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Brought to you by the Council of the Inspectors General on Integrity and Efficiency
Federal Reports
Report Date
Agency Reviewed / Investigated
Report Title
Type
Location
National Aeronautics and Space Administration
NASA's Fiscal Year 2024 Financial Statements Audit Management Letter
Twelve Selected States Did Not Accurately Calculate the Federal Share of Medicaid Collections Subject to the Increased COVID-19 Federal Medical Assistance Percentages
Medicaid Gross Spending on 10 Selected Diabetes and 2 Selected Weight Loss Drugs Totaled More Than $9 Billion in 2023, an Increase of 540 Percent From 2019
The Tennessee Valley Authority’s (TVA) Power Supply Plans (PSPs) combine optimized capacity and generation plans that balance load and power supply and provide detailed dispatch and generation forecasts used in resource decisions, budgeting, and analysis. PSPs incorporate key planning assumptions, including load and commodity forecasts, fleet characteristics, and other inputs, applying least cost planning methodology. TVA’s 2025 Draft Integrated Resource Plan identified the TVA region is experiencing increasing demand for electricity driven by population, employment, and industrial growth, weather trends, and increasing electric vehicle usage. Due to the importance of effective power supply planning to meet future load and energy demand requirements, we performed an evaluation of TVA’s analysis of the reliability of the PSP. The objective of our evaluation was to evaluate TVA’s process for analyzing the reliability of the PSP and taking corrective actions as necessary.
We determined TVA took steps to analyze the reliability of some elements of the PSP and took corrective actions as necessary. While TVA does not have a Standard Program and Process defining analysis of the reliability of the PSP, we found that TVA utilized several procedures and practices to provide governance of its power supply planning process. Additionally, we identified examples of corrective actions TVA had taken to improve the reliability of some aspects of the PSP.
We also found some elements of the PSP process that could impact its reliability. Specifically, we identified (1) significant variance in near-term planned system changes, (2) misalignment of cost assumptions in the modeling and approvals process, (3) some PSP input controls not working as designed, and (4) several Standard Programs and Processes past their review cadence.
Major Programs: Company Established a Management Framework for Long Distance Fleet Replacement Program but Can Improve Risk Management and Clarify Lines of Authority
Our objective was to assess the company’s management and oversight of this program and to identify any risks to its successful delivery.
We found that the company is in the process of identifying car builders for the first phase of the Long Distance Fleet Replacement Program—intended to replace equipment on 9 of 15 long distance routes. The company plans to use up to $7 billion it received through the 2021 Infrastructure Investment and Jobs Act for this first phase. Early challenges in developing design requirements for the trainsets, however, have delayed the schedule. Moreover, the complexity of the program itself poses an innate risk of cost increases and additional delays. Given the program’s significant size, any such increases or delays could have cascading impacts on the company’s ability to accomplish other major capital projects and maintain its existing long distance service. We also found that although the company has established a management framework to execute the program once it selects a car builder, it has not fully developed contingency plans for the program’s highest risks or established clear lines of authority, resulting in slow decision making.
Because the company is in the process of amending its requirements for the trainsets, we are not making a recommendation in this area but note that any future decisions that would add complexity to this program warrant thoughtful consideration and caution. Regarding the management framework, we recommend the company review and clarify roles, responsibilities, and lines of authority for each stage of the program; fill program vacancies; and identify contingencies for its high impact risks.
An Amtrak conductor based in Miami, Florida, was terminated from employment on December 13, 2024, following an administrative hearing. Our investigation found that the employee violated company policies by failing to report two domestic violence-related criminal convictions to the company within 72 hours after conviction, as required by company policy. The employee also violated company policy by being dishonest with our agents during his interview.
We assessed Agency compliance with applicable policy requirements and procedures for the Defense Intelligence Agency’s Military Equal Opportunity Program. We issued the results of our evaluation, along with one recommendation, in a final report dated December 13, 2024.
We obtained the U.S. Department of Housing and Urban Development’s (HUD) two nondisclosure policies and two nondisclosure forms applicable to HUD employees. We also obtained 13 nondisclosure agreements between HUD and HUD employees. The nondisclosure policies, forms, and agreements did not include the anti-gag provision as required by the Whistleblower Protection Enhancement Act (WPEA) of 2012. HUD had not ensured that these nondisclosure policies, forms, and agreements included the anti-gag provision as required by law.
When HUD employees are subject to policies, forms, and agreements that do not include the anti-gag provision as required by law, the employees may be discouraged from exercising their legally protected whistleblower rights. In addition, implementing or enforcing nondisclosure policies, forms, or agreements that do not include the anti-gag provision may be a prohibited personnel practice, and the practice may result in disciplinary action or a civil penalty. It may also be a violation of the Antideficiency Act to use congressionally appropriated funds to implement or enforce nondisclosure policies, forms, and agreements that do not include the anti-gag provision as required by annual appropriations acts. We did not make a determination on whether violations of the Antideficiency Act took place at HUD because the Office of the Chief Financial Officer is responsible for making such determinations.
HUD program offices followed a decentralized process for implementing and enforcing nondisclosure policies, forms, and agreements applicable to HUD employees. However, as part of this decentralized process, the Office of General Counsel and program offices did not ensure that HUD’s nondisclosure policies, forms, and agreements included the anti-gag provision as required by WPEA. Based on the nondisclosure agreements we reviewed, HUD did not communicate to its employees the legal requirement to include the anti-gag provision in nondisclosure policies, forms, and agreements. Additionally, HUD’s nondisclosure policies did not communicate that HUD employees must include the anti-gag provision in nondisclosure forms and agreements.
WPEA requires agencies that have a nondisclosure policy, form, or agreement to post the anti-gag provision on the agency website, accompanied by the list of Executive orders and statutory provisions that are controlling in case of a conflict. On October 15, 2024, in response to our evaluation, HUD posted this information on its website.
We provided HUD with six recommendations to ensure HUD’s compliance with the legal requirement to include the anti-gag provision in its nondisclosure policies, forms, and agreements. Because we received and agreed with the Office of the Chief Administrative Officer’s proposed management decision, the status of recommendations 1 and 2 is “resolved-open.” The status of recommendations 3, 4, 5, and 6 will remain “unresolved-open” until we agree to the proposed management decisions from Office of the Chief Financial Officer, OGC, and the Government National Mortgage Association (Ginnie Mae).
Financial Audit of USAID Resources Managed by the Office of Development Projects and Social Works in Benin Under Cooperative Agreement 72068020CA00001, January 1 to December 31, 2023
Financial Audit of Inclusion Program in Vietnam Managed by Center for Creative Initiatives in Health and Population, Cooperative Agreement 72044020CA00004, January 1 to December 31, 2023
U.S. Department of Housing and Urban Development Personally Identifiable Information Risk Management in a Zero Trust Environment (2023-OE-0007) Evaluation Report
The OIG evaluated the U.S. Department of Housing and Urban Development’s (HUD) progress in applying zero trust security principles to protect personally identifiable information (PII). HUD maintained a significant number of records that contain PII with limited zero trust controls in place to secure these data. In FY 2022, HUD established a zero trust implementation plan to help the agency address the five zero trust pillars established by CISA; however, by FY 2024, HUD had made limited progress in the initiatives established in its plan. In FY 2024, HUD began to implement some technical controls to support identity pillar functions but lacked overall direction and a clear plan to make significant zero trust progress. HUD did not have an automated process to inventory or categorize data, which restricted its visibility into its PII. HUD monitored its information technology (IT) and cybersecurity risks through its OCIO risk register process; However, the register did not contain specific ZTA implementation risks. HUD did not ensure that systems applied granular access controls, including access tailored to individual actions and individual resource needs. Lastly, agencies were required to fully implement multifactor authentication (MFA) by November 2021 and phishing-resistant MFA for external users by January 2023. As of May 2024, HUD had begun phishing-resistant MFA implementation for just one of its authentication systems. We issued six recommendations to improve HUD’s management of PII in a zero trust environment.
The VA Office of Inspector General (OIG) conducted a national review of the Veterans Health Administration (VHA) to assess the policy pertaining to osteoporosis screening and to determine osteoporosis screening rates in women patients enrolled in VHA primary care who are age 65 and older. Osteoporosis is a disease characterized by decreased bone mineral density (BMD) and bone quality, resulting in an increased risk of fractures.
VHA policy states that preventive care for women patients must include osteoporosis screening, and the OIG found that VHA osteoporosis screening practices generally align with United States Preventive Service Task Force recommendations. VHA offers BMD testing at most of its facilities and utilizes BMD testing in the community when not available at the facility or for otherwise eligible patients.
The OIG estimated that 87 percent of the review population completed BMD testing and 93 percent of the review population had or were offered BMD testing. OIG-estimated screening rates were higher than VHA-estimated screening rates, although different methodologies were used to determine screening rates. The OIG identified patients who were at risk for osteoporosis and fracture who were not offered BMD testing.
VHA implemented measures to improve osteoporosis screening, including introduction of a toolkit and a clinical reminder. Improvement in osteoporosis screening rates temporally correlated with the implementation of the clinical reminder. Clinical reminder use appeared to vary between facilities as the OIG observed that there were sites where none of the sampled patients had identified osteoporosis clinical reminder use after implementation of the clinical reminder.
The OIG recommended that the Under Secretary for Health work with the Women’s Program Office to gain an understanding of barriers to osteoporosis clinical reminder use and, based on results, implement action as needed.
OIG reviewed the Forest Service’s funding and monitoring of selected IIJA project proposals for the Collaborative Aquatic Landscape Restoration Program.
Audit of the Office of Justice Programs Victim Assistance Funds Subawarded by the Oklahoma District Attorneys Council to Northwest Domestic Crisis Services, Inc., Woodward, Oklahoma
A Review of the Federal Bureau of Investigation’s Handling of Its Confidential Human Sources and Intelligence Collection Efforts in the Lead Up to the January 6, 2021 Electoral Certification
Financial Audit of USAID Resources Managed by Pro-Health International in Nigeria Under Cooperative Agreement 72062020CA00005, January 1 to December 1, 2023
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 Northport Healthcare System in New York. This evaluation focused on five key content domains:
• Culture
• Environment of care
• Patient safety
• Primary care
• Veteran-centered safety net
The OIG made two recommendations for improvement in one domain.
1. Environment of care
• Secure all medications and the supplies used to administer medications in the Emergency Department
• Confirm staff are knowledgeable about how the lobby kiosks function to assist veterans with sensory impairments
The U.S. Department of Housing and Urban Development (HUD) Office of Inspector General (OIG) conducted penetration testing concurrently with our fiscal year 2024 Federal Information Security Modernization Act of 2014 (FISMA) evaluation. The objective of the penetration testing evaluation was to test the technical implementation of a limited set of security controls for a selection of HUD information systems and applications: the Office of Housing’s Federal Housing Administration Catalyst system, the Office of the Chief Financial Officer’s Line of Credit Control System (LOCCS), the Office of Community Planning and Development’s Disaster Recovery Grant Reporting (DRGR) system, and the Office of Public and Indian Housing’s National Standards for the Physical Inspection of Real Estate (NSPIRE) system.
Our assessment identified nine significant weaknesses related to data protection and website security, underscoring the need to strengthen technical security controls. To address these findings, we provide 13 new recommendations, which will be formally tracked by our office, and 7 opportunities for improvement. These recommendations are designed to enhance HUD’s IT security posture by preventing unauthorized data access, ensuring the integrity and confidentiality of sensitive information, and protecting against web-based threats.
OIG has determined that this report contains sensitive information and is therefore not appropriate for public disclosure.
Investigative Summary: Findings of Misconduct by Assistant United States Attorney (AUSA) for Misuse of Position, Misuse of Government Property, Improper Acceptance of Gifts, and Misuse of Government Travel Card, While on Detail Overseas
Our Objective(s)To determine whether (1) Weaver and Tidwell, L.L.P.'s audit work complied with the Single Audit Act of 1984, as amended, the Office of Management and Budget's Uniform Guidance, and the extent to which we could rely on the auditor's work on the U.S. Department of Transportation's (DOT) major programs, and (2) the Dallas Area Rapid Transit's (DART) reporting package complied with the reporting requirements of the Uniform Guidance.
Why This AuditDuring the fiscal year that ended on December 31, 2022, DART expended approximately $380 million from DOT programs. Weaver and Tidwell determined DOT's major programs were FTA's Federal Transit Cluster and FRA's Consolidated Rail Infrastructure and Safety Improvements Program. We performed a quality control review on the single audit that Weaver and Tidwell conducted to verify compliance with Federal laws and regulations.
What We FoundReview of Audit Work
Weaver and Tidwell complied with the requirements of the Single Audit Act, the Office of Management and Budget's Uniform Guidance, and DOT's major programs.
We found nothing to indicate that Weaver and Tidwell's opinion on DOT's major programs were inappropriate or unreliable.
Review of Reporting Package.
We did not identify any deficiencies that required correction and resubmission.
RatingWe assigned Weaver and Tidwell an overall rating of Pass.
The U.S. Postal Service has service standards or timeliness goals for delivering mail after receiving it from a customer. The delivery service standard for First‑Class Mail varies between two to five days, depending on the distance it travels. For First‑Class Mail that is both collected and delivered within the same district (turnaround mail) the standard is two days. The Postal Service’s goal is to deliver at least 92.5 percent of First‑Class Mail within the service standard.
This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the Durham 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 11 recommendations for improvement in two domains: 1. Environment of care • High-alert medications in a secure or locked area • Expired medical supplies and clean supply areas • Cleaning and disinfection • Safety of crossing area • Accurate directories • Navigational features for sensory-impaired veterans • Staff communication with sensory-impaired veterans • Environment of care trends 2. Patient safety • Joint Patient Safety Reporting system • Communication and follow-up for urgent, noncritical abnormal test results • Patient safety trends
Financial Audit of USAID Resources Managed by Wits Health Consortium (Pty) Ltd in Multiple Countries Under Multiple Awards, January 1 to December 31, 2023
Audit of the Schedule of Expenditures of Centers for Civic Initiatives Tuzla, Under Multiple Awards in Bosnia and Herzegovina, January 1 to December 31, 2023
The VA OIG contracted with the independent public accounting firm CliftonLarsonAllen LLP (CLA) to audit VA’s financial statements as of the end of fiscal years (FYs) 2024 and 2023. CLA provided an unmodified opinion and noted material weaknesses and significant deficiencies in internal control and instances of noncompliance with laws and regulations. Regarding internal control, CLA identified three material weaknesses. A material weakness is a deficiency, or combination of deficiencies, in internal control over financial reporting such that there is a reasonable possibility that a material misstatement of the entity’s financial statements will not be prevented or detected and corrected on a timely basis. CLA also identified three significant deficiencies. A significant deficiency is a deficiency, or combination of deficiencies, in internal control over financial reporting that is less severe than a material weakness yet important enough to merit attention by those charged with governance.
CLA is responsible for the attached audit report dated November 15, 2024, and the conclusions expressed in the report. The OIG does not express opinions on VA’s financial statements, internal control, or compliance with FFMIA, nor does the OIG express conclusions on VA’s compliance with laws and regulations. The independent auditors will follow up on these internal control and compliance findings and evaluate the adequacy of corrective actions taken during the FY 2025 audit of VA’s financial statements.
The U.S. Postal Service’s mission is to provide timely, reliable, secure, and affordable mail and package delivery to more than 160 million residential and business addresses across the country. The U.S. Postal Service Office of Inspector General (OIG) reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission.
The U.S. Postal Service’s mission is to provide timely, reliable, secure, and affordable mail and package delivery to more than 160 million residential and business addresses across the country. The U.S. Postal Service Office of Inspector General (OIG) reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission.
A Review of the Department of Justice’s Issuance of Compulsory Process to Obtain Records of Members of Congress, Congressional Staffers, and Members of the News Media
(U) Unclassified Summary of the Evaluation of the Accountability Controls for Seaports of Debarkation in the U.S. European Command Area of Responsibility
Evaluation of KOTO-FM, San Miguel Educational Fund, Inc., Telluride, Colorado, Compliance with Selected Communications Act and General Provisions Transparency Requirements, Report No. ECR2417-2501
Audit of the Schedule of Expenditures of the Independent Election Commission Under Implementation Letter 278-IL-DO2-IEC-IPP-01, IEC Partnership Program in Jordan, Development Objective Agreement 278-CDCS-DRG-00, January 1 to December 31, 2023
FINANCIAL MANAGEMENT: Management Letter for the Audit of the Department of the Treasury's Consolidated Financial Statements for Fiscal Years 2024 and 2023
The OIG's Office of Analytics and Innovation (OAI) conducted a survey of Forest Service Firefighters to better understand the perceived impact of the Infrastructure Investment and Jobs Act (IIJA) on firefighters, including authorized pay increases, occupational series changes, and programs relevant to firefighters.
An Amtrak customer service representative based in West Palm Beach, Florida, signed a civil settlement agreement on December 6, 2024, with the U.S. Attorney’s Office, Southern District of Florida. The employee agreed to pay $32,481 in restitution and a penalty of $1,500 related to the fraudulent receipt of a $42,900 Economic Injury Disaster Loan (EIDL). Our investigation found that the employee applied for an EIDL loan for economic losses resulting from the pandemic related to self-employment or businesses he allegedly owned. We found that the employee submitted an application containing false statements and information to qualify for the loan. As a result, the employee received an EIDL loan in the amount of $42,900 to which he was not entitled.
FIN MGT: Mgmt Letter for the Deficiencies in Internal Control over Cash Mgmt Systems at the Bureau of the Fiscal Service Identified during the Audit of the Department of the Treasury's Consolidated Financial Statements for Fiscal Years 2024 and 2023
The AmeriCorps Office of Inspector General (AmeriCorps OIG) investigated allegations that the City of Oakland, Office on Aging (City of Oakland) paid Senior Companion Program (SCP) and Foster Grandparent Program (FGP) volunteers full stipends when volunteers either did not serve or document the hours claimed following the end of AmeriCorps’ authorization for grantees to pay volunteers a temporary allowance due to the COVID-19 pandemic.
We performed an audit of costs billed to the Tennessee Valley Authority (TVA) by GE Vernova International, LLC (GEVI) for parts and services for the covered units at the Allen Combined Cycle Plant as part of a long-term service agreement under Contract No. 11930. Our audit objective was to determine if costs were billed in compliance with the contract’s terms. Our audit scope included about $48.5 million in costs billed from January 1, 2021, through March 31, 2024.
In summary, we determined (1) GEVI applied incorrect discounts to noncapital parts, resulting in an overbilling of $4,278 and (2) TVA was not aware GEVI provided noncapital parts from foreign countries, including one country that was not compliant with the Trade Agreements Act as required by the contract. In addition, we noted opportunities to improve contract administration by TVA. Specifically, (1) TVA did not receive detail cost breakouts for fixed price services to determine the reasonableness of the fixed price and if the contract’s time and material rates and negotiated discounts were used to build up the fixed price; (2) TVA and GEVI agreed in a letter to revise some of the terms of the long-term service agreement in accordance with the letter’s appendix; however, the appendix was not included with the contract documentation in TVA’s Maximo system; and (3) the contract contained inconsistent language.
Our audit objective was to assess the First Responder Network Authority’s Nationwide Public Safety Broadband Network services in response to the devastating wildfires that broke out on the Hawaiian island of Maui in August 2023. We focused on AT&T’s operational response, FirstNet Authority’s oversight of AT&T from a program and contract perspective, and the extent the network was a reliable means of communicating for public safety agencies during the wildfire response.
We found that FirstNet Authority’s network services were not effective in supporting the public safety response to the Maui wildfires. Specifically, FirstNet Authority did not ensure that (I) timely, adequate network services were provided to support public safety’s response, (II) a sufficient plan for business continuity and disaster recovery was developed before the wildfires, and (III) network service response efforts were accurately reported afterward.
Audit of the Office of Justice Programs Victim Assistance Grants Awarded to the West Virginia Department of Homeland Security, Division of Administrative Services, Justice and Community Services, Charleston, West Virginia
Staffing Shortages Limited IHS's Capacity To Effectively Administer Much-Needed Sanitation Projects Funded by the Infrastructure Investment and Jobs Act
COVID-19: Data Sharing Project Finds Billions Paid to Same Likely Fraudsters Under Both the Unemployment Insurance and Economic Injury Disaster Loan Programs
The Office of Inspector General (OIG) is issuing this inspection report to determine whether data sharing between the Employment and Training Administration and the U.S. Small Business Administration (SBA) could mitigate the risk of fraudulent unemployment insurance benefit payments and SBA disaster program disbursements.
In 2020, soon after Congress expanded the Unemployment Insurance and Economic Injury Disaster Loan Programs in response to the adverse economic effects caused by the Coronavirus Disease 2019 pandemic, the U.S. Department of Labor OIG and SBA OIG respectively began reporting on heightened risks of fraud and found similar fraud indicators. The two OIGs found that billions of dollars were paid to the same likely fraudsters under both programs. The DOL and SBA OIGs identified this issue through a data use agreement and subsequent data sharing and matching project, highlighting an opportunity to collaborate on data matching to mitigate fraud.
SBA OIG made three recommendations – two to facilitate improved fraud controls via collaboration and one to reevaluate eligibility. SBA agreed with the three recommendations, and the planned actions will resolve those recommendations.
COVID-19: Data Sharing Project Finds Billions Paid to Same Likely Fraudsters under Both the Unemployment Insurance and Economic Injury Disaster Loan Programs
The U.S. Postal Service’s mission is to provide timely, reliable, secure, and affordable mail and package delivery to more than 160 million residential and business addresses across the country. The U.S. Postal Service Office of Inspector General (OIG) reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission.