Federal Reports

Making accurate and consistent decisions on disability compensation claims is vital to ensuring eligible veterans receive their benefits. The Veterans Benefits Administration (VBA) uses the Quality Review and Consistency Program (consistency study program) to ensure accurate and timely claims processing. The VA Office of Inspector General (OIG) examined whether VBA managed the consistency study program to improve uniformity in processing disability benefits claims. This review is one in a series of five reports regarding VBA’s quality assurance program. The consistency study program identifies error trends in quality reviews to develop consistency studies for claims processors. The program completed 60 consistency studies from October 1, 2015, through April 30, 2019, and conducted required training. However, the OIG found VBA missed opportunities to drive nationwide uniformity in claims processing. For example, the Compensation Service could have shared more accessible information with regional offices on their claims processors’ knowledge and performance. VBA’s Office of Field Operations (OFO) also did not ensure all claims processors participated in required studies, nor did staff follow up on study results to ensure improvements were made. The office was reported to have prioritized productivity over accuracy. The OIG concluded OFO should require regional office managers to take corrective action on consistency study results to improve accuracy and staff performance. Overall, VBA lacked strong processes for sharing and monitoring study results and could capitalize on information it already collects to help close knowledge gaps and improve the consistency of claims decisions. Recommendations include that the Compensation Service ensure detailed consistency study reports go to OFO and all regional office managers. OFO should also develop a process to monitor regional offices to increase employee participation in consistency studies and require regional managers to review study results to address performance issues.

In June 2016, the Postal Service developed the Enterprise Transportation Analytics (ETA) system which uses GPS technology to provide near real-time visualizations and reports of Highway Contract Route (HCR) vehicles and thus enabling management to evaluate HCR compliance with contract requirements. The Postal Service also replaced its existing GPS program with a new GPS technology solution covering HCRs, Postal Vehicle Service, and leased trailers. The Postal Service planned to use the GPS program to measure HCR trailer usage, provide location visibility, estimate time of arrival, optimize travel routes, and improve service. Our objective was to assess the Postal Service’s management of Highway Contract Route (HCR) compliance with the Global Positioning System (GPS) program.

Peer Review on the Federal Labor Relations Authority, Office of Inspector General audit organization performed by the Inspector General of the National Endowment for the Humanities.

What We Looked AtThe Federal Information Security Modernization Act of 2014 (FISMA) requires agencies to implement information security programs. FISMA also requires agencies to have annual independent evaluations performed to determine the effectiveness of their programs and report the results of these reviews to the Office of Management and Budget (OMB). To meet this requirement, the Surface Transportation Board (STB) requested that we perform its fiscal year 2020 FISMA review. We contracted with Williams Adley & Company-DC LLP (Williams Adley), an independent public accounting firm, to conduct this audit subject to our oversight. The audit objective was to determine the effectiveness of STB's information security program and practices in five function areas--Identify, Protect, Detect, Respond, and Recover.What We FoundWe performed a quality control review (QCR) of Williams Adley's report and related documentation. Our QCR disclosed no instances in which Williams Adley did not comply, in all material respects, with generally accepted Government auditing standards.RecommendationsSTB concurs with Williams Adley's six recommendations.

OIG reviewed FSA’s implementation of emergency assistance for honeybeeclaims for PY 2017.

OIG evaluated FSA's administration and oversight of WHIP, a USDA disaster assistance program.

The Office of Inspector General (OIG) provides oversight to U.S. Department of Agriculture (USDA) programs and operations to help ensure that USDA is able to provide the best possible service to the public and American agriculture. OIG focuses its efforts to advance the value, safety and security, and integrity of USDA programs. In providing such oversight, OIG makes recommendations to address agency programs and core management functions that may be vulnerable to waste, fraud, abuse, and mismanagement. These vulnerabilities can affect USDA’s ability to achieve its mission. Since the Reports Consolidation Act of 2000, OIG has annually reported on the Department’s progress in addressing its most critical management challenges. The COVID-19 pandemic, and USDA’s increased responsibilities for program delivery, have made addressing these challenges even more important.

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

The VA Office of Inspector General (OIG) conducted a healthcare inspection after receiving a referral from OIG inspectors regarding facility leaders’ response to a report that a urologist had severe hand tremors and possibly low vision. The OIG identified two adverse clinical outcomes in 121 of the urologist’s surgical patients, neither of which required an increased level of care and did not result in long-term impact. The OIG determined the two complications were appropriately managed by the urologist, reported through the patient safety reporting system, and acted upon. Facility leaders failed to adequately oversee the urologist’s performance by not formally evaluating a report of the urologist’s physical impairments that could have posed a risk to patient safety. The facility conducted management reviews of the urologist, but deficiencies were identified in the processes used. Failures in facility leaders’ privileging processes led to delays in removing the urologist’s privilege to perform open procedures and a failure to inform the urologist of active privileges. Facility leaders were noncompliant with VHA directives that require reporting adverse privileging actions to the National Practitioner Data Bank and reporting patient safety concerns to state licensing boards. Consequently, patient safeguards intended to be achieved through reporting did not occur. Frequent personnel changes in facility-leader positions may have contributed to failures in oversight, privileging, and practitioner reporting processes. The noncompliance with facility and VHA policies likely occurred due to poor communication regarding the urologist’s practice and privileging status, a lack of knowledge of position responsibilities, and inexperienced support staff. The deficiencies found in the focused professional practice evaluation processes and National Practitioner Data Bank reporting were consistent with issues previously identified by the OIG. Duplicative recommendations were not made regarding these issues. The OIG made six recommendations to the Veterans Integrated Service Network 7 and facility directors.

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

We audited the Tennessee Valley Authority’s (TVA) business meeting and hospitality expenses to determine if they complied with TVA’s Business Meetings and Hospitality policy and any other applicable TVA guidance. Our audit scope included approximately $6.5 million in business meeting and hospitality expenses occurring from October 1, 2018, through September 30, 2019.Our audit found TVA’s approval process did not ensure expenses complied with the Business Meetings and Hospitality Policy. Specifically, we found expenses were approved for (1) reimbursement and/or payment without the required information and supporting documentation included with the expense voucher, (2) questionable team-building expenditures, and (3) prohibited alcohol expenditures. We also found a lack of guidance for compliance with TVA’s Food Services Policy. Additionally, we found the process for approving large meeting expenses and guidance for the classification of meeting-related expenses could be improved.We made five recommendations to TVA management to strengthen controls around business meetings and hospitality by (1) developing additional guidance to ensure compliance with the Business Meetings and Hospitality Policy and Food Services Policy, and (2) reinforcing the existing Food Services Policy. TVA management provided actions they plan to take to address each of our recommendations.

We included an audit of the Tennessee Valley Authority’s (TVA) plans for an active shooter incident in our annual audit plan due to the potential risk of an active shooter incident occurring. Our audit objective was to determine if TVA has adequate plans in place to prevent, prepare for, and manage active shooter incidents. The audit scope included all program documentation and records that support TVA's plans to prevent, prepare for, and manage active shooter incidents as of May 13, 2020. We compared TVA’s procedures around preventing, preparing for, and managing active shooter incidents to best practices recommended by the Department of Homeland Security (DHS). DHS best practices include four steps (Connect, Plan, Train, and Report) to apply in advance of an incident or attack. We found TVA has plans in place to prevent, prepare for, and manage active shooter incidents that include steps to address the connecting and planning phases of DHS recommendations to prepare for active shooter incidents. However, we found the training and reporting steps need improvement. Specifically, we found TVA’s Active Threat Awareness program training is not mandatory and less than 10 percent of TVA’s employees have taken the training. In addition, portions of best practices related to active threat awareness are included in at least ten TVA Standard Programs and Processes rather than a single document and are not easily accessible by employees. TVA management agreed with our findings and recommendations.

The cover page of this report was updated on 2/5/21 to include a comment box that states, "The statements made on pages 2 and 20 regarding OCC providing whistleblower complaints to Treasury OIG Office of Investigations (OI) were clarified in a memorandum dated February 5, 2021 (OIG-CA-21-016). The memorandum clarified that OCC should continue to send allegations of OCC employee misconduct and Orders of Investigations to OI."Please read this report in conjunction with Treasury OIG Memorandum, OIG-CA-21-016, Whistleblower Referrals to the Department of the Treasury Office of Inspector General, Office of Investigations, dated 2/5/2021.

What We Looked AtWe performed a quality control review (QCR) on the single audit that RHR Smith & Company (Smith) performed for the Green Mountain Transit Authority’s (Authority) fiscal year that ended June 30, 2018. During this period, the Authority expended approximately $14.5 million from the U.S. Department of Transportation’s (DOT) grant programs. Smith determined that DOT’s major program was the Federal Transit Cluster. Our QCR’s objectives were to determine (1) whether the audit work complied with the Single Audit Act of 1984, as amended, the Office of Management and Budget’s Uniform Guidance, and the extent to which we could rely on the auditors’ work on DOT’s major programs; and (2) whether the Authority’s reporting package complied with the reporting requirements of the Uniform Guidance. We FoundSmith’s audit work complied with the requirements of the Single Audit Act, the Uniform Guidance, and DOT’s major program. We found nothing to indicate that Smith’s opinion on DOT’s major program was inappropriate or unreliable. However, we identified a deficiency in Smith’s audit work that should be corrected in future audits. We also identified deficiencies in the Authority’s reporting package that required correction and resubmission.

What We Looked AtFreight trains in the United States generally operate with a conductor, who is responsible for the train, freight, and crew, and an engineer, who operates the locomotive. To ensure that only people who meet minimum Federal safety standards serve as conductors, in 2011, the Federal Railroad Administration (FRA) issued a rule for the certification of conductors, Title 49, Code of Federal Regulations, Part 242. This rule requires railroads to have a formal program for training prospective conductors and determining that they are competent before they are certified. Given the potential impact of the conductor certification rule on railroad safety, we initiated this audit to assess FRA’s oversight of railroad conductor certification programs. What We FoundFRA does not have sufficient oversight controls to consistently assess railroads’ compliance with Part 242 requirements. Specifically, FRA reviews of railroad conductor certification programs lack formal procedures. FRA officials currently evaluate programs using a checklist with some Part 242 requirements, an industry group program template, and officials’ professional judgment. These narrow reviews are not comprehensive, however, because programs are not evaluated at a consistent level of detail, and the process remains undocumented. FRA officials also perform Part 242 inspections and compliance audits without comprehensive procedures. As a result, the audit documentation and inspection data do not identify all of the Agency’s Part 242 compliance audits or demonstrate audit quality. However, FRA is responsive to Part 242 waiver requests and conductor certification petitions. Specifically, the Agency has procedures in place for handling waiver requests and is meeting its goal timelines for reviewing and deciding on petitions. Our RecommendationsWe made five recommendations to improve FRA’s oversight of railroad conductor certification programs, guidance for program officials and inspectors, and quality of its audit data. FRA concurred with all of our recommendations, and we consider them resolved but open pending completion of the planned actions.

U.S. Customs and Border Protection (CBP) does not have a comprehensive strategy for meeting its LS-NII scanning needs at all CBP locations. Instead, CBP used multiple plans, such as its Multi-Year Investment and Management Plan, and individual acquisition plans for each type of LS-NII equipment it may purchase. At times, these acquisition plans contained conflicting information and did not align with the program’s approved life-cycle cost estimate. We made three recommendations to improve CBP’s acquisition planning for LS-NII needs and ensure effective investments for its non-intrusive inspection program. We recommended the DHS Under Secretary for Management require the acquisition program office to develop an approved strategy that aligns its NII key acquisition documents with CBP’s evolving investments in critical LS-NII equipment. In addition, the CBP Component Acquisition Executive should implement procedures to ensure better alignment and tracking of reliable LS-NII data, and ensure an NII strategy encompasses an approved Acquisition Program Baseline that includes key performance baselines for all critical LS-NII equipment. The Department did not concur with one recommendation but concurred with two of our three recommendations.

DHS’ information security program was not effective for Fiscal Year 2019 because the Department earned a maturity rating of “Ad Hoc” (Level 1) in three of five functions, compared to last year’s higher overall rating of “Managed and Measurable” (Level 4). We attributed DHS’ regression in managing its information security program to its recent decision to permit the Coast Guard to submit its cybersecurity and Federal Information Security Management Act (FISMA) reports to the Department of Defense rather than to DHS. This decision adversely affects Department senior leadership’s ability to make informed and risk-based decisions on essential cybersecurity activities such as risk management, weakness remediation, system inventory, incident reporting, and continuous monitoring. We made five recommendations. The Department concurred with all five recommendations.

On March 27, 2020, the President signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). To date the CARES Act has provided the U.S. Department of the Interior (DOI) with $909.7 million, which includes direct apportionments of $756 million to support the needs of DOI programs, bureaus, Indian Country, and the Insular Areas, and a $153.7 million transfer from the U.S. Department of Education to the BIE.This report presents the DOI’s progress as of August 31, 2020, in spending CARES Act appropriations. Specifically, the DOI’s expenditures to date total $526,662,366, and its obligations total $624,399,884.We are also monitoring the DOI’s progress on reporting milestones established by the CARES Act and the U.S. Office of Management and Budget.We anticipate issuing updated status reports monthly.

Final FY 2020 OIG Management Challenges Report 09282020

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

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

To see our report, click on the link below

The objective of this interim review is to provide RRB management with information that will assist them in ensuring compliance, transparency, and fiscal accountability under the CARES Act.

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

The Cybersecurity and Infrastructure Security Agency (CISA) increased the number of Automated Indicator Sharing (AIS) participants as well as the volume of cyber threat indicators it has shared since the program’s inception in 2016. However, CISA made limited progress in improving the overall quality of information it shares with AIS participants to effectively reduce cyber threats and protect against attacks. The lack of progress can be attributed to the limited number of AIS participants sharing cyber indicators with CISA, delays in receiving cyber threat intelligence standards, and insufficient staff. To be more effective, CISA should hire the staff it needs to provide outreach, guidance, and training. We made four recommendations to CISA to enhance the program’s overall effectiveness and cyber threat information sharing. CISA concurred with all four recommendations.

The VA Office of Inspector General (OIG) examined whether the Veterans Health Administration (VHA) adequately governs its purchase and use of robotic surgical systems. Employees at VA medical facilities submit applications to the VHA Office of Healthcare Technology Management to purchase these systems. The office reviews applications and recommends them to the assistant deputy under secretary for health for administrative operations for final approval. The systems cost between $1.5 million and $2.2 million each, including parts and maintenance. The OIG found VHA did not consistently support its acquisition of robotic surgical systems as required by VA policy. Between June 2013 and September 2018, the office recommended approving 45 applications. Of these, 13 systems had incomplete information to support a justification. In addition, 10 systems did not have documented evidence of final approval before acquisition. VHA also did not have comprehensive data on robotic surgeries. VHA’s National Surgery Office reported about 2,300 fewer procedures than the manufacturer of the robotic systems had recorded during fiscal year 2018. The manufacturer’s data was based on information the robotic systems automatically captured for each procedure. VHA underreported the number of robotic surgical procedures because medical facility staff coded them inconsistently in VA’s electronic health information system. VHA concurred with all OIG recommendations, including that VHA provide clearer instructions for preparing and supporting applications for high-cost, high-tech medical equipment and ensure applications are reviewed and validated before they are recommended for final approval. VHA also agreed to evaluate the need and justification for the 10 surgical systems acquired without final approval. Finally, in response to OIG recommendations, VHA will develop guidance for coding robotic surgical procedures accurately and consistently and evaluate whether the National Surgery Office needs to obtain data from the system manufacturer to validate VHA data.

The VA Office of Inspector General (OIG) received wide-ranging allegations of misconduct in the operations of the Veterans Health Administration’s Consolidated Patient Account Center (CPAC) field offices, which function within the Office of Community Care and conduct medical billing functions for VA medical centers in designated regions. The OIG substantiated the following allegations: 1. CPAC management improperly used government funds to purchase food for CPAC employees in fiscal years 2015 and 2016 in connection with events held as part of VA’s Diversity and Inclusion initiative; 2. One CPAC violated VA policy for disposing of excess equipment when computer monitors were given to a local school without following established procedures; and 3. Some CPAC field offices violated VA policy requiring that destruction of temporary paper records be performed pursuant to a written contract. The OIG made two recommendations, with which VA concurred and took prompt corrective action. The OIG considers these recommendations closed. Allegations relating to improper travel, the misuse of funds for the purchase of daily planners and a wheelchair, and the improper use of purchase cards for armored car services were not substantiated.

The Federal Emergency Management Agency (FEMA) mismanaged the distribution of commodities in response to Hurricanes Irma and Maria in Puerto Rico. FEMA lost visibility of about 38 percent of its commodity shipments to Puerto Rico, worth an estimated $257 million. Commodities successfully delivered to Puerto Rico took an average of 69 days to reach their final destinations. Inadequate FEMA contractor oversight contributed to the lost visibility and delayed commodity shipments. FEMA did not use its Global Positioning System transponders to track commodity shipments, allowed the contractor to break inventory seals, and did not ensure documented proof of commodity deliveries. Given lost visibility and delayed shipments, FEMA cannot ensure it provided commodities to Puerto Rico disaster victims as needed to sustain life and alleviate suffering as part of its response and recovery mission. In addition, FEMA’s mismanagement of transportation contracts included multiple contracting violations and policy contraventions that ultimately led to contract overruns of about $179 million and at least $50 million of questioned costs. We made five recommendations that, if implemented, should improve FEMA’s management and oversight of its disaster response activities. FEMA concurred with four of the five recommendations. Recommendations 1 through 4 are considered open and resolved. Recommendation 5 is considered resolved and closed.

Previous Office of Inspector General (OIG) audits found that States had improperly paid Medicaid managed care entities capitation payments on behalf of deceased beneficiaries. We conducted a similar audit of the North Carolina Department of Health and Human Services, Division of Health Benefits, which administers the Medicaid program.Our objective was to determine whether North Carolina made capitation payments on behalf of deceased beneficiaries.

We determined significant amounts of overtime were worked by employees at some gas plants. Specifically, we determined 69 percent (221,517 hours) of the 318,903 hours of overtime was performed at 7 of the 17 plants. The overtime worked at these 7 plants was the equivalent of 51 full-time employees. We also determined some employees worked significant amounts of overtime. For example, we found 51 instances during fiscal years 2018 and 2019 where employees worked over 1,000 hours of overtime and 2 of these employees had nearly 2,000 hours of overtime in a single year. Additionally, we determined the Tennessee Valley Authority (TVA) may not be accurately capturing the effects of fatigue because (1) fatigue assessments are no longer required when significant overtime is worked and (2) fatigue data is not trended with health and safety data in TVA’s medical case management system.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations related to the prior authorization drug request process. The OIG substantiated that the prior authorization drug request consult template included limited space for prescribers to enter treatment rationale and prescribers did not always know about an option to document unlimited supplemental information. The Pharmacy and Therapeutics Committee included adequate mental health representation; however, the relationship between the committee’s leaders and the mental health representative was problematic and noncollaborative. While the OIG did not determine that the prior authorization drug request or appeals process delayed treatment, a mental health prescriber may have contributed to one patient not receiving medications. Prescribers were unfamiliar with, or erroneously understood, the process for expediting an appeal and mental health prescribers modified their prescribing practices to avoid pharmacy processes. Since 2019, facility leaders were aware of, and did not effectively resolve, unprofessional communications between Mental Health and Pharmacy Services staff, including a mental health prescriber improperly documenting critical comments and disagreeing opinions within patients’ electronic health records. Further, Pharmacy Services staff and leaders sent disrespectful emails about Mental Health Service staff. The OIG substantiated that a pharmacist canceled medication orders without communicating with a patient; however, facility policy requires the requesting prescriber, not the pharmacist, to notify the patient of medication information. The OIG did not substantiate that pharmacists canceled medication orders without communicating with the requesting prescriber or that pharmacist reviewers denied a large number of prior authorization drug requests. The OIG made five recommendations to the Facility Director related to prescriber education, promotion of mental health prescribers’ pursuit of the most effective treatment plan, review of improper electronic health record entries and email, and evaluation of ways to improve workplace relationships.

The VA Office of Inspector General (OIG) investigated allegations that the former executive director of the Idaho Veterans Research and Education Foundation, a VA-affiliated nonprofit, raised her own pay without the board of directors’ approval and misused the nonprofit’s credit card. The OIG also assessed controls over, and oversight of, the nonprofit’s expenditures and payments made by VA to the foundation. The OIG substantiated the allegation that the former executive director received a salary increase without approval. Furthermore, a former assistant who is now the executive director also received a questionable salary increase. The OIG also found that the Boise VA Medical Center made about $50,600 in improper payments to the nonprofit from January 2014 through April 2018 due in part to insufficient oversight. Inadequate board oversight also allowed the executive director to gain full control over the use of nonprofit funds, enabling her to use the nonprofit’s credit card for more than $44,000 in unallowable personal expenses. The former executive director pleaded guilty to one count of federal program theft in US District Court in April 2019. She admitted using the nonprofit’s credit card inappropriately and attempted to conceal that by altering bank statements. She paid about $44,300 in restitution and was later sentenced to five years’ probation. The OIG recommended that the medical center director determine whether administrative action should be taken against the nonprofit’s current executive director and ensure the nonprofit requires two or more responsible officials to oversee salary changes and implements stronger credit card controls. Additional recommendations were for the medical center director to establish procedures for staff to consistently review nonprofit invoices prior to payment to confirm receipt of contracted goods and services, and that periodic reviews are conducted of nonprofit invoices that staff authorized for payment.

We determined significant amounts of overtime were worked by employees at all six of TVA’s coal plants. Specifically, the overtime worked at these plants was the equivalent of 165 full-time employees. In addition, we determined some individual employees worked significant amounts of overtime. For example, we found 37 instances during fiscals years 2018 and 2019 where employees worked over 1,000 hours of overtime and 1 employee who worked over 2,300 hours of overtime in a single year. We also determined TVA may not be accurately capturing the effects of fatigue because (1) fatigue assessments are no longer required when significant overtime is worked and (2) fatigue data is not trended with health and safety data in TVA’s medical case management system. Additionally, employees expressed concerns regarding the adverse impact of understaffing on safe operation of coal plants.

The Office of the Inspector General conducted a review of the Watts Bar Nuclear Plant (WBN) Radiation Protection (RP) organization to identify factors that could impact WBN RP’s organizational effectiveness. Our report identified behaviors that had a positive impact on WBN RP. However, we also identified a behavior that could negatively affect WBN RP. Specifically, we identified a behavioral risk related to accountability that, if left unaddressed, could impact WBN RP’s effectiveness and its continued ability to meet its responsibilities in support of WBN’s mission. We also identified operational positives regarding WBN RP’s working relationship with outside departments and having enough resources to do the work.

DHS has not fulfilled most of the 13 responsibilities of the Geospatial Data Act. To comply with one responsibility, DHS has a Geospatial Information Officer and a dedicated Geospatial Management Office whose duties include overseeing the Act’s implementation and to coordinate with other agencies. However, DHS has only partially met, or not met, the remaining 12 responsibilities in the Act. DHS’ lack of progress in complying with the responsibilities outlined in the Act can be attributed to multiple external and internal factors. External factors include the need for additional guidance from the Federal Geographic Data Committee and the Office of Management and Budget to properly interpret and implement certain responsibilities. Internal factors include competing priorities that diverted resources away from fulfilling the Act’s 13 responsibilities. We made three recommendations that focus on increasing the resources necessary to comply with DHS’ 13 responsibilities under the Act. The Department concurred with all three recommendations.

We audited the U.S. Department of Housing and Urban Development’s (HUD) Office of Policy Development and Research’s implementation of the responsibilities stated in the Geospatial Data Act of 2018 (The Act). We performed this review in response to a congressional mandate that HUD’s geospatial data be audited at least once every 2 years. The Act requires that we audit HUD’s collection, production, acquisition, maintenance, distribution, use, and preservation of geospatial data. Our audit objective was to determine whether HUD had implemented the 13 required responsibilities stated in section 759(a) of the Act.HUD had implemented 9 of the 13 responsibilities stated in section 759(a) of the Act. It was working toward implementing the remaining four responsibilities stated in sections 759(a)(1), 759(a)(2), 759(a)(4), and 759(a)(5) of the Act. This condition occurred because HUD did not allocate the necessary resources to ensure that it accomplished all 13 required responsibilities. As a result, HUD may not meet the necessary standards to promote transparency and accountability in providing accurate and complete information to stakeholders. Specifically, there is a risk that HUD may not have accurate and complete geospatial data available for use by other Federal agencies; State, local, and tribal governments; and other interested stakeholders. These uses include public health, economic growth, environmental protection and other purposes, improved policymaking, creation of public-private partnerships, and enhanced data usability and value.We recommend that the Assistant Secretary for Policy Development and Research take appropriate actions to prioritize the required resources to ensure that HUD fully implements the responsibilities as required by sections 759(a)(1), 759(a)(2), 759(a)(4), and 759(a)(5) of the Act.

We found that the Department is in compliance with the applicable requirements outlined under section 759(a) of the Geospatial Data Act. Specifically, we found that the Department implemented all 10 of the 13 covered agency responsibilities listed in Section 759(a) of the Geospatial Data Act that we reviewed. We were unable to evaluate compliance with three covered agency responsibilities as the strategic planapplicable to two of the responsibilities has not yet been issued by the Federal Geographic Data Committee and applicable data standards related to the third responsibility have not yet been defined by the FGDC and Office of Management and Budget.

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

The VA Office of Inspector General (OIG) conducted an inspection to evaluate allegations that coordination and quality of care issues contributed to a delay in transfer and led to a patient death shortly after transfer from the Robert J. Dole VA Medical Center (facility) in Wichita, Kansas, to a community hospital. The OIG substantiated that coordination and quality of care issues in the management of a patient who presented to the facility’s Emergency Department with acute coronary syndrome (ACS) symptoms contributed to the patient’s death. The Emergency Department physician mismanaged the patient’s care by failing to initiate a timely transfer to a hospital capable of providing percutaneous coronary intervention (PCI). The patient presented to the Emergency Department in early 2019 with ACS symptoms. The physician contacted a facility cardiologist who advised transfer to a community hospital capable of PCI. The physician made two calls to a community hospital to initiate the transfer. The first call was to contact the patient’s personal community cardiologist. The second call, placed 50 minutes after the patient’s arrival to the facility Emergency Department, was to the on-call cardiologist at the community hospital who accepted the patient for admission. During transport, the patient became unstable and died soon after arriving at the community hospital. The OIG concluded that failure to transfer the patient for PCI within 30 minutes of arrival limited the patient’s chances for the best possible outcome. The facility conducted a review of the patient’s care but did not determine any contributing factors that led to the transfer delay or take actions to improve the emergent transfer process. The OIG made one recommendation to the Veterans Integrated Service Network Director related to peer review and nine recommendations to the Facility Director related to staff training, interfacility transfers, policy updates, committee oversight, and institutional disclosure.

Pursuant to the VA Choice and Quality Employment Act of 2017, the Office of Inspector General (OIG) conducted a review to identify clinical and nonclinical occupations experiencing staffing shortages within the Veterans Health Administration (VHA). This is the seventh iteration of the staffing report and the third report evaluating facility-level data. The OIG evaluated severe occupational staffing shortages identified through surveying medical center directors and compared this information to the previous two years. The OIG found that 95 percent of VHA facilities identified at least one severe occupational staffing shortage. The total number of identified severe occupational staffing shortages was 2,430. The most frequently cited occupational shortages were in the Medical Officer and Nurse occupations—derived from assignment codes used by VHA to designate specialties within the corresponding Office of Personnel Management occupational series. Sixty percent of facilities identified Psychiatry as the most frequently reported clinical severe occupational staffing shortage. Custodial Worker was the most frequently reported nonclinical occupation by 47 percent of facilities. Practical Nurse was the most frequently reported Hybrid Title 38 occupation. The OIG observed annual decreases in the overall number of severe shortages since fiscal year 2018. The number of occupations reported by at least 20 percent of facilities decreased from 30 in fiscal year 2018 to 17 in fiscal year 2020. The number of facilities reporting no severe occupational shortages increased from zero to seven over the last three years. One facility reported zero severe occupational staffing shortages in fiscal year 2020; however, in fiscal years 2018 and 2019, that facility reported the highest overall number of shortages across VHA. The OIG made no recommendations.

To view the report, please click on the link below.

U.S. Customs and Border Protection (CBP) did not adequately safeguard sensitive data on an unencrypted device used during its facial recognition technology pilot (known as the Vehicle Face System). A subcontractor working on this effort, Perceptics, LLC, transferred copies of CBP’s biometric data, such as traveler images, to its own company network. The subcontractor obtained access to this data without CBP’s authorization or knowledge, and compromised approximately 184,000 traveler images from CBP’s facial recognition pilot. Later in 2019, the Department of Homeland Security experienced a major privacy incident, as the subcontractor’s network was subjected to a malicious cyber attack. While CBP and DHS took immediate action to mitigate the data breach, we attribute this incident to the subcontractor violating numerous DHS security and privacy protocols for safeguarding sensitive data. Consequently, this incident may damage the public’s trust in the Government’s ability to safeguard biometric data, and may result in travelers’ reluctance to permit DHS to capture and use their biometrics at U.S. ports of entry. We made three recommendations to aid CBP in addressing the vulnerabilities that caused the 2019 data breach, and to better mitigate future incidents through greater oversight of third-party partners. CBP concurred with all three recommendations.

OIG reviewed whether APHIS adequately administered the NVS to ensure it is prepared to respond to animal diseases affecting human health and the economy.

What We Looked AtWe performed a quality control review (QCR) on the single audit that Cherry Bekaert, LLP performed for the City of Charlotte’s (City) fiscal year that ended June 30, 2018. During this period, the City expended approximately $100 million from the U.S. Department of Transportation’s (DOT) grant programs. Cherry Bekaert determined that DOT’s major programs were the Federal Transit Cluster, the Airport Improvement Program, and the Highway Planning and Construction Cluster. Our QCR objectives were to determine (1) whether the audit 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 auditors’ work on DOT’s major programs; and (2) whether the City’s reporting package complied with the reporting requirements of the Uniform Guidance. What We FoundCherry Bekaert’s audit work complied with the requirements of the Single Audit Act, the Uniform Guidance, and DOT’s major programs. We found nothing to indicate that Cherry Bekaert’s opinion on each of DOT’s major programs were inappropriate or unreliable. However, we identified deficiencies in Cherry Bekaert’s audit work that should be corrected in future audits. In addition, we identified a deficiency in each of the City’s initial and revised reporting packages that required correction and resubmission.

We evaluated the National Park Service’s (NPS’) general agreements (GAs) to determine if the NPS oversees its GAs to ensure compliance with policies and governing laws.We found that the NPS did not oversee its GAs to ensure compliance with policies and governing laws. The NPS did not maintain a central inventory for its GAs and was unaware of the number of active GAs. Therefore, we selected three parks to review in the Intermountain Region: Yellowstone, Grand Teton, and Rocky Mountain.We found the NPS was misusing GAs at all three parks we reviewed, which is likely a result of the informal review process associated with these instruments. During our evaluation, we determined that the NPS used the GAs to provide financial assistance or transfer goods or services to non-Federal entities, in apparent contravention of policies and laws. Further, we noted that personnel who were not authorized to commit NPS resources signed the GAs that inappropriately transferred something of value, which puts the NPS at risk of unauthorized commitments. The NPS has neither provided clear, consistent guidance, nor provided training on how to develop and use GAs at the national level.We make five recommendations to help the NPS improve oversight of its GAs. Based on the NPS’ response to our draft report, we consider one recommendation unresolved, one recommendation resolved and implemented, and three recommendations resolved but not implemented. We will refer the recommendations to the Assistant Secretary for Policy, Management and Budget for resolution and to track implementation.

We reviewed 6 of the 11 recommendations from our 2018 evaluation report titled, The Bureau of Indian Education Is Not Ensuring That Background Checks at Indian Education Facilities Are Complete, to verify whether the Bureau of Indian Education implemented them.We confirmed that Recommendations 1 – 3 and 6 – 8 have been resolved and implemented.

We reviewed the 13 recommendations from our 2017 report titled Stronger Internal Controls Needed Over Indian Affairs Loan Guarantee Program to verify whether the Bureau of Indian Affairs’ Office of Indian Energy and Economic Development implemented them.We confirmed that the 13 recommendations have been resolved and implemented.

We reviewed Recommendations 1, 2, 5, and 6 from our 2016 report titled U.S. Department of the Interior’s Continuous Diagnostics and Mitigation Program Not Yet Capable of Providing Complete Information for Enterprise Risk Determinations to verify whether the OCIO implemented them.We consider Recommendations 1, 2, 5, and 6 resolved and implemented.

OIG reviewed USDA’s CoE initiative to determine if its functional areas were effective and sustainable and whether USDA complied with applicable laws and regulations.

Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program (MSSP) may be eligible to receive shared savings payments from the Centers for Medicare & Medicaid Services (CMS) if the ACOs reduce health care costs and satisfy the MSSP quality performance standard for their assigned beneficiaries. As part of the standard, ACOs must report to CMS complete and accurate data on all quality measures. For performance year (PY) 2017, ACOs were required to report data on 31 quality measures through 3 methods of submission: a patient survey, claims and administrative data, and the designated CMS web portal. If ACOs do not report complete and accurate data, shared savings payments could be affected. Previous OIG audits of two selected ACOs assessed whether they reported complete and accurate data on selected quality measures. Our objective was to determine whether CMS’s monitoring activities were effective for ensuring that ACOs report complete and accurate data on quality measures.

A Mechanical Inspector based in Beech Grove, Indiana, violated Amtrak policies by posting images and material characterized as disturbing, offensive, and inappropriate on a publicly available social media site. The former employee admitted to posting images which promoted Nazi ideologies on a social media website which identified him as a company employee. We also found that he was arrested in November 2016 for Driving Under the Influence and did not report his arrest to the company as required by company policy. The employee resigned on September 9, 2020, in lieu of a disciplinary hearing and is not eligible for rehire.

The Office of the Inspector General conducted a review of the Treasury organization to identify factors that could impact Treasury’s organizational effectiveness. Our report identified behaviors that had a positive impact on Treasury. These included interactions with team members and leadership. We also identified risks to operations that, although minimal, could impede Treasury’s effectiveness if unaddressed. While interviews with Treasury personnel indicated effective performance of job responsibilities, we identified risks, including (1) uncertainty in business model changes for one Treasury department and (2) risks related to effective service to business partners.