Federal Reports

An Amtrak ticket/accounting representative based in Greensboro, North Carolina, was terminated from employment on March 27, 2025, following an administrative hearing. Our investigation found that the former employee violated company policy by allowing an unknown and un-ticketed individual to proceed to the train platform and put an unidentified package onto the train without knowing its contents. The package was subsequently found to contain illegal narcotics. The former employee is not eligible for rehire.

In July 2024, VA informed Congress that the Veterans Health Administration (VHA) might need an additional $12 billion in funding in fiscal year (FY) 2025 to support medical care for the last three months of FY 2024 and all of FY 2025—primarily for community care, staffing, prosthetics, and pharmacy. In August, the OIG began reviewing the causes contributing to VHA’s subsequent request for additional funds, and in September, Congress passed legislation requiring the OIG to review the circumstances that led to VA’s announced funding shortfall.

The OIG found the FY 2024 President’s Budget, which included the advance appropriations for FY 2025, relied on outdated data and assumptions, including lower-than-actual costs for new medications and both direct and community care. Also, a legislative budget cap limited VHA’s ability to increase the FY 2025 advance appropriations, although leaders believed they could keep spending within funding limits by developing cost-saving options. The goals and options that emerged from a January 2024 financial sequester did not achieve the necessary cuts, such as reducing hiring and community care obligations. In August 2024, VA requested supplemental appropriations of $12 billion to cover medical care for the rest of FY 2024 and all of FY 2025. By November, VHA had revised this estimated shortfall to $6.6 billion for only the remainder of FY 2025. Congress passed a continuing resolution in mid-March 2025 to fund VA’s remaining FY 2025 medical care at $6 billion from the Toxic Exposures Fund.

VHA concurred with the OIG’s recommendations to review how VHA projects medical care budget needs (including staffing) and to develop an approach to form more accurate estimates; consider changes to allow program offices and other experts to weigh in on inputs for model projections; and conduct fiscal reviews at least quarterly to assess key cost drivers.

This report presents the results of our audit to evaluate the U. S. Postal Service’s management of Postal Vehicle Service operations.

The OIG conducted a legislatively mandated review of the circumstances and the underlying conditions that led to VBA announcing a potential shortfall and the need for FY 2024 supplemental funding.

In July 2024, the VA Secretary announced to Congress that VBA needed about $2.9 billion, in addition to the approximately $193.4 billion previously appropriated, to cover disability compensation, pension, and readjustment benefits for over seven million veterans through September 2024. VBA officials attributed this projected shortfall to processing more claims than ever before, expanded eligibility for PACT Act compensation benefits, unprecedented outreach to potential beneficiaries, increased payments and obligations, and more eligible participants for education and job training programs. If funding was even one dollar short at year-end, veterans’ benefits payments would be delayed.

The President signed a supplemental appropriations bill on September 20 to provide VBA with the funding. On October 28, VA officials reported to Congress that no supplemental funding was actually needed for the two accounts. The OIG’s analysis showed VBA’s actual spending did not consistently exceed planned amounts for either account. VBA had not included realized prior-year recoveries in its monthly status report calculations throughout the year, which would have shown a reduced risk of a shortfall by year-end. VBA officials reported that a projected lack of carryover funding for use at the end of the fiscal year raised concerns about depleting FY 2024 resources. Furthermore, VBA expected claims processing would surge to meet year-end regional office metrics, but a VA analysis did not show a spike in compensation and pension obligations. Although VBA acted to prioritize veterans’ benefits, the OIG found that improved financial oversight, reporting accuracy, and communications may have obviated the need for a supplemental funding request. The OIG made four recommendations to VBA to improve financial management practices and communications.

We evaluated the effectiveness of the requisition, vetting, and screening of Defense Attaché Service personnel. We issued the results of our evaluation, along with four recommendations, in a final report dated March 27, 2025.

Why We Did This Report

The U.S. Environmental Protection Agency Office of Inspector General is issuing this report addressing concerns regarding access to Superfund information identified in the EPA’s annual reports to Congress.

Summary of Findings

We discovered that more than half of federal facility and some nonfederal facility Five-Year Reviews, or FYRs, are not publicly available, despite the EPA stating in its annual Superfund FYR Reports to Congress that the FYRs can be found on its “Search for Superfund Five-Year Reviews” webpage.

After meeting with more than 140 individuals from DHS and other Federal agencies, we determined U.S. Immigration and Customs Enforcement (ICE) cannot effectively monitor the location and status of all unaccompanied alien children (UACs) once released or transferred from Department of Homeland Security and U.S. Department of Health and Human Services’ (HHS) custody. From fiscal years 2019 to 2023, ICE transferred more than 448,000 UACs to HHS; most were released to sponsors. However, more than 31,000 of the 448,000 children’s release addresses were blank, undeliverable, or missing apartment numbers. ICE also was not always aware of the location for UACs who fled HHS’ custody.

The AmeriCorps Office of Inspector General investigated potential displacement of paid staff at Hawaii Community Assets (HCA), undisclosed dual employment by a program official at HCA and Aloha United Way (AUW), and improper charging of time by two Volunteers in Service to America (VISTA) program officials at AUW.

A former AmeriCorps grantee staff member (“Complainant”) alleged that management at the grantee terminated the Complainant’s employment after the Complainant made a protected disclosure related to the Complainant’s concerns about the grantee’s financial management and stewardship. AmeriCorps OIG concluded that the evidence did not support the allegations of whistleblower retaliation. The grantee terminated the Complainant based on performance issues that predated any protected disclosure.

The Inspector General is pleased to present the Office of Inspector General (OIG) Oversight Plan for Calendar Year 2025. This risk-based plan intends to serve as a roadmap for the OIG’s independent and objective oversight of the U.S. AbilityOne Commission’s programs and operations through reviews, such as audits and evaluations, focused on preventing and detecting fraud, waste and abuse, and enhancing economies and efficiencies.

Throughout the oversight cycles, the OIG continues to focus on high-risk areas in the program and operations. The OIG's process to assess and prioritize the planned work included, among other factors, assessing the top management and performance challenges, congressional interests, key risks for which the Commission and other stakeholders expressed concern, and the results of our prior work. The OIG then used this information to inform the design of oversight reviews for usefulness to the Commission for its work and operations.

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

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

The OIG issued six recommendations for improvement in three domains:
 1.    Environment of care
   •    Accessible parking space access aisles and pavement markings
   •    Crosswalk visibility and pedestrian safety
   •    Doorway safety
   •    Hand hygiene supplies
 2.    Patient safety
   •    Communication of test results
 3.    Veteran-centered safety net
   •    Social work positions

Jacksonville State University (Jacksonville State) did not always account for and expend Federal Emergency Management Agency (FEMA) grant funds according to Federal regulations and FEMA guidelines. Specifically, Jacksonville State did not fully comply with Federal regulations and FEMA guidelines to include federally required contract provisions in its disaster contracts. Jacksonville State’s exclusion of the required contract provisions exposed FEMA funding to unnecessary risks.

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to a congressional referral regarding the care of a patient who was admitted for alcohol withdrawal and later died at the Hampton VA Medical Center (facility) in Virginia.

The OIG identified failures in the management of alcohol withdrawal symptoms of this complex patient by nursing staff and providers. Nursing staff failed to accurately and timely assess the patient’s alcohol withdrawal symptoms and consistently administer medications in adherence with the facility’s Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-AR) protocol used to determine the severity of the symptoms and clinical response. Additionally, the OIG found concerns with the timeliness of nursing staff’s electronic health records (EHR) documentation of CIWA-AR assessment scores. Delayed entries of assessment scores may affect providers’ clinical decisions. These failures may have affected the overall management of the patient’s alcohol withdrawal symptoms.

The OIG determined that facility providers failed to recognize the severity of the patient’s alcohol withdrawal. Based on past medical history and admissions, the patient was considered high risk for developing delirium, a severe form of alcohol withdrawal. According to clinical guidelines, delirium can be effectively treated with a benzodiazepine medication such as lorazepam. The OIG found one provider did not confirm the availability of lorazepam before making a clinical decision to use another medication that was not a benzodiazepine. Another provider documented symptoms suggestive of severe alcohol withdrawal but failed to identify several risk factors of severe withdrawal and treat the symptoms. These failures likely contributed to the patient not being afforded evidence-based care for prevention of delirium and severe alcohol withdrawal.

The OIG made seven recommendations to the Facility Director related to compliance with facility CIWA-AR protocol, CIWA assessment, and the management of severe alcohol withdrawal.

For our audit of the U.S. Census Bureau's 2020 Post-Enumeration Survey (PES) results, our objective was to assess the validity of those results as they related to overcounts and undercounts. We found that I. Operational disruptions and mitigations in response to missing data increased uncertainty in PES estimates; II. A smaller-than-anticipated sample size contributed to increased uncertainty in PES estimates; and III. The bureau did not carry out quality control processes for PES operations as planned.

OIG determined whether the Forest Service had controls for selecting, funding, tracking, and implementing infrastructure funding to mitigate environmental hazards on Federal land.

KPMG LLC conducted an annual independent audit to determine the effectiveness of DOI’s FY 2024 FISMA programs and practices. 

We audited the HUD Office of Housing Counseling to assess its processes for achieving its goal to advance homeownership through prepurchase and postpurchase homeownership counseling, including its use of performance metrics and the collection and use of outcome data.  We selected this review because housing counseling plays a significant role in improving housing outcomes for home buyers, homeowners, and renters.

HUD’s Office of Housing Counseling collects data related to housing counseling activity from its approved housing counseling agencies.  It did not, however, use performance metrics or benchmarks for prepurchase and postpurchase homeownership counseling to measure whether this activity was contributing to its goal of advancing homeownership, nor did it conduct detailed analysis of the activity data to help identify trends.  The Office of Housing Counseling acknowledged there are limitations in the data it collects about housing counseling agency performance.  However, it believes that its periodic reviews of housing counseling agencies along with its existing data collection efforts are sufficient to measure performance in its programs.  With enhanced use of performance metrics and data, HUD can better assess how impactful prepurchase and postpurchase homeownership counseling is in advancing sustainable homeownership.  

We recommend that HUD’s Office of Housing Counseling (1) more clearly define successful prepurchase and postpurchase homeownership counseling outcomes and use these definitions to help establish performance metrics and benchmarks; (2) implement routine client outcome data analysis to identify trends, quantify performance metrics and benchmarks, and measure the impact of prepurchase and postpurchase counseling on advancing homeownership; and (3) enhance monitoring of HUD-approved housing counseling agencies’ performance against the established performance metrics. 

During the week of September 16, 2024, we performed a self-initiated audit at the Boston Processing and Distribution Center (P&DC) and three delivery units serviced by the P&DC. The delivery units included the Brookline Branch, Fort Point Station, and the Revere Carrier Annex in Boston, MA.

We issued individual reports for the three delivery units and another one for issues identified at the P&DC. We issued another report summarizing the results of our audits at all three delivery units with specific recommendations for management to address. We also responded to a delegation of U.S. Senators and Representatives to review specific mail delivery concerns in Massachusetts.

Two employees violated Amtrak policies by not disclosing a potential conflict of interest when they were assigned to a Technical Evaluation Committee for an infrastructure assessment program. While participating on the committee, both employees failed to disclose that a family member worked for one of the companies they were evaluating. One employee resigned and is not eligible for rehire, while the other received a final warning disciplinary letter.

The Office of the Inspector General conducted an audit to determine the effectiveness of the U.S. Government Publishing Office’s (GPO) fleet management and identify opportunities for improvement. The OIG selected 48 vehicles and 50 industrial trucks to 
assess fleet operations’ conformity with GPO’s policies and procedures.

Federal Law Enforcement in Chicago Seizes $214 Million in Alleged “Pump and Dump” Investment Fraud Investigation; Seven Defendants Indicted

This report presents the results of our Technology, Infrastructure, and Site Security Review.

This Office of Inspector General (OIG) Care in the Community healthcare inspection program report describes the results of a focused evaluation of community care processes at eight South Central VA Health Care Network Veterans Integrated Service Network (VISN) 16 medical facilities with a community care program. 

This evaluation focused on six domains:
   •    Leadership and Administration of Community Care
   •    Community Care Diagnostic Imaging Results
   •    Administratively Closed Community Care Consults
   •    Community Care Provider Requests for Additional Services
   •    Care Coordination Activities for Patients Referred for Community Care
   •    Urgent Care in the Community

The OIG issued 13 recommendations for improvement in the six domains:
   •    Leadership and Administration of Community Care
     o    Community care oversight councils
     o    Staffing needs
     o    Patient safety event entry and briefing
     o    Community care document importing
   •    Community Care Diagnostic Imaging Results
     o    Significant findings alert
   •    Administratively Closed Community Care Consults
     o    Medical documents after administrative closure
   •    Community Care Provider Requests for Additional Services
     o    Request processing
     o    Approval and denial letters
   •    Care Coordination Activities for Patients Referred for Community Care
     o    Community Care–Care Coordination Plan note
     o    Appointment confirmation
   •    Urgent Care in the Community
     o    Community Care–Urgent Care Record note

This report presents the results of our audit of Mail Theft Mitigation and Response at the Beechnut, Debora Sue Schatz, and T W House Stations in Houston, TX (Project Number 25-023). The stations are in Texas 2 District of the Retail and Delivery Operations, Southern Area. Our objective was to assess the U.S. Postal Service’s actions taken to mitigate and respond to mail theft in Houston, TX. This is one of a series of mail theft audits across the Postal Service.

The AmeriCorps Office of Inspector General investigated allegations that Movement of Youth, located in Durham, NC, improperly paid living allowances to AmeriCorps members before they were enrolled into the My AmeriCorps Portal and the AmeriCorps grants management system (eGrants).

The AmeriCorps Office of Inspector General investigated alleged whistleblower retaliation at an AmeriCorps grantee. Following receipt of AmeriCorps OIG's report summarizing the investigation, AmeriCorps did not substantiate the complaint or order relief. 

The National Telecommunications and Information Administration (NTIA) is responsible for administering $48.2 billion provided by the Infrastructure Investment and Jobs Act (IIJA) for four different broadband programs, namely the Broadband Equity, Access, and Deployment program, the Middle Mile Broadband Infrastructure Grant program, the Digital Equity Act program, and the Tribal Broadband Connectivity Program. Each has different programmatic requirements, but they all aim to expand broadband infrastructure and promote broadband adoption and use.

The objective for this evaluation was to identify potential challenges for deploying broadband to underserved and unserved communities. We interviewed NTIA and state and territory broadband office representatives, surveyed broadband offices, and sent questionnaires to industry stakeholder associations. Broadband officials and industry stakeholders identified challenges with the following: (1) statutory requirements, (2) Notice of Funding Opportunity provisions, (3) supply chain and labor market shortages, and (4) NTIA’s communication process. Our report describes these challenges and does not make recommendations.

This report presents the results of our audit of the Mail Theft Mitigation and Response: Sacramento, CA.

Why We Did This Report

The U.S. Environmental Protection Agency Office of Inspector General conducted this evaluation to determine whether the upgrade to the Superfund Enterprise Management System is likely to facilitate improved documentation of institutional controls in the “Institutional Controls” module.

Summary of Findings

Because of system limitations and insufficient guidance, the information in the classic SEMS “Institutional Controls” module is not complete and available for reporting, monitoring, and other oversight activities. The upgrade to SEMS 2.0 is unlikely to improve this condition. Specifically, classic SEMS and SEMS 2.0 do not track institutional controls as independent elements of a site remedy, and they do not allow users to track planned institutional controls. In addition to these system design limitations, at the time of our fieldwork, the Office of Land and Emergency Management had not mandated that the regions use the “Institutional Controls” module, nor had it issued guidance regarding the purpose and use of the module. Consequently, the regions do not use the “Institutional Controls” module consistently, so the data do not completely or accurately reflect actual site conditions.

We assessed NPS’ process for estimating and adjusting project cost estimates for construction contracts awarded using GAOA funds.

The VA Office of Inspector General (OIG) assessed aspects of community care and VA direct care programs at the Montana VA Healthcare System (system) for fiscal year 2022.

Among patients who received VA primary care and VA mental health care, 98.8 and 77.5 percent, respectively, did so exclusively through VA direct care. The utilization of specialty care services through only VA direct care or only community care depended on the type of specialty care sought. Most community care referrals were requested due to patients’ associated drive times to access needed care.

The OIG found that:
   •    VA staff acted on most direct and community care referrals within two days.
   •    Approximately 65 percent of VA direct care referrals reviewed (not canceled or discontinued) had an associated appointment set within seven days, and approximately 56 percent of community care referrals reviewed had an associated appointment set within 21 days.
   •    VA staff completed approximately 95 and 48 percent of direct and community care referrals, respectively, within 90 days of the requested date.
   •    Approximately 39 percent of patients with community care referrals for primary care obtained an appointment within 20 days of the requested date, and about 64 percent of patients received an appointment for mental health care within 20 days of the requested date.
   •    Approximately 97 percent of all community referrals were for specialty care; 54 percent of patients received an appointment within 28 days of the requested date.
Finally, the OIG identified two potentially disqualified former VA providers associated with community care claims paid by the system.

The OIG made five recommendations to the Montana VA Healthcare System Director related to timely appointment setting, timely completion of community care appointments, consult management, appointment wait times, and utilization of eligible community care providers.

Veterans are eligible to receive community care under certain circumstances, such as when their local VA medical facility does not provide the requested service or when a provider determines community care is in their best medical interest. In October 2020, the Veterans Health Administration’s (VHA) Office of Integrated Veteran Care (IVC) began implementing the Veteran Self-Scheduling (VSS) process at VA medical facilities. The process allows eligible veterans to schedule their appointments directly with community providers after these providers receive an approved request for services and an authorization for a veteran to receive care from them. Although many facilities implemented the process in 2020, staff were not required to offer the option until September 2023. The VA Office of Inspector General (OIG) conducted a review to determine whether IVC had adequate controls in place and whether IVC provided effective oversight of the process.

The OIG found IVC needs to improve its oversight of the VSS process to strengthen support and mitigate the risk of misuse of the scheduling option. IVC did not adequately help facilities use and monitor VSS before requiring them to use it. Additionally, neither IVC nor facility leaders implemented controls to identify potential misuse of VSS, such as opting veterans into the system without their permission or knowledge. If oversight is not improved, inappropriate use of the VSS option may go undetected, and veterans may experience delays in care.

The acting under secretary for health concurred with OIG’s eight recommendations for the under secretary to make sure IVC, in coordination with VHA’s chief operating officer and the Veterans Integrated Service Networks, take appropriate steps to better assist medical facilities with implementing VSS, improve controls over VSS so that the scheduling process is used appropriately, and improve oversight to make sure the process works as intended.

OIG reviewed whether the Forest Service converted seasonal wildland firefighters to full-time permanent Federal employees and accurately implemented salary increases for Federal wildland firefighters according to the Infrastructure Investment and Jobs Act.

In 2023, the VA OIG received several allegations that raised concerns about the management of supplies and equipment and workplace culture at the Michael E. DeBakey VA Medical Center in Houston, Texas. The OIG initiated this review to evaluate whether the Houston facility supply chain management staff established and maintained inventory controls in accordance with VA policy. The OIG identified deficiencies in managing supplies, equipment, and implant inventory at the Houston facility. Supply chain management staff did not ensure accurate recording and accountability of expendable supplies, nonexpendable equipment, and implants in the inventory management systems, as mandated by VHA policy. These deficiencies stemmed from inadequate oversight and failure to follow inventory procedures, risking the loss of supplies or use of expired products for patient care. The OIG made 10 recommendations to the Houston medical facility director: six recommendations to improve inventory management oversight and compliance with inventory procedures and four recommendations to improve implant management.

The Tennessee Valley Authority’s (TVA) 5-year Enterprise Technology Plan seeks to transform the way TVA does business through technology and digital innovation.  Digital Finance is one of seven efforts within this multi-year initiative, aimed at modernizing and streamlining TVA’s financial systems and processes.  Modernization of the general ledger (GL) is the first step within Digital Finance. The objectives of the GL Modernization project include implementing an enterprise financial management system with minimal customization, redefining and modernizing TVA’s chart of accounts, and modernizing and optimizing boundary systems (applications, systems, or platforms outside of the GL that interface with the GL).  Since its approval, the project has experienced cost increases and schedule delays.  Approved funding increased from $67.1 million to $104.7 million in November 2023. Although originally estimated to be completed by June 2025, the in-service date was moved up to January 2025.  In December 2024, the GL project was approved for $169 million in funding with an in-service date of November 2025.  Due to the impact of the project across TVA business units, we scheduled an evaluation of the GL Modernization project.  The objective of this evaluation was to determine the causes for cost increases and schedule impacts on the GL Modernization project.  We identified three primary causes of cost increases and schedule impacts on the GL Modernization project, including (1) inadequate identification of project requirements, (2) an incomplete project schedule, and (3) instances of ineffective contractor management. Specifically, detailed requirements were not identified early in the project.  Instead, detailed requirements are being identified as the project progresses. Also, input from key stakeholders was not adequate as the project began.  As a result, the GL project team did not understand the complexities and interdependencies of boundary systems and internal reporting needs were not included in the initial project scope.  In addition, the GL project schedule was incomplete and did not include all the project’s activities and associated resource needs, such as those related to boundary systems and internal reporting.  Finally, TVA did not provide effective management of some contractors involved in the project, resulting in missed opportunities to address system integrator performance issues.  In addition, TVA contracted for services that may not have provided value to the project. For example, TVA paid a contractor to negotiate savings with the system integrator but project cost increases make it difficult to determine if the savings were legitimate. 

Evaluation of the Federal Labor Relations Authority's Preparedness Against Cybersecurity Attacks, Fiscal Year 2025