Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations related to surgical services, information security, and facility leaders’ response to patient safety concerns.

The OIG substantiated the facility lacked services required to support the assigned inpatient invasive procedure complexity designation. Waivers for these services were approved; however, the OIG found delays with waiver requests and a concern with failing to monitor timeliness of patient transfers. The OIG did not substantiate a failure to meet blood bank or surgical coverage requirements but identified concerns with surgical service leaders’ engagement with the blood utilization committee and facility leaders’ failure to consider an institutional disclosure.

The OIG was unable to determine if facility leaders failed to ensure on-site supervision of postgraduate year one (PGY-1) surgery residents. The OIG found inconsistencies with interpretation of Veterans Health Administration (VHA) policy and is concerned that the Office of Academic Affiliations guidance given to Veterans Integrated Service Network (VISN) 10 leaders regarding PGY-1 surgery resident supervision does not meet the policy’s intent.

The OIG substantiated facility leaders failed to ensure information security when physicians provided unauthorized VA computer access to residents.

The OIG did not substantiate surgeons failed to meet standards for postoperative documentation or that facility leaders were unresponsive to patient safety concerns. However, the OIG found concerns with the monitoring and sustainment of related action plans.

The OIG made three recommendations to the Under Secretary for Health regarding invasive procedure complexity infrastructure, supervision of PGY-1 surgery residents, and processes related to health profession trainee computer access; three recommendations to the VISN Director regarding invasive procedure waiver requests and resolution of patient safety concerns; and six recommendations to the Facility Director regarding facility surgical infrastructure and waiver requirements, blood utilization committee participation, institutional disclosure, operative documentation compliance, and information security.

The Office of the Inspector General contracted with Sikich CPA LLC to conduct this audit.  Its objective was to assess the effectiveness of the information security policies, procedures, and practices of the U.S. Nuclear Regulatory Commission Region IV facility.  The findings and conclusions presented in this report are the responsibility of Sikich.  The OIG’s responsibility is to provide oversight of the contractor’s work in accordance with generally accepted government auditing standards.

Based on its assessment period from April 2024 through October 2024, Sikich found that although the NRC generally implemented effective information security policies, procedures, and practices for Region IV, the agency’s implementation of a subset of selected controls was not fully effective.  There were weaknesses in Region IV’s information security program and practices.  As a result, two recommendations were made to assist Region IV in strengthening its information security program.

This report presents the results of our audits of delivery operations and property conditions in the Ohio 2 District in the Central Area.

USDA OIG assessed whether dog breeders corrected previous noncompliances and whether the USDA's Animal and Plant Health Inspection Service carried out enforcement actions for substantiated Animal Welfare Act violations.

In May 2024, we conducted on-site, unannounced inspections at five U.S. Customs and Border Protection (CBP) facilities in the Tucson area, specifically four U.S. Border Patrol (Border Patrol) facilities and one Office of Field Operations port of entry. At the time of our on-site inspections, Border Patrol held 1,381 detainees in custody in the Tucson Coordination Center, Tucson Soft-sided Facility, Nogales Processing Facility, and Ajo station. In all four facilities, we found Border Patrol held detainees longer than specified in the National Standards on Transport, Escort, Detention, and Search, which generally limits detention to 72 hours. Overall, Border Patrol met other applicable standards to provide or make available amenities such as food, water, and medical care to detainees. However, we found Border Patrol did not follow standard procedures for managing detainee property in one holding facility, instances where agents did not document welfare checks for detainees with medical conditions, holding cells that were over capacity, and insufficient medical staffing. In addition, we found data integrity issues with information in Border Patrol’s electronic system of record, e3.

Kevin Leonard, a Tennessee resident, was sentenced on January 31, 2025, in U.S. District Court, Southern District of California, for health care fraud. Leonard was sentenced to 5 years of probation and ordered to forfeit $234,000. Leonard was a patient broker who unlawfully brokered patients to clinical treatment facilities owned and operated by Paragon Recovery LLC. In exchange, Leonard and others received kickback payments. The scheme resulted in the inflated fraudulent billing of insurance providers, including Amtrak’s.
 

In addition, Casimiro Bojorquez, a California resident, pleaded guilty on January 14, 2025, to conspiracy related to the health care fraud scheme. Our investigation found that Bojorquez and others conspired to solicit, offer, and receive illegal remunerations for referrals to clinical treatment facilities owned and operated by Paragon Recovery. Amtrak’s insurance providers were billed approximately $1,152,000 by facilities owned and operated by Paragon Recovery over the course of the scheme.

Bojorquez and two other codefendants will be sentenced at a future date.

Amtrak uses operational technology (OT) systems to manage equipment that controls train operations, such as communications and dispatching. Disruptions to these systems resulting from a disaster—whether caused by human or technical error, natural disasters, cybersecurity attacks, or physical attacks—could cause train delays and cancellations, revenue losses, and safety risks. Accordingly, our objective was to assess the company’s disaster recovery practices for its OT systems. Given the sensitive nature of the report’s information, we summarized the results in this public version of the report. Our assessment of the company’s disaster recovery practices for its OT systems resulted in three recommendations. Company executives agreed with our recommendations and described ongoing and planned actions to address them.

At the request of the Tennessee Valley Authority’s (TVA) Supply Chain, we examined the cost proposal submitted by a contractor for the New Caledonia Gas Plant.  Our examination objective was to determine if the cost proposal was fairly stated.  The contractor proposed a target cost estimate (TCE) of approximately $474.7 million for the construction of a potential simple cycle natural gas electricity generating plant at TVA’s New Caledonia site in Steens, Mississippi.

In our opinion, the cost proposal was overstated. Specifically, we found the proposal for the $474.7 million New Caledonia Gas Plant project included (1) overstated labor costs, (2) inflated subcontract costs, (3) overstated or unallowable other direct costs, (4) understated equipment costs, and (5) overstated (i.e., general and administrative, fee, and taxes).  We estimated TVA could avoid $63.7 million on the proposed $474.7 million New Caledonia Gas Plant project by negotiating appropriate reductions to the proposed TCE.  Additionally, we suggest TVA negotiate to revise the draft contract language and rate attachments to incorporate appropriate changes.

The proposal also included an alternative option to complete the project under a fixed price compensation method for a firm fixed price of approximately $506.4 million.  We analyzed the TCE proposal and alternative fixed price proposal and determined it would be more cost efficient for TVA to (1) negotiate appropriate reductions, including any necessary scope changes, and (2) utilize the TCE instead of agreeing to the fixed price proposal.

The Office of the Inspector General performed an audit of the Tennessee Valley Authority’s (TVA) cybersecurity vulnerability management program.  Our objective was to determine if TVA is compliant with the Cybersecurity and Infrastructure Security Agency (CISA) Binding Operational Directive (BOD) 22-01, Reducing the Significant Risk of Known Exploited Vulnerabilities (KEVs), and CISA BOD 19-02, Vulnerability Remediation Requirements for Internet-Accessible Systems. 

We determined TVA generally complied with CISA BOD 19-02 and CISA BOD 22-01; however, two requirements were not fully met. Specifically, TVA did not (1) update CISA with modifications to the inventory of internet-accessible internet protocol (IP) addresses within the five-day requirement or (2) meet the CISA required remediation timeline for 8 of 22 KEVs.

In compliance with the Act, the U.S. Environmental Protection Agency Office of Inspector General conducts periodic audits, assessments, and reviews of the travel and purchase card programs at the EPA and the U.S. Chemical Safety and Hazard Investigation Board. In fiscal year 2024, however, the EPA OIG did not perform a purchase or travel card program audit, review, or assessment for the EPA or the CSB. Also, as of the date of this letter, there are no outstanding OIG recommendations related to the EPA or CSB travel and purchase card programs.

The Federal Election Commission (FEC) Office of the Inspector General (OIG) implemented its annual work 
plan to ensure its resources are effectively and efficiently utilized throughout the performance year.

Objective:  To determine whether the Social Security Administration correctly applied workers' compensation (WC) off-set for Disability Insurance beneficiaries who received WC payments from Colorado and Minnesota.

The Department of Homeland Security has taken steps to develop guidance and establish oversight for artificial intelligence (AI) use, but more action is needed to ensure DHS governs and manages AI use appropriately. DHS issued AI-specific guidance, appointed a Chief AI Officer, and established multiple working groups and its AI Task Force to help guide the Department’s AI efforts. However, more action is needed to ensure DHS has appropriate governance for responsible and secure use of AI.

We performed an audit of Carrington Mortgage’s compliance with Federal Housing Administration (FHA) requirements for foreclosures that started in 2022. Pursuant to the Coronavirus Aid, Relief and Economic Security Act (CARES Act), as extended by the Secretary, from March 18, 2020, through July 31, 2021, there was a pause on new and ongoing foreclosures for FHA single‐family mortgages for homes that remained occupied. We selected Carrington because it was among the first servicers to resume initiating foreclosures after the moratorium ended with a foreclosure rate above 1 percent. Our audit objective was to determine whether Carrington complied with FHA’s requirements for loss mitigation before initiating and continuing foreclosure.

Carrington did not follow FHA’s requirements for more than 18 percent of its foreclosures in 2022. Based on a statistically valid sample drawn from a universe of 7,998 FHA‐insured loans totaling more than $907 million, Carrington did not complete the required loss mitigation activities before initiating or continuing foreclosure for an estimated 1,451 loans.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess confidential complaints alleging a veteran was going to be discharged from the Housing and Urban Development VA Supportive Housing (HUD-VASH) program and “should not have been,” and that other veterans were discharged from HUD-VASH “for no reason.” The OIG also evaluated access to primary care for veterans enrolled in HUD-VASH who remain unhoused.

The OIG did not substantiate that the veteran, nor other veterans, were discharged from the HUD-VASH program “for no reason.” However, deficiencies existed with the veteran’s case management, including treatment plan and discharge documentation. The OIG determined similar deficiencies occurred in the case management of other veterans discharged from HUD-VASH. Additionally, the electronic health records of many unhoused HUD-VASH veterans, who did not have scheduled primary care appointments, demonstrated the absence of treatment plans and assignments to primary care teams.

Deficiencies in case management and failures in supervisory oversight resulted in missed opportunities for improved case management for HUD-VASH veterans. The OIG is concerned that the absence of treatment plans, as well as primary care assignments, could affect HUD-VASH case management staff’s ability to coordinate veteran-centered care and may contribute to deficient facilitation of clinical services for this vulnerable population.

The OIG made five recommendations to the Facility Director related to completion and oversight of HUD-VASH documentation, HUD-VASH discharges, and assignment to primary care teams for unhoused HUD-VASH veterans.

The VA Office of Inspector General (OIG) reviewed a hotline complaint from January 2023 alleging that the Atlanta VA medical center’s call center was not answering calls and scheduling appointments within the expected time frame due to staffing shortages.

The OIG substantiated the allegations that the call center did not meet Veterans Health Administration (VHA) abandonment rate and timeliness standards because the call center did not have enough staff answering calls during the review period, which can lead to delays in scheduling appointments, potentially increase wait times, and decrease access to care. During the review period, the call center did not meet VHA’s call center standards, with 30 percent (rather than 5 percent) of the callers abandoning their calls, and only 22 percent (rather than 80 percent) of answered calls picked up within 30 seconds. Based on VHA’s recommended call center staffing model, the OIG estimated the call center needed 53 staff to answer the 135,600 calls received during the review period; the call center averaged 29 staff.

Other factors contributed to the call center’s inability to meet the performance standards. Call center supervisors focused on reviewing daily performance reports and real-time data provided through the call center dashboard, but they did not review cumulative data that could improve staff monitoring to ensure adequate phone coverage throughout the day and help address substandard handle times. Call center staff raised concerns during the review about possible problems in the management of the specialty care clinic telephone lines and mental health queue, which may also need to be addressed by facility leaders.

The OIG made three recommendations to the Veterans Integrated Service Network director and one recommendation to the facility director to assess the staffing and operations of the contact center and specialty care queues at the facility.

Why We Did This Report

The Government Charge Card Abuse Prevention Act of 2012, Pub. L. 112-194, and Office of Management and Budget Circular No. A-123, Appendix B, A Risk Management Framework for Government Charge Card Programs, direct that the head and inspector general of each executive agency with more than $10 million in annual purchase card spending submit a joint semiannual report on purchase card violations to the Office of Management and Budget director.

Summary of Findings

The U.S. Environmental Protection Agency reported no violations for its semiannual period. No information that is inconsistent with the EPA’s violation report came to the EPA OIG’s attention. Additionally, the EPA OIG received no allegations regarding misuse of a purchase card during this semiannual period.

An Electrical Technician based in Washington, D.C., was arrested for driving more than 100 miles per hour while pursued by police and passing vehicles on the shoulder. He was charged with driving under the influence and other driving violations. He was held without bond on December 18, 2024, and remains incarcerated until his jury trial scheduled for March 17, 2025. While incarcerated, he applied for leave under the Family Medical Leave Act and failed to report his arrest to the company. The former employee resigned on January 29, 2025. He is ineligible for rehire.

Ernesto Ruiz of Orlando, Florida, pleaded guilty on January 29, 2025, in the Circuit Court of Orange County, State of Florida, to fraudulent use of a credit card. The same day, Ruiz was sentenced to one day incarceration and ordered to pay a special assessment of $618. Our investigation found that Ruiz and codefendant Eric Cardenas were part of a sophisticated credit card fraud ring operating throughout central Florida. They used fraudulently obtained credit cards, to include an Amtrak Wright Express Corporation (WEX) card, to purchase fuel.

Cardenas previously pleaded guilty and was sentenced in November 2024.

Our Objective(s)To perform a quality control review (QCR) of KPMG LLP's management letter related to the audit of DOT's consolidated financial statements as of and for the fiscal years ended September 30, 2024, and September 30, 2023. We reviewed KPMG's management letter, dated November 27, 2024, and related documentation.
About This ReportWe contracted with the independent public accounting firm KPMG, LLP, to audit DOT's consolidated financial statements. KPMG also issued a management letter discussing internal control matters that KPMG was not required to include in its audit report.
What We FoundThe independent auditor, KPMG, found six internal control matters in DOT's management of operations.

Federal Highway Administration's (FHWA) weaknesses within the user profile system change management process.
FHWA's weakness in accounting policies for Federal Lands Highway construction.
Enterprise Services Center's (ESC) weakness in control over Central Accounting Reporting System Classification, Transactions, and Accountability module reconciliation.
ESC's weakness in control over quarterly review of the journal voucher control log.
OST's weakness in control over management legal schedule and management legal letter.
FHWA's weaknesses in controls over the inputs to the Federal aid grant accrual.

Our QCR disclosed no instances in which KPMG did not comply, in all material respects, with U.S. generally accepted Government auditing standards.
RecommendationsWe agree with KPMG's 11 recommendations to strengthen DOT's information system and business process controls.

Our Objective(s)To perform a quality control review (QCR) of Allmond & Company, LLC's (Allmond) management letter related to the audit of NTSB's financial statements as of and for the fiscal years ended September 30, 2024, and September 30, 2023. We reviewed Allmond's management letter, dated November 6, 2024, and related documentation.
About This ReportWe contracted with the independent public accounting firm Allmond to audit NTSB's financial statements. Allmond also issued a management letter discussing internal control matters that Allmond was not required to include in its audit report.
What We FoundThe independent auditor, Allmond, found three internal control matters in NTSB's management of operations.

NTSB does not have agency-specific written policies and procedures for processing personnel actions.
NTSB does not review the Official Personnel Folders of transferred employees and employees returning to Federal service to verify the employees' payroll and benefits information is accurate and supported by appropriate documentation
NTSB does not have a procedure to validate upward and downward adjustment activity in the general ledger and to make the necessary corrections to ensure that both the upward and downward adjustment balances are accurate.

Our QCR disclosed no instances in which Allmond did not comply, in all material respects, with U.S. generally accepted Government auditing standards.
RecommendationsWe agree with Allmond's seven recommendations to help strengthen NTSB's internal controls.

The U.S. Department of Education (Department) is responsible for minimizing the risk that Federal funds will be lost when an Institution of Higher Education (IHE) stops participating in the programs authorized by Title IV of the Higher Education Act of 1965, as amended. When an IHE stops participating in Title IV programs, either voluntarily or involuntarily (due to closure or other circumstances), the closeout procedures it is required to perform and the liability assessment processes Federal Student Aid (FSA) performs, identify any program funds the IHE is required to return to the Department. If the required closeout procedures are not completed, an alternative assessment is conducted by FSA to determine whether the IHE must return program funds to the Department. We performed our inspection to determine the results of the Department’s processes for assessing and recouping liabilities from IHEs that closed from October 1, 2020, through September 30, 2023. We found that the Department has processes in place for assessing and recouping liabilities from IHEs that close. Based on these processes FSA’s School Participation Divisions (SPD) determined that as of March 2024, 47 of the 161 IHEs that closed between October 1, 2020, and September 30, 2023, should repay the Department a total of $34,593,135 in Title IV program funds. These processes also led to FSA’s SPDs assessing liabilities totaling $30,507,138 during the period we reviewed for 13 of the 19 closed IHEs we selected for review. The Department’s Office of Finance and Operations recouped a total of $812,998 of those liabilities from 8 of the 13 IHEs. However, despite these efforts, we found that five of the seven sampled SPDs that oversee IHEs and that we included in our review did not always follow the established processes to timely determine whether liabilities should be assessed against IHEs that closed. These processes are necessary to timely determine closed schools’ liabilities and to make those determinations in a manner consistent with established guidance. We did not identify any issues with the Department’s actions to recoup liabilities from the IHEs we sampled in our review.

The VA Office of Inspector General (OIG) conducted a follow-up healthcare inspection in response to a 2023 OIG report regarding mistreatment of a resident at the Miles City VA Community Living Center (CLC) and the Fort Harrison VA Medical Center (facility). The OIG did not receive new allegations but initiated the inspection to review the current state of the CLC, including corrective actions and sustainability of changes implemented by system leaders. In addition, the OIG reviewed staffing shortages affecting the quality of care for CLC residents.
The 2023 OIG report substantiated an allegation of resident mistreatment and identified issues related to reporting and oversight processes. The OIG made seven recommendations that were closed as of May 9, 2024. The OIG determined system leaders’ actions to address previously identified CLC deficiencies specific to rights of residents to refuse treatment, patient safety reporting, screening and admissions, physician care oversight and documentation, and nursing care operations were sustained; therefore, the OIG did not have recommendations related to these areas. 
The OIG, however, identified gaps in CLC physician coverage and staffing shortages for the CLC physical therapist and social worker positions, affecting quality of care for residents. The OIG found that when the CLC physician was on extended leave, medical coverage was by phone to the facility medical officer of the day located over 300 miles away. Physical therapy needs, such as timely access to durable medical equipment, were still being covered by existing system staff. A social worker, to address residents’ psychosocial needs, had been hired as of September 11, 2024. While the OIG did not find that the CLC staffing shortages resulted in resident harm, the gaps and shortages may limit access to and continuity of care for residents. The OIG made two recommendations to the Facility Director regarding staffing.

This letter responds to the Government Charge Card Abuse Prevention Act of 2012 (Charge Card Act) reporting requirement for the Federal Trade Commission (FTC) for fiscal year 2025.

We performed an audit of MidFirst’s compliance with Federal Housing Administration (FHA) requirements for foreclosures that started in 2022.  Pursuant to the Coronavirus Aid, Relief and Economic Security Act (CARES Act), as extended by the Secretary, from March 18, 2020, through July 31, 2021, there was a pause on new and ongoing foreclosures for FHA single‐family mortgages for homes that remained occupied. We selected MidFirst Bank because it was among the first servicers to resume initiating foreclosures after the moratorium ended with a foreclosure rate above 1 percent.  Our audit objective was to determine whether MidFirst Bank complied with FHA’s requirements for loss mitigation before initiating and continuing foreclosure.

 MidFirst Bank did not follow FHA’s requirements for more than 14 percent of its foreclosures in 2022.  Based on a statistically valid sample drawn from a universe of 7,363 FHA-insured loans totaling $890 million, MidFirst did not complete the required loss mitigation activities before initiating or continuing foreclosure for an estimated 1,038 loans.  

Williams, Adley & Company – DC, LLP (Williams Adley), under contract with the Department of Homeland Security Office of Inspector General, issued an Independent Accountant’s Review Report on the United States Coast Guard (Coast Guard) Detailed Accounting Report for Drug Control Funds. Coast Guard’s management prepared the Table of FY 2024 Drug Control Obligations and related assertions to comply with the requirements of the ONDCP Circular, National Drug Control Program Agency Compliance Reviews, dated September 9, 2021.

Williams, Adley & Company – DC, LLP (Williams Adley), under contract with the Department of Homeland Security Office of Inspector General, issued an Independent Accountant’s Review Report on the United States Coast Guard’s (Coast Guard) FY 2024 Drug Control Budget Formulation Compliance Report. Coast Guard’s management prepared the Budget Formulation Compliance Report and the related assertions to comply with the requirements of the ONDCP Circular, National Drug Control Program Agency Compliance Reviews, dated September 9, 2021.

The U.S. AbilityOne Commission OIG has received zero complaints against OIG employees in the past five years.  Therefore, zero complaints contained an element of sexual harassment.

This report presents the results of our audit of progress on improvements at Richmond, VA, Regional Processing and Distribution Center.
 

A train director based in Chicago, Illinois, pleaded guilty on January 27, 2025, in Marion Superior Court, Indiana, to felony theft. The same day, the employee was sentenced to a 545-day suspended sentence and 545 days of probation. The employee was ordered to take an anti-theft class and pay restitution in the amount of $8,978 to the Indiana Department of Workforce Development. Our investigation found that the employee fraudulently applied for and received pandemic unemployment related funds to which she was not entitled.

We discuss DOI’s progress in implementing Government charge card recommendations in FY 2024 and other DOI-related charge card activities. 

The Federal Emergency Management Agency (FEMA) obligated $267.7 billion (95.3 percent) of disaster relief funding available between fiscal years 2017 and 2023 for disaster-related activities, as authorized by the Robert T. Stafford Disaster Relief and Emergency Assistance Act, as amended, 42 United States Code 5121 et seq. (Stafford Act). Approximately $8.1 billion (2.9 percent of the disaster relief funding available) was set aside or transferred to other programs in accordance with applicable laws. Specifically, FEMA set aside $4.6 billion for pre-disaster mitigation and transferred $3.5 billion out of the Disaster Relief Fund to other appropriations.

The Office of the Inspector General (OIG) contracted with Sikich to conduct this performance audit.  The objective was to assess the effectiveness of the information security policies, procedures, and practices of the U.S. Nuclear Regulatory Commission’s (NRC) Technical Training Center (TTC).  The findings and conclusions presented in this report are the responsibility of Sikich.  The OIG’s responsibility is to provide oversight of the contractor’s work in accordance with generally accepted government auditing standards. 

Based on its assessment period from March 2024 through October 2024, Sikich found that although the NRC generally implemented effective information security policies, procedures, and practices for the TTC, the agency’s implementation of a subset of selected controls was not fully effective.  There were weaknesses in the TTC’s information security program and practices.  As a result, six recommendations were made to assist the TTC in strengthening its information security program.

An Amtrak passenger engineer based in Miami, Florida, was terminated from employment on January 24, 2025, following an administrative hearing. Our investigation found that the employee violated company policies by engaging in outside employment for another company while on a medical leave of absence from Amtrak. The former employee is not eligible for rehire.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess facility leaders’ responses to a dermatologist’s deficiencies in quality of care and documentation. The OIG found supervisory staff and senior leaders failed to adequately address patient care concerns outlined by staff in 48 patient safety reports and two consecutive unsatisfactory proficiency reports. Specifically, supervisory staff failed to correct the dermatologist’s delays in performing biopsies and misuse of copy and paste in electronic health records, and did not comprehensively review whether the dermatologist documented procedures not performed. 

The Chief of Staff (COS) reported being unaware of the extent of the dermatologist’s deficiencies, despite attending meetings where the information was shared. The Facility Director did not ensure timely initiation of the State Licensing Board (SLB) reporting process after facility leaders had evidence to support the dermatologist’s failure to meet standards of clinical practice and the Medical Executive Board’s recommendation to not renew clinical privileges.

The COS told the OIG that reviews of the dermatologist’s care were completed, and disclosures were not warranted because no patient harm was identified. However, the OIG found that the reviews were neither comprehensive nor conducted by a dermatologist. Additionally, after the OIG site visit, the chief of dermatology reviewed electronic health records and identified that two patients should have received alternative treatments, one patient did not have all identified lesions addressed, and four patients experienced biopsy delays. Therefore, the OIG concluded that further reviews of the care provided by the dermatologist and reconsiderations for disclosures are warranted. 

The OIG made eight recommendations related to delays in the SLB reporting process, and leaders not adequately addressing clinical deficiencies, misuse of copy and paste, documentation of procedures, and the need for follow-up care and disclosure.

An Amtrak customer service representative based in Tucson, Arizona, was terminated from employment on January 23, 2025, following an administrative hearing. Our investigation found that the employee violated company policies by providing discounts, on two separate occasions, to two individuals who did not appear to be entitled to the discounted train travel. The former employee is not eligible for rehire.

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

Amtrak (the company) contracted with the independent certified public accounting firm of Ernst & Young LLP to audit its consolidated financial statements as of September 30, 2024, and for the year then ended, and to provide a report on internal control over financial reporting and on compliance and other matters. Because the company receives federal assistance, it must obtain an audit performed in accordance with generally accepted government auditing standards.

As required by the Inspector General Act of 1978, as amended, we monitored the audit activities of Ernst & Young to help ensure audit quality and compliance with auditing standards. Our monitoring focused on two Ernst & Young reports and disclosed no
instances in which Ernst & Young did not comply, in all material respects, with generally accepted government auditing standards. We reached this conclusion by monitoring Ernst & Young’s audit activities, which included reviewing its reports, auditor independence and qualifications, audit plans, detailed testing results, summary work papers, and quality controls. We also attended key meetings.

Ernst & Young’s first report was its audit of the company’s consolidated financial statements for fiscal year (FY) 2024. In a report dated December 12, 2024, Ernst & Young concluded that the company’s consolidated financial statements were presented fairly, in all material respects, in accordance with U.S. generally accepted accounting principles. Further, the report emphasized that the company has a history of operating losses and without receipt of federal government funding, the company will not be able to continue in its current form, and significant operating changes, restructurings, or bankruptcy might occur.

We audited the Puerto Rico’s Department of Natural and Environmental Resources (PRDNER’s) use of Federal Emergency and Pandemic Relief Financial Assistance Funds. Our audit objective was to determine whether federal funds received by PRDNER to support its fisheries in recovering from the impacts of the COVID-19 pandemic1 and damages caused by several hurricanes were properly disbursed and used for their intended purpose. We conducted this audit in response to a congressional request, and answers to congressional questions about disaster relief funds are included in this report.

Overall, we found that for the funds it expended, PRDNER properly disbursed and used funds as intended. However, PRDNER was slow in spending funds, as only approximately 7 percent of the total disaster assistance funds ($801,362 of the approximate $11.4 million) have been expended since April 1, 2020. Additionally, PRDNER has expended funds for only 4 of the 17 (approximately 24 percent) combined projects under both awards.

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 seven VA Sierra Pacific Veterans Integrated Service Network (VISN) 21 medical facilities with a community care program. This evaluation focused on five 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: Scheduling and Communication with Patients Referred for Community Care

The OIG issued 13 recommendations for improvement in the five domains:
•    Leadership and Administration of Community Care
o    Community oversight councils functioning according to charters
o    Entering patient safety events in the Joint Patient Safety Reporting system
o    Briefing patient safety trends, lessons learned, and corrective actions
o    Scanning community care documents into the electronic health record
•    Community Care Diagnostic Imaging Results
o    Using the significant findings alert for abnormal diagnostic imaging results
•    Administratively Closed Community Care Consults
o    Confirming patients attended appointments obtaining medical documents
o    Making two attempts to obtain medical documents after administratively closing consults
•    Community Care Provider Requests for Additional Services
o    Processing requests
o    Sending approval and denial letters to community providers and patients
•    Care Coordination: Scheduling and Communication with Patients Referred for Community Care
o    Timely scheduling of patients
o    Confirming patients attended appointments
o    Using the Community Care–Care Coordination Plan note to document care coordination activities