Federal Reports

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

The Office of Inspector General received an anonymous complaint alleging that: (1) Department of Energy Headquarters’ Sensitive Compartmented Information Facilities (SCIF) in the Forrestal Building have been out of compliance with U.S. Intelligence Community requirements; (2) the Office of Intelligence and Counterintelligence (DOE-IN) authorized a contractor employee to procure a contract for a congressionally directed review of DOE-IN’s Counterintelligence (CI) Program, which may have been a conflict-of-interest violation; and (3) DOE-IN has contractor employees conducting inspections of DOE-IN’s CI Program.

We initiated this inspection to determine the facts and circumstances regarding the alleged management concerns at DOE-IN.

We substantiated the allegation that Department Headquarters’ SCIFs in the Forrestal Building did not meet U.S. Intelligence Community requirements. Specifically, we found that SCIF reaccreditations, technical security reviews, and self-assessments were not conducted for some SCIFs occupied by DOE-IN. These issues occurred, in part, because DOE-IN did not develop and implement a formal corrective action plan with a strategic approach to improve SCIF compliance at Department Headquarters, including the necessary resources to implement the corrective action plan. To its credit, we noted that DOE-IN began making progress in calendar year 2023. In addition, we did not substantiate the allegation that DOE-IN authorized a contractor employee to procure a contract for a congressionally directed review of DOE-IN’s CI Program; therefore, we did not substantiate the allegation that there was a conflict-of-interest violation. Further, while we substantiated the allegation that DOE-IN has contractor employees conducting inspections of DOE-IN’s CI Program, we determined that the use of contractor personnel to conduct these inspections is not against DOE-IN policy. DOE-IN leadership approves the selection of the lead inspector and provides Federal oversight for CI Program inspections.

Noncompliance with U.S. Intelligence Community security requirements, which ensure that critical safeguards are fully implemented, may result in degradation of the security posture for SCIFs, potentially exposing highly classified national security information.

To address the issues identified in this report, we have made two recommendations that, if fully implemented, should help ensure that the Department maintains its Headquarters’ SCIFs in compliance with U.S. Intelligence Community requirements.

Savannah River Nuclear Solutions, LLC (SRNS) operates the Savannah River Site under a management and operating (M&O) contract which contains provisions and requirements governing the purchase of services from contractor-affiliated sources such as parent companies (i.e., corporate reachback).

We conducted this audit to determine whether: (1) SRNS’ use of corporate reachback at the Savannah River Site was in compliance with its M&O contract provisions and requirements governing the use of corporate reachback; and (2) the overall costs incurred for these activities were reasonable, allocable, and allowable.

We found that SRNS did not comply with its M&O contract requirements to use competition in purchasing services from contractor-affiliated sources; therefore, we are questioning the costs incurred for numerous corporate reachback activities as unallowable.

The issues we identified occurred, in part, because of the Department of Energy’s lack of oversight in ensuring SRNS followed the M&O contract requirements to: (1) sufficiently document the special expertise for each seconded corporate reachback acquisition when not using competition; and (2) sufficiently document the reasonableness of the costs incurred.

This report contains five recommendations that, if fully implemented, should help ensure SRNS follows its M&O contract requirements to use competition when purchasing services from a contractor-affiliated source. Although management concurred with our recommendations, we consider the action taken to address our recommendations unresponsive to the underlying concerns that prompted the recommendations.

An Amtrak Director based in New York City used his company-issued computer for personal business on company time. Those activities included visiting clothing, apparel, and design websites, excessively watching non-work related YouTube videos and visiting other personal-use websites. The employee was terminated on December 26, 2024, and he is not eligible for rehire.

OIG reviewed the Rural Business-Cooperative Service’s internal controls over the Meat and Poultry Processing Expansion Program grant recipients’ use of funds.

An Amtrak customer service representative based in Miami, Florida, signed a civil settlement agreement on December 21, 2024, with the U.S. Attorney’s Office, Southern District of Florida. The employee agreed to pay $48,000 in restitution and penalties related to the fraudulent receipt of two pandemic related loans. The employee applied for and received an Economic Injury Disaster Loan in the amount of $30,500 and a Paycheck Protection Program loan in the amount of $12,522.50. The loan applications contained false statements and information to qualify for the loans. As a result, the employee received Coronavirus Aid, Relief, and Economic Security Act funds to which he was not entitled.

We audited WSFR grants awarded by FWS to the Washington Department of Fish and Wildlife to ensure compliance and cost allowability.

We found that OWPO did not: review quarterly reports, ensure that IBC assessed risk, have an effective site visit policy, and provide enough guidance.

During the week of July 29, 2024, we performed a self-initiated audit at the Denver Processing and Distribution Center (P&DC) and four delivery units serviced by the P&DC. The delivery units included the Brighton Main Post Office, Edgewater Branch, Mile High and Stockyards stations in the Denver, CO area.

We issued individual reports for the four delivery units and the P&DC. We issued another report summarizing the results of our audits at all four delivery units with specific recommendations for management to address.

We conducted an audit of Peace Corps operations in Uganda (hereafter referred to as “the post”) from February through August 2024. Our objective in auditing the Uganda post was to determine whether its financial and administrative operations were functioning effectively and in compliance with Peace Corps policies and Federal regulations.

The objective of this audit was to determine the extent to which the Defense Intelligence Agency’s (DIA’s) strategic efforts to timely develop, acquire, adopt, and maintain secure and reliable artificial intelligence (AI) capabilities improved intelligence collection and analysis in accordance with applicable policies, standards, and requirements. Additionally, we assessed whether there were any administrative or technical barriers to DIA’s accelerated adoption of AI capabilities. We issued the results of our evaluation, along with ten recommendations, in a final report dated December 20, 2024.

The OIG Audit office initiated this audit based upon an assessment of program risks. Our audit objective was to determine whether the U.S. AbilityOne Commission’s (Commission) enterprise risk management (ERM) process is effective and used to make risk-based decisions. 

Although the Commission has designed and implemented a formal ERM program, the OIG determined that the ERM program is not fully effective. This could impact the Commission’s ability to make fully informed risk-based decisions. Specifically, we found that the Commission’s ERM process and related internal controls need improvements, and the Commission lacked the ERM training to identify and correct these improvement areas. 

The OIG recommended that the Commission ensure that the appropriate individuals are trained through a structured ERM program training, assess and update existing ERM policies and procedures, and research and adopt an appropriate ERM maturity model. We also recommended that the Commission develop and implement effective key controls and results assessment, include a process in the ERM program to document management’s determination of key process decisions for its other process considerations, and develop and implement a process for tracking the consolidation of risks.

The purpose of this report is to summarize the OIG’s oversight and investigative work involving Federal student assistance programs and operations over the past 6 FYs—FY 2019 through FY 2024 and to provide the office of Federal Student Aid (FSA) with context on historical areas of weakness involving internal controls. To identify common themes across internal control vulnerabilities identified during our audit work, we evaluated recommendations made in OIG reports to address those vulnerabilities and assessed their correlation with each internal control component. And, in this effort, we analyzed complaints received by the OIG Hotline specific to Federal student assistance programs and FSA operations to identify trends and fraud indicators, summarized investigative results related to student aid fraud, and assessed their correlation to internal controls. We also took a close look at a type of fraud that accounts for a large portion of our student aid fraud investigative caseload—student aid fraud rings.

The results of this effort are intended to provide context on historical areas of weakness and vulnerabilities in FSA’s internal controls identified through the OIG’s audit work and provide insight gleaned from the OIG’s investigative work on the importance of strengthening internal controls to help mitigate the risk of fraud in the Federal student assistance programs. By strengthening its internal controls, FSA can better ensure that Federal student assistance programs are carried out as required, achieve the desired results, and that vital Federal student aid assistance reach the intended recipients.

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

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

The OIG issued four recommendations for improvement in two domains:
1. Environment of care
• Separation of clean and dirty equipment and supplies
• Clean and safe environment
• Communication with sensory-impaired veterans
2. Patient safety
• Identify opportunities for improvement, implement action plans, and evaluate actions for sustained improvement

The VA Office of Inspector General (OIG) conducted a follow-up healthcare inspection at the Tuscaloosa VA Medical Center (facility) in Alabama to evaluate the status of patient safety program deficiencies identified in a 2023 OIG report and Veterans Integrated Service Network (VISN) 7’s oversight of the facility’s patient safety program. Additionally, the inspection evaluated actions taken to address deficiencies in the community living center (CLC) regarding residents at risk for elopement identified in a 2022 OIG report.
In contrast to previous findings, the OIG found that the facility’s patient safety program complied with VA-mandated standards. The OIG’s analysis of facility patient safety data showed the patient safety manager appropriately accepted or rejected event reports; considered significant safety events for root cause analysis; and completed eight annually required patient safety analyses for fiscal year 2023.
While the VISN patient safety officer’s oversight of patient safety programs improved, the OIG identified the need for qualitative analysis of patient safety data, which is essential to assess the impact and effectiveness of VISN patient safety programs and develop effective actions plans.
Facility leaders addressed the deficiencies identified in the 2023 and 2022 OIG reports and determined actions taken by the facility leaders resulted in a facility culture where patient safety has become paramount. The OIG concluded that a commitment to continue to administer a high-quality patient safety program was evident in facility leaders’ actions.
The OIG determined that the facility resolved previous concerns regarding the safety and security of the residents in the CLC as well as implemented a review process to ensure electronic health record documentation for residents at risk for elopement was consistent with facility policy.
The OIG made three recommendations to the VISN Director related to the patient safety officer’s qualitative reviews of patient safety data.

To see our report, click on the link below

This report presents the results of our audit of the U. S. Postal Service’s oversight of Parcel Select.

The OIG Evaluation office initiated an evaluation to determine whether the U.S. AbilityOne Commission’s 2022-2026 Strategic Plan contained the necessary framework, including specific operational initiatives, objectives, and associated performance measures. This evaluation was conducted to identify elements to consider incorporating in the next iteration of their strategic plan.

Overall, the Commission created a thoughtful and attainable approach to developing a new strategic plan to work toward the goal of modernizing the AbilityOne Program. We found that the Commission’s 2022-2026 Strategic Plan includes all required strategic plan elements according to federal regulations.
The Commission is a non-Chief Financial Officers (CFO) Act agency, and some statutory elements are not required. As a part of this evaluation, the OIG identified that the inclusion of two additional elements would further enhance the effectiveness of the next iteration of the Commission’s strategic plan. Specifically, the Commission potentially missed key learning opportunities for its strategic plan goals, objectives, and measures because it did not conduct evidence building activities or perform its own internal program evaluations. Furthermore, the Commission should incorporate more quantitative measures in the next iteration. Although the Commission has met federal requirements, these additional elements would provide a more comprehensive and evidence-based approach for measuring the progress toward goals and objectives in the AbilityOne program.

The OIG recommended that the AbilityOne Commission meet with Commission members and stakeholders to determine whether (1) incorporating evidence building and (2) program evaluation into its next strategic planning process would help in identifying key    areas of improvement and improve outcomes. The OIG also recommended that the AbilityOne Commission enhance its ability to track and monitor progress and the successful implementation of agency goals, by establishing and incorporating quantitative measures into the 2026-2030 strategic plan.

HUD’s Office of Housing contracts with performance-based contract administrators to administer the housing assistance payments (HAP) contract with owners. Through RAD, HUD oversees the HAP contracts for converted properties and monitors owners for compliance with HUD’s requirements, which include maintaining (1) units in decent, safe, and sanitary condition and (2) reserve for replacement accounts to help defray the cost of replacing properties’ capital items.

We found HUD needs to improve its oversight of the physical condition of public housing units that converted to PBRA and FHA-insured PBV under the RAD program. Of the 242 units we observed, 65 percent contained 576 deficiencies, 63 of which were life-threatening deficiencies. Converted properties are required to maintain reserve for replacement accounts to fund extraordinary maintenance, repair, and replacement of capital items. However, owners’ reserve for replacement accounts’ balances were not supported for 13 of the 14 properties reviewed. Further, HUD did not ensure that initial inspections of converted properties occurred in a timely manner.

The unit deficiencies occurred because the properties’ (1) management officials did not ensure that staff or contractors inspected the physical condition of RAD units annually and (2) maintenance departments were understaffed, resulting in delayed inspections and repairs. Further, HUD did not ensure that its staff consistently performed management and occupancy reviews (MOR) to monitor the operation of the properties for compliance with HUD’s requirements for the physical condition of RAD units and reserve for replacement accounts. Specifically, for the properties that we reviewed, HUD’s staff had not conducted (1) initial MORs for 50 percent of the properties even though they had been converted under RAD between 3 to 10 years ago and (2) timely initial MORs for nearly 48 percent of the properties. HUD also did not have a (1) process for monitoring the timeliness of properties’ initial inspections and (2) clear guidance specifying the timing of initial inspections for non-FHA-insured PBRA properties.

As a result, families resided in units that were not decent, safe, and sanitary. Further, there is an increased risk of (1) additional families’ residing in units that are not decent, safe, and sanitary and (2) properties’ reserve for replacement accounts being insufficiently maintained to address extraordinary maintenance, repair, and replacement of capital items. Further, HUD did not have necessary information to determine the (1) initial physical of condition of the units, including identifying deficiencies that require timely corrective actions, and (2) timing of properties’ next inspection, which is based on each property’s previous inspection score.

We made several recommendations to HUD to improve its oversight of properties converted under RAD. Specifically, we made recommendations related to determining the timing and completion of initial and subsequent MORs, including issuing updated guidance that includes a system to track the timeliness of initial MORs. We also made recommendations to provide training to staff members to ensure that they have the skills necessary to complete MORs of converted properties and to review the reserve for replacement account balances for all properties to ensure the accuracy of the account balances. Lastly, we made recommendations for HUD to implement adequate procedures and controls to ensure that servicing lenders comply with HUD time requirements in initial inspections of converted properties and determine an appropriate timeframe for when noninsured PBRA converted properties should be initially inspected and work with the Real Estate Assessment Center to ensure that inspections are ordered and completed within that timeframe.

In accordance with the Government Performance and Results Modernization Act of 2010, this report presents the results of the OIG's work over fiscal year 2024 in meeting its performance goals.

In June 2019, the Tennessee Valley Authority (TVA) completed an Integrated Resource Plan and recommended the expansion of solar generating capacity by up to 14,000 megawatts (MW) by 2038. According to TVA’s fiscal year 2020 Sustainability Report, TVA set a sustainability aspiration to achieve 10,000 MW of solar generation by 2035. To help achieve this goal, TVA purchased 3,000 acres to construct an estimated 200 MW solar facility in Lawrence County, Alabama. TVA purchased 139,750 solar panels, totaling $30 million, in December 2019 for installation at the Lawrence County Solar (LCS) project. TVA began receiving these solar panels in late January 2020 and received the final shipment on March 30, 2020. The project was originally estimated to be in service by December 2023. Due to delays in the LCS project, the solar panels purchased in 2019 were transferred to another TVA project. TVA subsequently purchased an additional 581,250 solar panels for $92.7 million in May 2023 for installation at the LCS project.

TVA’s Standard Programs and Processes 34.000, Project Management, states risk assessments should be performed as early as possible in a project to identify critical technical, performance, schedule, and cost risks. Due to the length of time the solar panels purchased in 2019 for the LCS project have been in inventory, we performed an audit of TVA’s assessment of risks associated with solar panel purchases for the LCS project. Our audit objective was to determine if TVA assessed risks in accordance with applicable policies and procedures prior to the purchase of solar panels for the LCS project. Our audit scope included the solar panels purchased in calendar years 2019 and 2023.

We determined TVA (1) did not perform a risk assessment prior to purchasing solar panels in 2019 and (2) only performed a partial risk assessment prior to the purchase of the 2023 solar panels. Additionally, the solar panels purchased in 2023 were procured after the project had been placed on hold by TVA.

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

This report presents the results of our audit of Network Changes: Local Transportation Optimization.

The VA Office of Inspector General (OIG) conducted a review of Veterans Health Administration (VHA) inpatient mental health unit (mental health unit) suicide risk identification processes, suicide prevention safety plans, mental health treatment coordinator (MHTC) role requirements, and discharge care coordination procedures.

Given patients’ increased suicide risk after discharge, continuity of care is critical to mitigating risk. VHA requires that every patient receiving mental health services be assigned a principal mental health provider to support care coordination.

Staff failed to document required suicide risk screening for 27 percent of patients and did not complete safety plans for 12 percent of discharged patients. The OIG concluded that failure to complete suicide risk identification processes may result in an underestimation of patients’ risk, and failure to complete a safety plan can contribute to diminished utilization of coping strategies and supportive resources.

Over 30 percent of facilities lacked an MHTC policy and mental health unit staff failed to assign an MHTC for nearly 40 percent of patients. Over half of surveyed patients with an assigned MHTC could not identify the MHTC and more than 25 percent of MHTCs were uninvolved in discharge care coordination or the transition to outpatient care. 

While most patients, regardless of MHTC assignment, attended at least one outpatient mental health appointment within 90 days, over half of surveyed patients identified self-motivation and 20 percent identified encouragement from a family member or friend as contributing to appointment attendance. The OIG concluded that the MHTC model failed to effectively facilitate care coordination and MHTC assignment was not associated with a patient’s likelihood of attending post-discharge treatment engagement.

The OIG made eight recommendations to the Under Secretary for Health related to suicide risk identification and safety planning; MHTC written guidance, assignment, and effectiveness; post-discharge mental health appointment scheduling; and post-discharge treatment engagement.

The VA Office of Inspector General (OIG) conducted a national review to evaluate the Veterans Health Administration’s (VHA’s) suicide risk screening and evaluation training, adherence, and oversight procedures. VHA’s standardized Suicide Risk Identification Strategy (Risk ID) process requires annual screening using the Columbia-Suicide Severity Rating Scale (screening) and comprehensive suicide risk evaluation (evaluation) in response to a positive screening. VHA also recognized the need for screening beyond annual screening and implemented setting-specific Risk ID requirements in 10 clinical settings.

The OIG found that VHA’s required suicide prevention training does not include Risk ID processes or requirements. Training related to Risk ID responsibilities is available. However, the training is optional and not monitored.

VHA has not established annual or setting-specific Risk ID performance benchmarks and has conveyed inconsistent expectations to facility leaders and staff. In fiscal year 2023, annual screening and evaluation adherence was 55 and 82 percent, respectively. In a November 2020 memorandum, VHA expected 100 percent adherence, while other VHA documents reference expectations ranging from 81 to 95 percent. Furthermore, except for emergency department and urgent care settings, VHA does not monitor setting-specific Risk ID adherence.

The OIG determined that staff encountered barriers to completing Risk ID screening and evaluation, which included (1) limited engagement of facility clinical staff, (2) lack of facility leaders’ support, (3) limitations of performance data, and (4) unclear delineation of responsibilities.

The OIG made six recommendations to the Under Secretary for Health related to suicide risk and intervention training, suicide screening and evaluation performance benchmarks, setting-specific Risk ID monitoring, effectively addressing barriers to Risk ID non-adherence, non-mental health clinical specialty leaders’ awareness of Risk ID requirements, and clear identification of Risk ID monitoring and oversight responsibilities.

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

The VA Office of Inspector General (OIG) conducted a healthcare inspection to determine the validity of an allegation that select therapists do not maintain optimal utilization of individual mental health clinics and clinic administrative processes related to the Choose My Therapy (CMT) program, creating barriers to patients receiving care, timely care, or follow-up care at the Hinesville VA Clinic (Clinic).

The OIG substantiated that therapists’ clinic utilization rates were not optimal. Analysis of clinic utilization data revealed that Clinic therapists who provided individual psychotherapy generally had clinic utilization rates ranging from 32–68 percent, which was below the lowest target of 80 percent recommended by the Veterans Health Administration (VHA). The Clinic mental health section chief (section chief) acknowledged awareness of low utilization rates since 2022 but cited competing priorities as barriers to change.

The OIG analyzed data of 285 unique patients who received a diagnostic evaluation and found that patients experienced delayed access to mental health care. Specifically, a median wait time of at least three weeks between three subsequent individual psychotherapy sessions. Delayed initiation of mental health treatment may put patients at risk for negative outcomes, and VHA expects sessions to occur weekly. Further analysis of the data showed a progressive loss of patients engaged in treatment.

The OIG learned that Clinic mental health staff utilized a prohibited waitlist. The section chief confirmed the waitlist was discontinued in April 2023 and reported that patients’ care requests have since been tracked through clinical consults in electronic health records.

The OIG made six recommendations to the Facility Director related to optimizing clinic utilization, accurate use of current procedural terminology codes, consult management and patient scheduling processes, review of patients who experienced individual therapy delays and were on the discontinued waitlist, and evaluation of CMT programs operating in other facility locations.

Objective: To determine whether the Social Security Administration issued payments to beneficiaries who were deceased according to New York City’s vital statistics records.

This Annual Plan presents the major initiatives and priorities the OIG intends to undertake in FYS 2025-2026 to assist the U.S. Department of Education (Department) in fulfilling its responsibilities to America’s taxpayers and students. The plan details the assignment areas and resources that the OIG plans to devote to evaluating the efficiency, effectiveness, and integrity of Department programs and operations. The plan incorporates suggestions from Department leaders and staff, Congress, and the Office of Management and Budget.

For our audit of the U.S. Department of Commerce’s (the Department’s) Enterprise Continuous Diagnostics and Mitigation (ECDM) program, our objective was to assess the effectiveness of the program. To address this objective, we assessed data quality, data security, and aspects of program management in a recent ECDM tool procurement decision. We found that I. ECDM data quality does not fully support Department oversight and reporting needs; II. The National Institute of Standards and Technology does not consistently control and thoroughly test the ECDM program’s information system changes; III. The ECDM program’s information system is relatively secure but has some internal security weaknesses; IV. Deficiencies in ECDM program management place future enterprise cybersecurity tool deployments at risk; and V. The Department does not fully incorporate bureau-incurred costs in its ECDM project cost tracking.

The U.S. International Development Finance Corporation (DFC) Office of Inspector General (OIG) contracted with the independent public accounting firm RMA Associates, LLC (RMA) to conduct an audit of DFC’s acquisition of goods and services. The objective of this audit was to determine whether DFC complied with applicable goods and services contract regulations, policies, and procedures. We evaluated six goods and services contracts. This included one contract for hardware, one for technical support services, one large software purchase, one contract for legal services, and two contracts for consulting services.

We found issues with inaccurate and incomplete bankruptcy data, outdated policies and procedures, and inconsistent internal control documentation.

We performed this audit to determine whether Federal Student Aid's (FSA) oversight of its contractor’s acceptability review process ensured that annual proprietary institutions audits meet applicable audit reporting requirements. We found that FSA’s oversight of its contractor’s acceptability review process could be improved to ensure that annual proprietary institution audits meet applicable audit reporting requirements. We identified the following weaknesses in FSA’s oversight processes:

• FSA did not ensure its contractor’s compliance audit acceptability review process included audit reporting requirements necessary for program oversight.
• FSA’s sampling methodology used to select some proprietary institution audits for quality control reviews (QCR) had not been reassessed since it was established around 2005.
• FSA’s oversight activities relating to some proprietary institution audits did not always identify instances where audit reporting requirements necessary for program oversight were not met.
• FSA did not perform an additional level of review of audit reporting requirements for proprietary institution audits that were identified by its contractor as requiring review and resolution by FSA.

In addition, the Other Matters section of this report includes information on a substantial backlog of financial statement audits identified by the contractor for detailed review and resolution by FSA.