ensure mission resilience while protecting the health and safety of the NRO contractor workforce. The OIG also identified potential impacts to the NRO's mission that could influence the efficiency and effectiveness of NRO's activities moving forward.

The OIG investigated an allegation that a company improperly billed hours in late 2018 and early 2019 to a grant it received from the National Fish and Wildlife Foundation (NFWF) to manage Hurricane Sandy coastal resiliency projects.We determined that five employees of the company recorded 561.75 labor hours to the NFWF grant when, in fact, they worked on a National Oceanic and Atmospheric Administration contract. We learned that the company corrected the improper billing and took administrative action against four employees before we initiated our investigation. The company did not charge the NFWF for the 561.75 labor hours; it, however, also never notified the NFWF of the problem.As a result of our investigative efforts, the company conducted a second review of the billing on the NFWF grant and determined that additional hours charged by three of its employees to the NFWF grant were inappropriate. The company subsequently reimbursed the NFWF $44,332.94. On October 14, 2020, the NFWF provided the company with a written notice terminating its grant agreement, effective 30 days from the date of the memo.

An Amtrak yard conductor based in Washington, DC, resigned from the company on December 31, 2020, prior to his administrative hearing. The former employee was administratively charged by Amtrak management for actions that brought discredit to the company. Our investigation found that the former employee had been indicted on state child molestation charges in June 2020. On December 15, 2020, the former employee was convicted of the charges and sentenced to 18 months in prison, one year home confinement, and five years’ probation.

The National Security Agency Office of the Inspector General (OIG) released the unclassified report on its review of the Agency’s Implementation of Executive Order 13950 on Combating Race and Sex Stereotyping.

The Minneapolis Main Post Office is located in the Northland District of the Central Area. OIG data analytics identified Minneapolis Main Post Office as having a large stamp inventory of approximately $3 million. Our objective was to determine whether the Minneapolis Main Office properly accounted for stamps, money orders, and cash.

This report includes EAC OIG’s independent assessment of the top management challenges facing EAC in fiscal year 2021.

The Election Assistance Commission Office of Inspector General reviewed the audit operations of FEC OIG.

In response to the U.S. Chemical Safety and Hazard Investigation Board’s request, the OIG for the U.S. Environmental Protection Agency—which also serves as the OIG for the CSB—completed an evaluation of the CSB’s compliance with Executive Order 13950, Combating Race and Sex Stereotyping.

The OIG investigated an allegation that a former Bureau of Land Management (BLM) surveyor violated ethics rules by representing his current employer in matters on which he personally and substantially worked while at the BLM.We did not find evidence that the former employee violated post-Government employment ethics laws or engaged in any conduct that could be construed as representing his current employer in matters related to the survey at issue.

The Postal Service contracts with a variety of suppliers for goods and services such as technical and consulting services. Accenture Federal Services (Accenture) accounted for the highest amount of funds the Postal Service spent for IT contracts during FYs 2018 and 2019 – about $332 million. Our objective was to assess contractual compliance and oversight of the Postal Service’s Accenture information technology (IT) contracts for fiscal years (FY) 2018-2019.

See the additional details link below for the full report, report summary, multimedia or any agency follow-up.

See the additional details link below for the full report, report summary, multimedia or any agency follow-up.