Federal Reports

DHS generally met deadlines for responding to simple Freedom of Information Act (FOIA) requests, it did not do so for most complex requests. A significant increase in requests received, coupled with resource constraints, limited DHS’ ability to meet production timelines under FOIA, creating a litigation risk for the Department. Additionally, DHS has not always fully documented its search efforts, making it difficult for the Department to defend the reasonableness of the searches undertaken. With respect to responding to congressional requests, we determined DHS has established a timeliness goal of 15 business days or less; however, on average, it took DHS nearly twice as long to provide substantive responses to Congress, with some requests going unanswered for up to 450 business days. Further, DHS redacted personal information in its responses to congressional committee chairs even when disclosure of the information was statutorily permissible. This was a descriptive report and contained no recommendations. In its response, DHS acknowledged FOIA backlogs remain a problem, despite increasing requests processed. DHS stated its process responding to congressional requests varies greatly and that its redactions are appropriate.

To view a set of interactive dashboards with up-to-date data on COVID-19 cases in this facility, click the link below.

To view a set of interactive dashboards with up-to-date data on COVID-19 cases in this facility, click the link below.

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Nashville VA Medical Center in Tennessee to evaluate alleged deficiencies in cardiac telemetry monitoring services including policies, staffing, and communication. The OIG did not substantiate • The system’s policy related to telemetry monitoring and practices was outdated, • Staffing shortages or inadequate training of staff performing telemetry monitoring, • Telemetry patients with “do not resuscitate” orders did not receive clinically appropriate interventions, or • Nursing staff had knowledge deficits related to the care of telemetry patients with do not resuscitate orders. However, there were identified isolated communication issues between telemetry technicians and telemetry patient nurses related to the specific location and movement of telemetry patients while in the hospital. The OIG did not make a recommendation since an electronic patient tracking system was available in case of an emergency. In addition, in 2018, facility leaders identified other telemetry communication issues. The OIG reviewed facility leaders’ actions and noted overall improvement since staff training in February 2019. Therefore, the OIG made no recommendation. The OIG identified improper reusable medical equipment practices with the return of used and contaminated telemetry boxes and the location of clean supplies. System leaders took immediate steps and the OIG determined that no further action was indicated. The OIG determined the rapid response team policy and staff practice regarding the initiation of a rapid response team call did not always align, which is important to mitigate system vulnerabilities. The OIG made one recommendation to the Tennessee Valley Healthcare System Director to ensure consistency between the system’s policy and actual practice for initiating a rapid response team call.

OIG conducted the audit of Peace Corps/Ghana from July 15, 2019 to August 2, 2019. Our overall objective in auditing overseas posts is to determine whether the financial and administrative operations are functioning effectively and in compliance with Peace Corps policies and Federal regulations. The post’s financial and administrative operations required improvement to comply with agency policies and applicable Federal laws and regulations. Our report contains 52 recommendations directed to both the post and headquarters. Our recommendations included strengthening controls over managing imprest funds, Volunteer payments, property accountability, grants management, security certifications, financial management system access, and bill of collections; ensuring that contracts are adequately executed, and purchases are adequately authorized.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Kansas City VA Medical Center and multiple outpatient clinics in Kansas and Missouri. The inspection covers key clinical and administrative processes associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. The executive leaders were permanently assigned. Employee satisfaction survey results revealed opportunities for the Associate Director for Patient Care Services to improve employee engagement and empowerment. Patients appeared generally satisfied with the care provided. Review of the facility’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risks. Executive leaders were generally knowledgeable within their scope of responsibilities contributing to specific poorly performing Strategic Analytics for Improvement and Learning quality measures. However, the OIG noted that only 6 of 29 VHA quality metrics showed high performance compared to other facilities, indicating multiple opportunities exist for improvement. The OIG issued 20 recommendations for improvement in seven areas: (1) Quality, Safety, and Value • Root cause analysis processes (2) Medical Staff Privileging • Professional practice evaluations • Provider exit review processes (3) Environment of Care • Medication storage • Clinic privacy (4) Medication Management • Behavior risk assessment • Urine drug testing • Informed consent • Follow-up after therapy initiation • Pain Management Committee processes (5) Mental Health • Suicide prevention training (6) Care Coordination • Life-Sustaining Treatment Decisions Committee processes (7) High-Risk Processes • Risk analysis • Airflow monitoring • Environmental safety • Equipment storage • Staff training

The VA Office of Inspector General (OIG) reviewed the Systematic Technical Accuracy Review (STAR) program, which helps the Veterans Benefits Administration (VBA) provide timely and accurate disability compensation benefits to veterans and their beneficiaries. VBA’s STAR analysts perform quality reviews on randomly selected claims for disability compensation to identify errors and deficiencies in how claims were processed and to provide feedback to personnel to improve decision-making. The OIG review team examined whether STAR staff conducted accurate quality reviews of claims decisions, had adequate procedures to ensure corrective actions were timely and correct, and provided feedback to managers and staff to improve decision-making. The OIG found that STAR analysts were generally identifying benefit entitlement errors but not placing as much emphasis on finding procedural deficiencies. The OIG team determined there was no formal secondary review process for procedural deficiencies. An estimated 55 percent of claims had deficiencies (including benefit entitlement errors that could affect veterans’ disability compensation payments) and procedural deficiencies (such as veterans having to report for an unnecessary medical examination). Problems were also noted with the process for correcting errors that resulted in untimely and inaccurate actions, as well as with outdated or inaccessible feedback from reviews that did not enhance the quality of claims decisions. The OIG made six recommendations for ensuring STAR analysts follow the quality review checklist. Improvements to the second senior review process were also recommended for both analyst-identified deficiencies and to scan for errors missed by analysts, as well as advancing the processes to correct errors. In addition, VBA was called on to assess the training requirements for STAR staff; establish adequate policies, procedures, and monitoring to ensure corrections are completed timely and accurately; and to develop a plan to provide quality review data and feedback to assist managers in improving decision-making on claims.

Quality review team (QRT) program specialists oversee employees in the Veterans Benefits Administration (VBA) who process disability compensation claims. The VA Office of Inspector General (OIG) examined whether QRT specialists conducted accurate quality reviews; regional office managers decided employee requests for reconsideration of errors appropriately; and employees corrected claims-processing errors based on established standards. The OIG found that QRT specialists, who are supposed to identify claims-processing errors made by employees, missed errors in approximately 9,900 of the 28,400 quality reviews (35 percent) completed during the review period. Furthermore, the process in which QRT specialists review one another’s work was inadequate to identify errors missed during the initial quality review. Performance reviews of QRT specialists also did not ensure competency for identifying errors. Regional office managers did not follow VBA procedures by overturning errors identified by QRT specialists. The OIG estimated that during the review period, regional office managers inappropriately overturned errors in 430 of 870 quality reviews (about 50 percent) where claims processors requested a reconsideration of QRT specialist- identified errors. Finally, VBA has not established adequate oversight or accountability to ensure the timeliness of error corrections. The OIG estimated that during the review period 2,000 of 4,400 identified errors (45 percent) were not corrected in a timely manner and 810 of 4,400 identified errors (18 percent) were not corrected at all. The OIG recommended the under secretary for benefits (1) revise the current peer review process to make certain all errors are identified during quality reviews, (2) revise the QRT specialist performance review process to for competency in identifying errors, (3) revise the error reconsideration process to adhere to VBA procedures and promote objectivity, and (4) improve oversight of the error correction process.

Under the prospective payment system (PPS), Medicare pays home health agencies (HHAs) for each 60 day episode of care that beneficiary receives, called a payment episode. During our audit period, if an HHA provided four or fewer visits in a payment episode, Medicare paid the HHA a standardized per-visit payment. Claims for these types of payments are called Low Utilization Payment Adjustment (LUPA) claims. Once a fifth visit was provided during the payment episode (i.e., above the LUPA threshold), Medicare paid an amount for the services provided that was, in general, substantially higher than the per-visit payment amount. Because of the large payment increase starting with the fifth visit, HHAs have an incentive to improperly bill claims with visits slightly above the LUPA threshold.

In 2017, HHS declared the opioid epidemic in the United States a public health emergency. The misuse of and addiction to opioids-including prescription pain relievers, heroin, and synthetic opioids such as fentanyl-is a serious national crisis that affects public health as well as social and economic welfare. In 2018 alone, there were more than 46,000 opioid-related overdose deaths in the United States. As part of its efforts to combat the opioid crisis, the Health Resources and Services Administration (HRSA) awarded $200.5 million in Access Increases in Mental Health and Substance Abuse Services (AIMS) grants to health centers nation-wide. OIG audited HRSA's oversight of AIMS supplemental grant funding as part of our oversight on the integrity and proper stewardship of Federal funds used to combat the opioid crisis.

For a covered outpatient drug to be eligible for Federal reimbursement under the Medicaid program's drug rebate requirements, manufacturers must pay rebates to the States for the drugs. However, previous OIG audits found that States did not always bill and collect all rebates due for drugs administered by physicians.

Medicare paid approximately $2.2 billion for psychotherapy services provided to Medicare beneficiaries nationwide during calendar years 2017 and 2018. Prior OIG audits and reviews found that Medicare had made millions of dollars in improper payments for mental health services, including psychotherapy services. Using data analysis techniques, we identified On-Site Psychological Services, P.C. (On-Site), at risk for noncompliance with Medicare billing requirements.

The Child Care and Development Block Grant Act (CCDBG Act) of 2014 added new requirements for States that receive funding from the Child Care and Development Fund (CCDF) to conduct comprehensive criminal background checks on staff members and prospective staff members of child care providers every 5 years. Criminal background check requirements apply to any staff member who is employed by a child care provider for compensation or whose activities involve the care or supervision of children or unsupervised access to children.

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) issued a management advisory memorandum to the Veterans Benefits Administration (VBA) to request VBA examine a relatively small number of apparent overpayments by the Vocational Rehabilitation and Employment Program. The payments made to schools covered veterans’ tuition. The OIG analyzed the data on 1.8 million payments and determined that the program potentially made 360 errors from January 1, 2014, through December 30, 2019, totaling $554,998 in overpayments. The potential overpayments ranged from $18 to $237,762 and averaged $1,542. The OIG in alerting VBA did not determine if the program corrected or recovered the overpayments. The errors appeared to have resulted from program staff transposing numbers or adding one or more digits to the invoice amounts: • In February 2018, a program participant was invoiced $3,614 by a university in California, but program staff paid the university $6,314. Staff apparently transposed the three and the six in the invoice amount when entering it into the system for payment. • In October 2017, a program participant was invoiced $4,495 from another university in California, but program staff paid the university $44,950. Staff apparently added a zero to the invoice amount when entering it into the system. • In July 2016, a program participant was invoiced $238 from a Missouri university, but program staff paid the university $238,000. Staff apparently added three zeros to the invoice amount when entering it into the system. Due to the small percentage of errors, the OIG did not initiate an audit or investigation. However, it provided the potential errors to VBA to allow it to investigate and take actions when appropriate to recover any overpayments. The OIG asked VBA to provide updates for any actions it takes on the potential errors and the outcome of the actions.

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Atlanta VA Health Care System in Decatur, Georgia (facility), to review allegations and concerns of delays in care related to three patients’ non-VA community care (NVCC) consult appointments. The OIG confirmed these three patients experienced delays in the scheduling of their consults but did not identify an increase in risk of or an adverse clinical outcome for these patients.The OIG performed an expanded review of 221 consults and found that delays occurred. The OIG determined two patients had increased risks of an adverse clinical outcome due to delays in scheduling their appointments. Although the delays placed patients at increased risk, both patients received care and neither patient experienced an adverse clinical outcome. The OIG did not identify risks of or adverse clinical outcomes for the other patients. The facility had a backlog of open NVCC consults, and the OIG found deficiencies in processing, scheduling, and timeliness of these consults. Contributory factors also included, but were not limited to, inconsistent scheduling processes, inconsistent oversight, and deficiencies with third-party administrator scheduling oversight; shortages o f facility NVCC staff; and lack of training and supervision for facility NVCC scheduling staff. The facility did not consistently meet facility process requirements for scheduling audits and lacked a process to identify consults that were missing documentation after administrative closure. The OIG made six recommendations to the Facility Director related to consult performance measurements, backlog and monitoring of open NVCC consults, hiring and training of NVCC staff, patient case reviews, and NVCC policy.

An Amtrak Customer Service Representative in Reno, Nevada, was terminated from employment on July 20, 2020, following his administrative hearing. Our investigation found the employee stole funds from credit cards presented to him by Amtrak customers purchasing train travel. The cards, known as J-Pay Release cards, were pre- loaded with $200 in funds and were issued by the California Department of Corrections to inmates upon their release from custody. The former employee surreptitiously switched out fully-loaded J-Pay cards presented to him by those customers after debiting for the requested travel and returned completely depleted J-Pay cards instead. It is estimated that the former employee stole over $100,000 in stored value from the stolen J-Pay cards.

We contracted this audit with Cotton & Company LLP, which found that FEMA did not ensure the Florida Department of Emergency Management (FDEM) monitored the Polk County School Board (PCSB) to ensure it established and implemented policies, procedures, and practices to account for and expend PA grant funding in accordance with Federal regulations and FEMA guidance. For example, PCSB was unable to support $46,168 in food spoilage costs; requested and received funding through a Florida Public Assistance grant for ineligible contract costs incurred under Project 2658 for debris removal and related costs; and charged $897 in unallowable costs associated with ineligible fringe benefits for substitute employees. We made 13 recommendations that, when implemented, should improve PCSB’s management of FEMA Public Assistance funds. FEMA concurred with our 13 recommendations.

U.S. Immigrations and Customs Enforcement (ICE) does not follow its written policy when conducting disciplinary reviews of Senior Executive Employees (SES) employees, which risks creating an appearance that SES employees receive more favorable treatment than non-SES employees. We reviewed the disciplinary proceedings of the former SES official to evaluate whether ICE’s deviation from the written policy, or any other evidence, in that case indicated that the official received favorable treatment, as alleged. We did not find evidence of actual favoritism or inappropriate influence in the official’s disciplinary or security clearance review processes. We recommended that ICE finalize and issue its draft policy documenting the process for disciplining SES members. We made one recommendation that will enhance transparency in ICE’s disciplinary program. ICE concurred with our recommendation and took action to resolve and close it.

The objective of our audit was to determine whether the Department’s fleet program operates in accordance with applicable federal fleet requirements for vehicle operations, acquisitions, and utilization. We found that the Department is not operating its fleet program in accordance with federal fleet requirements. Specifically, we identified issues in the following areas: (1) Operations—The Department’s fleet inventory data is unreliable due to inaccuracies and incompleteness. (2) Acquisitions—The Department’s Personal Property Management Manual lacks commercial lease guidance for the Office of the Secretary, which did not document justifications for vehicle specifications or upgrades. (3) Utilization—The Department does not consistently document vehicle usage, conduct comprehensive utilization reviews, and determine its optimal fleet inventory. We recommend that the Chief Financial Officer and Assistant Secretary for Administration do the following: (1) Periodically review and ensure all bureau vehicle information is complete and accurate in the Department’s FMIS. (2) Update the PPMM to include guidance for OS commercial leasing. The Department should ensure other PPMM requirements do not similarly exclude OS. (3) Document justifications for mission-essential vehicle specifications when not obtaining leased vehicles through GSA. (4) Update policies and procedures to include requirements for bureaus to maintain adequate documentation of vehicle usage. (5) Provide refresher training to fleet managers to ensure they are aware of all federal and updated Departmental fleet management requirements. (6) Direct Departmental / bureau fleet managers to perform and document an annual analysis of fleet utilization in accordance with Departmental policy and Congressional direction. (7) Perform a VAM study at least every 5 years, to produce a profile of its optimal fleet inventory, and periodically monitor results between VAM studies.

Our objective was to evaluate recent delivery and scanning performance for selected U.S. Postal Service delivery units we audited in fiscal year (FY) 2019. We audited seven of these units based on carriers returning late to the office and 11 units based on the number of package scans performed at the unit instead of the delivery address. These units are in 17 districts throughout the seven Postal Service areas.

We contracted this audit with Cotton & Company LLP, which found that FEMA did not ensure Monroe County, Florida (the County) established and implemented policies, procedures, and practices to ensure it accounted for and expended Public Assistance program grant funds awarded to disaster areas in accordance with Federal regulations and FEMA guidance. Specifically, the County did not allocate anticipated and actual insurance proceeds totaling $5 million to reduce FEMA’s share of disaster costs; charged $265,928 for ineligible stand-by time and other ineligible expenses; and requested $84,681 in unsupported and ineligible costs for multiple tasks including clearing emergency access and costs related to flooding. Additionally, the County overstated $34,378 in force account labor costs that were unreasonable and therefore ineligible for grant funding; overpaid a debris removal contractor, resulting in $2,403 in ineligible costs; and charged $1,080 to PW 1512 for security costs that were unsupported and are therefore ineligible for grant funding. We made 18 recommendations that that, when implemented, should improve Monroe County, Florida’s management of FEMA Public Assistance funds. FEMA concurred with our 18 recommendations.

We investigated whether Wild Horse and Burro Program staff used Government charge cards to pay for expenses related to personally owned horses.

We did not substantiate the allegation that a Bureau of Indian Affairs official violated the ethics pledge or ethics regulations.

Our objective was to (1) to determine whether the Social Security Administration (SSA) made payments to beneficiaries and representative payees who were deceased according to Oklahoma Department of Health vital records and (2) identify non-beneficiaries in the State files whose death information did not appear in Agency records.

A former Carman/Welder in Beech Grove, Indiana, pleaded guilty in United States District Court, Southern District of Indiana, to theft of property on July 17, 2020. The former employee was sentenced to one-year probation, a $4,000 fine and ordered to pay $56,297 in restitution to Amtrak. Our investigation found the employee stole power tools and scrap metal from the company and sold it for his personal gain. The employee previously resigned from the company on April 28, 2017, immediately prior to his administrative hearing.

OIG audit reports issued in FY 2019 demonstrated high levels of compliance with OIG quality assurance procedures, receiving an average compliance score of 92 percent.

The Office of Inspector General examined NASA’s Orion Program and evaluated its adherence to cost, schedule, and performance goals in readying the crew vehicle for the Artemis I and Artemis II missions.

On March 26, 2020, the VA Office of Inspector General (OIG) published its first COVID-19-focused report, OIG Inspection of Veterans Health Administration’s COVID-19 Screening and Pandemic Readiness. In that report, the OIG evaluated how the Veterans Health Administration (VHA) was preparing facilities to meet anticipated rising demands. This report outlines VHA’s continued response to the pandemic and provides VHA leaders’ descriptions of the evolving challenges they faced in caring for veterans and potentially nonveteran patients as well. The OIG engaged leaders from 70 selected facilities in discussions about patient-care services provided from March 11, 2020, through June 15, 2020. The discussions covered the management of urgent and emergent care, the adequacy of equipment and supplies, testing capabilities, Community Living Center (nursing home) admissions and discharges, testing protocols, and the engagement of community healthcare partners. Discussions also detailed Veterans Integrated Service Network leaders’ involvement in, and overall support of, facility operations. Finally, the OIG provided VHA leaders the opportunity to comment on plans to manage anticipated COVID-19 surges. Overall, this report highlights a multitude of actions taken by VHA, VISN, and facility leaders to maintain operations during a national emergency. With the uncertainty of timing and magnitude of possible recurrent outbreaks, this review presented strategies that various facilities put into place over the past several months that will hopefully promote discussion and consideration of lessons learned and best practices among facility and community healthcare leaders.

According to the Securing Our Agriculture and Food Act (SAFA), the program should provide oversight, lead policy initiatives, and coordinate with DHS components and Federal agencies. However, the Countering Weapons of Mass Destruction Office (CWMD) has not yet carried out a program to meet SAFA’s requirements. This occurred because CWMD believes it does not have clearly defined authority from the Secretary to carry out the requirements of the SAFA. In addition, since its establishment in December 2017, CWMD has not prioritized SAFA requirements but instead has focused its resources on other mission areas. As a result, CWMD has limited awareness of DHS’ ongoing efforts and cannot ensure it is adequately prepared to respond to a terrorist attack against the Nation’s food, agriculture, or veterinary systems. We made three recommendations to DHS’ CWMD to improve oversight, policy initiatives, and coordination of the Department’s efforts to protect the Nation’s food, agriculture, and veterinary systems.

We contracted this audit with Cotton & Company LLP, which found that FEMA did not ensure Lee County, Florida (the County) established and implemented policies, procedures, and practices to ensure it accounted for and expended PA program grant funds awarded to disaster areas in accordance with Federal regulations and FEMA guidance. Specifically, the County requested FEMA funding for $994,425 in unsupported force account labor, equipment, and materials; was unable to provide supporting documentation for $16,210 in costs incurred to operate an emergency shelter; did not maintain adequate documentation to support $267,452 in costs incurred for road repair services; did not include all required provisions in its contracts to obtain disaster recovery services related to Hurricane Irma; and had not evaluated the risk of subrecipients’ noncompliance with Federal requirements, obtained subrecipient audit reports, or developed plans for monitoring subrecipients. We made nine recommendations that, when implemented, should improve Lee County, Florida’s management of FEMA Public Assistance funds. FEMA concurred with all nine recommendations.

The OIG investigated an allegation that several minority-owned and small disadvantaged (8a) businesses may have coordinated their respective proposals to gain an unfair advantage in awards related to six contracts for technical support services at the U.S. Geological Survey (USGS).We found that these companies did not conspire to manipulate the bidding process as alleged. We found that the companies used the same consulting company to draft their respective proposals, which contained nearly identical language. The USGS ultimately did not accept any of the proposals.This is a summary of an investigative report we issued to the USGS Director.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Marion VA Medical Center and outpatient clinics in Illinois, Indiana, and Kentucky. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. The executive leadership team had been working together for 17 months. Patient experience surveys indicated that patients appeared satisfied with their care. The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial risk factors. The leadership team, specifically the Chief of Staff and Associate Director for Patient Care Services, had opportunities to improve their knowledge within their scopes of responsibility about Strategic Analytics for Improvement and Learning data and should continue to take actions to sustain and improve performance. The OIG issued 29 recommendations for improvement in eight areas: (1) Quality, Safety, and Value • Quality management activities • Utilization management processes (2) Medical Staff Privileging • Professional practice evaluations • Provider exit review forms (3) Environment of Care • Infection prevention procedures • Health information protection (4) Medication Management • Pain screening • Risk assessment • Urine drug testing • Informed consent • Patient follow-up • Pain Management Committee activities (5) Mental Health • Safety plans • Staff training (6) Care Coordination • Treatment notes (7) Women’s Health • Required staffing • Access to care and emergency contraceptives • Women Veterans Health Committee membership (8) High-Risk Processes • Required administrative processes • Staff training

In accordance with guidance from the Office of Management and Budget, we reviewed the “Payment Integrity” section in the U.S. Department of the Interior’s Agency Financial Report (AFR) for fiscal year (FY) 2019. Our objective was to determine whether the Department met the requirements of the Improper Payments Elimination and Recovery Act of 2010 (IPERA) and accurately and completely reported on improper payments in its AFR and accompanying materials.We found that the Department complied with all applicable IPERA reporting requirements for FY 2019, namely the first two requirements of six. We did not consider the four remaining IPERA reporting requirements applicable for this reporting period because the Department did not identify any programs that were susceptible to significant improper payments.We identified a minor reporting error. Specifically, the Department reported in its FY 2019 APR that it had risk assessed 93 programs when it had only risk assessed 86. Seven of the programs reported for FY 2019 were risk assessed in FY 2018. However, this reporting error does not change our determination that the Department complied with the requirement.

Due to the risk of personnel injury from arc flash hazards, we performed an evaluation to determine if (1) TVA’s arc flash procedures were being performed as required, (2) required personal protective equipment (PPE) was available and properly maintained, and (3) required training was completed. We determined some requirements of TVA’s arc flash procedure were not being performed. Specifically, we determined (1) some arc flash hazard analyses were not complete, reviewed timely, updated, or verified and submitted for record; (2) some identified arc flash hazards were not communicated accurately to workers; and (3) arc flash hazards were not consistently documented. In addition, we determined arc flash training needs improvement. Specifically, we determined (1) not all personnel assigned arc flash training had completed the training curriculum, (2) TVA’s identified population of individuals required to have arc flash training was incomplete and not a reliable indicator as to who is required by the Occupational Safety and Health Administration to receive the training, and (3) TVA does not require retraining at the frequency suggested by industry guidance. Also, while PPE was generally available and in good condition, PPE management practices could be improved.

HHS is one of the largest contracting agencies in the Federal Government and in fiscal year 2019 awarded contracts totaling approximately $27 billion, of which $7 billion related to Centers for Medicare & Medicaid Services (CMS) contracts. Congress has expressed concerns about and the media has reported on CMS's awarding of contracts for strategic communications services. Separately, OIG had begun preliminary work to review the strategic communications services contracts during CMS Administrator Seema Verma's tenure. Based on this preliminary work, we conducted an audit of these CMS contracts.

THE DEPARTMENT HAS DETERMINED THAT THIS REPORT CONTAINS SENSITIVE SECURITY INFORMATION (SSI) that is controlled under 49 CFR parts 15 and 1520 to protect Sensitive Security Information exempt from public disclosure. For U.S. Government agencies, public disclosure is governed by 5 U.S.C. 552 and 49 CFR parts 15 and 1520. A redacted version of the report will be posted here on our website when it is available. What We Looked AtThe Federal Aviation Administration (FAA) operates up to 172 Terminal Radar Approach Control (TRACON) facilities, which provide air traffic control services to pilots in the airspace immediately surrounding major airports. Currently, air traffic controllers use the Standard Terminal Automation Replacement System (STARS) to provide critical air traffic services at the 11 largest TRACONs, which handle about 33 percent of all TRACON traffic in the United States. Effective security controls and contingency plans at these 11 facilities are critical to maintaining the safety and security of the National Airspace System. Accordingly, we initiated this audit to (1) assess FAA’s identification and mitigation of security risks in STARS and (2) determine whether FAA’s contingency planning limits the effects caused by the loss of STARS operations at large TRACON facilities during emergencies. What We FoundFAA is identifying STARS’ security risks but is not mitigating vulnerabilities in a timely manner. In March 2019, for example, FAA found vulnerabilities in 53 of 73 STARS security controls but did not meet its own schedule for remediating them. DOT policy requires timely remediation of vulnerabilities to reduce the risk that an attacker could gain unauthorized access to mission-critical systems. In addition, the Agency’s STARS incident response policy does not comply with Federal requirements, and we found security control weaknesses that could make it harder for the Agency to ensure the confidentiality, integrity, and availability of STARS. Finally, FAA’s contingency plans for three large TRACONS are not sufficient to maintain continuity of air traffic operations during unplanned outages, as Agency policy requires. Our RecommendationsWe made 11 recommendations and consider recommendations 1–9 and 11 resolved but open pending completion of FAA’s planned actions. In accordance with DOT Order 8000.1C, we have asked the Agency to provide additional information on its planned actions for recommendation 10 within 30 days of the date of this report. 

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA Southern Nevada Healthcare System in North Las Vegas in response to a referral from the U.S. Office of Special Counsel, which contained allegations that facility leaders responded inadequately after a patient attacked and later threatened a social worker. The OIG determined that facility managers failed to timely respond after the social worker reported an assault during a home visit and did not address the social worker’s health needs after the assault. The social worker’s supervisor failed to immediately report the incident to community and VA police. The facility’s policies lacked specific guidance regarding employee emotional and mental health injuries. Further, the OIG substantiated that the social worker was not informed by a supervisor of a homicidal threat, occurring subsequent to the assault, until two weeks after facility leaders became aware of the threat. Deficient communication between the supervisor and the Deputy Chief of VA Police resulted in a delay in notification to the social worker as well as a failure to coordinate with the community police who had jurisdictional oversight. Additional issues included a delay in disruptive behavior flag placement, deficiencies in VA police Disruptive Behavior Committee participation, and vacancies and staff turnover in the facility Housing and Urban Development Veterans Affairs Supporting Housing (HUD VASH) program. The OIG made six recommendations related to staff and supervisor awareness and reporting compliance with patient disruptive behavior incidents occurring outside of VA grounds, traumatic injury needs of staff experiencing a work-related emotional or mental health injury, timely notification of threats to targeted staff, placement of patient record flags, VA police participation in the Disruptive Behavior Committee process, and a review of HUD-VASH staffing and training needs.

Five members of Congress asked the VA Office of Inspector General (OIG) to review the Veterans Health Administration’s (VHA) canine research approval process in response to public concerns about alleged animal welfare and oversight violations. In fiscal years (FY) 2018 and 2019, Congress mandated that the VA Secretary directly approve the use of appropriated funds for canine research. The OIG found VHA conducted eight studies without the former or current Secretary’s direct approval, resulting in the unauthorized use of $393,606 in appropriated funds.VA continued research using canines after the passage of the funding restrictions, in part, because VHA executives perceived that then VA Secretary David Shulkin had approved the continuation of the studies before his March 28, 2018, departure. Former Secretary Shulkin denied approving each study for continuation after funding restrictions were enacted. The OIG did not confirm Dr. Shulkin had directly approved continuation in a March 28, 2018, meeting on his last day as Secretary. VHA also did not have a formal procedure to obtain and document the Secretary’s approval. Unclear communication, inadequate recordkeeping, and failure to ensure approval decisions were accurately recorded and verified all contributed to VHA’s noncompliance. Providing unsupported and potentially inaccurate information on this topic could undermine public trust in VA and unnecessarily detract attention from its important statutory mission—supporting a wide range of authorized research on veterans’ health issues. The OIG recommended the under secretary for health establish a process to obtain the Secretary’s approval for canine research as required by federal law, ensure approval is documented, and prevent appropriated funds from being spent without approval. The OIG also recommended the under secretary report to Congress on FY 2018 and 2019 funds spent on canine research without the Secretary’s approval.

Our objective was to assess the effectiveness of the Postal Service’s informal grievance oversight. We reviewed informal grievance processes for 10 judgmentally selected facilities in eight Postal Service districts within four Postal Service areas. Specifically, we selected eight facilities based on their high grievance costs and high number of grievance payments and two based on their lower grievance costs compared to similarly sized facilities. These facilities included both processing and retail functions.

Our objective was to review access and wait times for people seeking assistance from, and problem resolution through, the Social Security Administration's (SSA) field offices.

Our objective was to review access and wait times for people seeking assistance from, and problem resolution through, the Social Security Administration's (SSA) field offices.

On March 27, 2020, the President signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), which provided the U.S. Department of the Interior (DOI) with $756 million to support the needs of DOI programs, bureaus, Indian Country, and the Insular Areas.As part of the CARES Act, the Bureau of Indian Education (BIE) received $69 million from the DOI to prevent, prepare for, and respond to the coronavirus pandemic. In addition to the CARES Act funding appropriated directly to the DOI, the CARES Act’s Education Stabilization Fund required the U.S. Department of Education to set aside $153.75 million for programs operated or funded by the BIE, in consultation with the Secretary of Interior.The CARES Act money will provide much-needed assistance for Indian schools. This report provides a snapshot of the BIE’s funding and planned expenditures.

To receive Federal funding for child welfare services, States are required to have a plan for overseeing and coordinating health care services for any child in foster care placement, including medications prescribed for the children. Psychotropic and opioid medications are among those that may be prescribed for children in foster care. Medications can have serious side effects, and ineffective monitoring may increase the risk for inappropriate dosing, frequent medication changes, or the use of inappropriate medication combinations. In recent audits, we found that children's case records did not always contain documentation to support that the required health care services were provided.

We determined that the city of Houston has adequate policies, procedures, and business practices that comply with Federal procurement regulations and FEMA guidelines to expend FEMA grant funds. We found Houston may have inappropriately included the $73.8 million cost of Houston First Corporation’s (Houston First) disaster damages in its damage estimate, even though it was not an eligible applicant for them. We did not examine procurement policies and procedures related to Houston First because the entity was outside the scope of our audit. During the audit, FEMA acknowledged it would reiterate in writing to the City of Houston the importance of proper oversight for all procurements executed by Houston First. This report contains no recommendations.

U.S. Customs and Border Protection has not demonstrated the acquisition capabilities needed to effectively execute the Analyze/Select Phase of the Wall Acquisition Program. Specifically, CBP did not conduct an Analysis of Alternatives to assess and select the most effective, appropriate, and affordable solutions to obtain operational control of the southern border as directed, but instead relied on prior, outdated border solutions to identify materiel alternatives for meeting its mission requirement. CBP did not use a sound, well-documented methodology to identify and prioritize investments in areas along the border that would best benefit from physical barriers. Additionally, the Department did not complete the required plan to execute the strategy to obtain and maintain control of the southern border, as required by its Comprehensive Southern Border Security Study and Strategy. Without an Analysis of Alternatives, a documented and reliable prioritization process, or a plan, the likelihood that CBP will be able to obtain and maintain complete operational control of the southern border with mission-effective, appropriate, and affordable solutions is diminished. We made three recommendations to improve CBP’s ongoing investments for obtaining operational control of the southern border. DHS concurred with recommendation 2 but did not concur with recommendations 1 and 3.

Due to the risk of personnel injury from arc flash hazards at nuclear plants, we performed an evaluation to determine if (1) TVA’s arc flash procedures were being performed as required, (2) required personal protective equipment was available and properly maintained, and (3) required training was completed. We found some requirements of TVA’s arc flash procedures were not being performed. Specifically, (1) arc flash hazard analyses were incomplete, not reflective of current plant operating conditions, and not reviewed timely; (2) identified hazards were not communicated accurately to workers; (3) plants had not adequately evaluated and implemented controls to reduce exposure to high hazard incident energies; and (4) hazards and mitigations were not routinely documented.In addition, we determined arc flash training needs improvement. TVA’s identified population of individuals required to have arc flash training had completed initial training; however, the trainee population was incomplete and not a reliable indicator as to who is required by the Occupational Safety and Health Administration to receive the training. TVA has also not implemented retraining at the frequency required by its procedures. Also, while personal protective equipment was generally available and in good condition, its management could be improved with an inventory listing and preventive maintenance.

The Columbus Processing & Distribution Center is in the Ohio Valley District of the Eastern Area. In fiscal year (FY) 2019, the Postal Service reported 2.1 million late trips nationwide due to contractor failure. From October 1, 2019, to March 31, 2020, the Columbus P&DC had the second highest number (10,948) of originating late trips due to contractor failure for P&DCs. The average time a trip was late was 43 minutes. There were 41 contractors with originating late trips due to contractor failure at the Columbus P&DC. Two contractors accounted for 61 percent of the failures. Our objective was to assess the management of HCR irregularities due to contractor failure at the Columbus P&DC.

As part of our annual audit plan, we audited costs billed to the Tennessee Valley Authority (TVA) by Trans Ash, Inc. (Trans Ash) for construction support services provided under Contract No. 10059. The contract provided that one or more compensation methods may be utilized to complete the work-cost reimbursable, target cost estimate, or fixed price. Our audit objectives were to determine if (1) costs were billed in accordance with the terms and conditions of the contract and (2) tasks were issued using the most cost efficient pricing methodology. Our audit scope included about $34.4 million in costs billed to TVA from May 20, 2015, through November 30, 2018. This included $20.9 million for cost reimbursable projects and $13.5 million for fixed price projects.In summary, we determined:Trans Ash overbilled TVA $1,592,128 on cost reimbursable projects, including (1) $1,312,051 in unapproved subcontractor costs, (2) $32,895 in ineligible fees associated with subcontractor costs, (3) $156,403 in labor and related costs, (4) $42,929 resulting from the use of lump sum pricing when the purchase order provided for a cost reimbursable compensation methodology, (5) $42,000 in temporary living costs, and (6) $5,850 in equipment costs.Trans Ash billed TVA for construction equipment rented from TVA's Equipment Support Services (ESS) group using the Trans Ash equipment rental rates included in the contract's rate schedule instead of billing TVA for the equipment rentals as a direct pass through cost, as required by the contract's terms and conditions. However, due to the process used by TVA to bill Trans Ash for ESS equipment rented, we could not determine the cost impact, if any, of Trans Ash billing ESS equipment using the contract's equipment rental rate schedule.The use of fixed price or unit rate payment terms on projects caused TVA to pay at least $1.6 million more than it would have if cost reimbursable payment terms had been used for those projects. Additionally, we determined the unit rate payment terms used by TVA to compensate Trans Ash were not provided for in the contract's terms and conditions.We also noted several opportunities to improve contract administration by TVA. Specifically, we determined TVA paid an additional $137,190 in noncraft labor costs due to conflicting contract language. In addition, we found (1) TVA could not locate any of the exhibits to the contract, (2) Trans Ash did not submit an electronic billing file to the TVA Office of Inspector General (OIG) in the format and frequency provided for in the contract's terms, and (3) the contract's Order of Precedence clause included inconsistent guidance on which documents took precedence in the event of a conflict.(Summary Only)