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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
Department of Education
Rehabilitation Services Administration’s Oversight of the State Vocational Rehabilitation Services Program
We performed this audit to determine whether Rehabilitation Services Administration (RSA) has sufficient processes for overseeing vocational rehabilitation (VR) program grantees’ effective use of funds in compliance with applicable requirements. We found that RSA generally had sufficient processes for overseeing State VR agencies’ effective use of funds. These processes included communicating clear, accurate, and timely guidance and technical assistance to State VR agencies; performing annual reviews for all State VR agencies; and conducting periodic onsite and offsite monitoring for selected State VR agencies. However, we found that RSA could strengthen its oversight in key areas by developing documented procedures for its annual reviews, improving its risk assessment processes by incorporating a risk factor that accounts for a State VR agency’s technical assistance needs, and establishing a reasonable period during which all State VR agencies must be subject to onsite or offsite monitoring at least once.
The U.S. Postal Service recently begun realigning its network by implementing Regional Processing and Distribution Centers (RPDC) to consolidate mail processing operations, reduce costs, and grow package business. To help support this strategy, the Postal Service deployed the Matrix Regional Sorter (MaRS). The MaRS is designed to increase package processing capacity and efficiency while using less floor space, a critical factor to the success of implementing the Postal Service’s network transformation and increasing their share in the growing package market.
The OIG conducted this follow-up inspection to determine whether information systems at the Southwest Consolidated Mail Order Pharmacy in Tucson, Arizona, were meeting federal security guidance. The OIG inspected the facility in 2021 and made six recommendations to correct security weaknesses.During this inspection, the team identified continuing deficiencies related to configuration management, security management, and access controls designed to protect systems from unauthorized access, alteration, and destruction. Regarding configuration management, the OIG found that the facility did not create plans for remediating vulnerabilities that had not been resolved within established time frames, and that network devices were running software that no longer met security requirements. Security management controls were deficient in that an administrator account was still active five months after the user’s employment was terminated, contrary to policy. Access controls were deficient in two respects: they did not isolate special-purpose system segments from the rest of the network, giving any user access to systems that run 50 potentially vulnerable special-purpose devices; and database audit logs used to assess the effectiveness of other security controls, recognize an attack, and investigate during or after an attack were not properly retained.Unless the facility takes corrective actions, it risks unauthorized access to critical network resources, loss of personally identifiable information, and inability to respond effectively to incidents. To correct the deficiencies, the OIG made five new recommendations.Although the findings and recommendations in this report are specific to the Southwest Consolidated Mail Order Pharmacy, the OIG noted that other VA facilities could benefit from reviewing this information and considering these recommendations.
Market Dominant mail — a category consisting primarily of First-Class Mail, Marketing Mail, and Periodicals — is the Postal Service’s largest source of funding, contributing 53 percent of the agency’s revenue in fiscal year (FY) 2023. Since 2006, however, mail volume has been in decline. The key factor driving ongoing decline in mail volume is “electronic diversion,” a term referring to the replacement of physical mail with electronic alternatives, such as the Internet, email, texting, and social media. This paper examines Market Dominant mail volume from FYs 2008 through 2023, presenting historical volume trends across classes of mail and describing key factors influencing these trends.
The Geospatial Data Act seeks to foster efficient, government-wide management of geospatial data—information identifying the geographic location and characteristics of natural or constructed features and boundaries on Earth. As required by the Act, we audited NASA’s collection, production, acquisition, maintenance, distribution, use, and preservation of geospatial data.
In fiscal year (FY) 2022, the Veterans Health Administration (VHA) launched a multiyear hiring initiative to expand veterans’ access to substance use disorder treatment. The VA Office of Inspector General (OIG) conducted this review to assess how well medical centers met the FY 2022 goal of hiring for 90 percent of the approved positions for the initiative.The OIG found that medical centers only hired about 26 percent of approved staff by the end of FY 2022 and spent approximately $8 million of the $96 million available in specific purpose funds for medical centers to hire behavioral health staff. In addition to external factors, the medical centers failed to meet this goal because VHA did not clearly communicate hiring priorities, define and assign responsibilities for implementation and oversight, and generally ensure accountability for achieving the initiative’s goals. The OIG also examined FY 2023 hiring and determined the initiative’s challenges persisted. By the end of FY 2023, medical centers only hired a two-year total of 837 people (65 percent rather than the 90-percent goal established for the first year) and spent $97 million of the two-year total of $267 million in specific purpose funds for the initiative. The remaining funds were spent on other nonhiring substance use disorder purposes, retained by medical centers for other unspecified purposes, or were returned to the finance office.VHA concurred with the OIG’s three recommendations to ensure the $14 million in funds retained by medical centers for other purposes have been properly spent, and to take other corrective actions to address the deficiencies identified in the report.
From our limited testing, we did not identify a systemic issue in which U.S. Customs and Border Protection (CBP) lost revenue due to expired statute of limitations. We reviewed 152 penalty cases, totaling $858.1 million, and determined that 144 (95 percent) were either closed, settled, in litigation, or submitted to the Treasury Offset Program. The statute of limitations no longer applied to these cases. The remaining eight penalty cases, totaling $1.5 million (0.2 percent) had expired and were subsequently closed. However, this does not equate to $1.5 million in lost revenue because CBP is allowed to close cases, for example, when the cost of continuing to pursue the case would exceed the potential amount to be recovered.
What We Looked At The Federal Information Security Modernization Act of 2014 (FISMA) requires agencies to implement information security programs. FISMA also requires agencies to have annual independent evaluations performed to determine the effectiveness of their programs and report the results of these reviews to the Office of Management and Budget. To meet this requirement, the Surface Transportation Board (STB) requested that we perform its fiscal year 2024 FISMA review. We contracted with Williams Adley & Company-DC LLP, an independent public accounting firm, to conduct this audit subject to our oversight. The audit objective was to determine the effectiveness of STB’s information security program and practices in five function areas—Identify, Protect, Detect, Respond, and Recover. We performed a quality control review (QCR) of Williams Adley’s report and related documentation. What We Found Our QCR disclosed no instances in which Williams Adley did not comply, in all material respects, with generally accepted Government auditing standards. Our Recommendations STB concurs with Williams Adley’s audit’s findings and nine recommendations.
The EPA failed to properly and timely disclose to the OIG unmistakable indicators of fraud against the EPA, the Clean Air Act, and the EPA's programs and operations by a business entity owner. As a result of the EPA's failure to properly disclose these indicators of fraud in a timely manner to the OIG, the U.S. Attorney's Office declined to pursue criminal charges against the business entity owner involved. Failure to disclose fraud, waste, and abuse, or other potential improper or illegal conduct involving an EPA program or operation can negatively impact the EPA's ability to fulfill its mission and ensure the soundness of, and confidence in, the EPA's programs and operations.
Overseas Contingency Operations - Summary of Work Performed by the Department of the Treasury Related to Terrorist Financing and Anti-Money Laundering for the Third Quarter Fiscal Year 2024
The VA Office of Inspector General (OIG) inspected the Southeast Louisiana Veterans Health Care System in New Orleans, Louisiana, in 2021 and made six recommendations. This follow-up inspection found that issues had not been fully resolved in response to those recommendations. The follow-up inspection reassessed the same financial activities and administrative processes: Medical/Surgical Prime Vendor program use, purchase card use, administrative staffing levels, and pharmacy operations.The inspection team visited the Southeast Louisiana Veterans Health Care System in August 2023; interviewed healthcare system leaders and staff; and reviewed data, supporting documents, and processes related to the healthcare system’s financial efficiency.The OIG identified issues with Medical/Surgical Prime Vendor program use, purchase card use, and pharmacy operations. In each area, the healthcare system made limited progress improving issues identified in the OIG’s 2021 report. The inspection team found that the healthcare system improved administrative staffing efficiency, but more opportunities for improvement exist.The OIG reiterated four recommendations from the 2021 inspection where the plans to address the recommendations had not been fully implemented. The OIG also added seven new recommendations to the healthcare system director designed to help officials improve performance. The intent is for system leaders to use these recommendations as a road map to improve financial operations. The recommendations address issues that, if left unattended, may eventually interfere with effective financial efficiency practices and the strong stewardship of VA resources.
Objective: To determine whether the Social Security Administration timely and accurately processed cases where a beneficiary's Medicare premium was higher than the Agency benefit payment.
An Amtrak carman based in Miami, Florida, signed a civil settlement agreement on September 3, 2024, with the U.S. Attorney’s Office, Southern District of Florida. The employee was ordered to pay $10,717 in restitution and a $1,883 penalty. Our investigation found that the employee falsified applications for two pandemic relief loans. The first loan was an Economic Injury Disaster Loan (EIDL) in the amount of $19,500. The loan was for an alleged agricultural business operated out of his home. The second loan was a Paycheck Protection Program (PPP) loan in the amount of $8,217, which was for an alleged trucking business. We interviewed the employee and he admitted that the agricultural business did not exist, and that his trucking business did not have any revenue or any employees. As a result, the employee received funds to which he was not entitled.
VA must submit an annual report to Congress documenting its capacity to provide specialized treatment for veterans with spinal cord injuries and disorders, traumatic brain injury, blindness, prosthetics and sensory aids, or mental health issues. Each year, the VA Office of Inspector General (OIG) is required to report to Congress on the accuracy of VA’s special disabilities capacity report. The OIG team identified data inaccuracies and omissions that resulted in some material errors in the fiscal year 2022 capacity report. Some of these issues persisted from the OIG’s previous reviews. As the OIG reported in its reviews of previous capacity reports, VA is unable to meet the requirement to compare its mental health capacity with 1996 levels for reasons that include changes in how treatment outcomes of veterans with mental illness are defined and tracked. The OIG continues to believe that, even if VA could compare capacity to 1996 levels, such reporting would not provide Congress with assurances that VA’s capacity is adequate to provide care to these high risk veterans. The Veterans Health Administration reported the wrong spending data for traumatic brain injury when it included obligations data at the national level rather than expenditures data at the national and network/geographic service area level. The capacity report also does not capture data on the services veterans receive through community care or the extent to which bed capacity at VA’s centers for spinal cord injuries and disorders is used. Finally, some medical facilities’ transitions to the Oracle Cerner electronic health record have affected the completeness of some facility, network, and nationally reported data elements. The OIG believes that VA should report special disability data for these facilities separately to allow Congress insight into annual trends across the facilities operating the new electronic health record.
In May 2021, the U.S. Environmental Protection Agency Office of Inspector General Office of Investigations initiated an investigation into allegations that an EPA-funded researcher may be associated with a Chinese talent recruitment program. Subsequently, the EPA OIG has identified a concern regarding the lack of oversight and controls during the EPA research grant application process and duration of the grant. In July 2023, the OIG initiated an investigation into allegations that a major United States university was allegedly receiving funds from China while simultaneously receiving funds from multiple federal agencies, including the EPA. As explained in further detail in this report, the Chinese government sponsors a malign foreign talent recruitment program which could have placed federal funds in jeopardy or resulted in the unauthorized transfer of intellectual property or other nonpublic information.
An Amtrak train attendant based in Miami, Florida, signed a civil settlement agreement on September 2, 2024, with the U.S. Attorney’s Office, Southern District of Florida. The employee was ordered to pay $10,000 in restitution and a $2,500 penalty. Our investigation found that the employee submitted a false claim for an Economic Injury Disaster Loan (EIDL) Advance of $10,000 for an alleged agriculture business, which operated out of his home. We interviewed the employee, who admitted he did not own an agricultural business and that his loan application contained false information. As a result, he received an EIDL loan advance in the amount of $10,000 to which he was not entitled.
This report was issued from a developing series of six reports taking an in-depth look at how six communities used the pandemic funding they received to address a wide range of needs. This report focused on Sheridan County, Nebraska, with a detailed look at six of the 31 pandemic programs that provided funding to the community. This report was led by the Pandemic Relief Accountability Committee in coordination with HUD OIG as a project participant as well as additional Federal OIGs.
Closeout Financial Audit of the Civil Society Participation With Conflict Victims Project in Colombia, Managed by Consultora Para los Derechos Humanos y el Desplazamiento, Cooperative Agreement AID-514-A-14-00006, January 1, 2023, to January 31, 2024
The Federal Information Security Modernization Act of 2014 (FISMA) requires each agency’s Inspector General (IG) to conduct an annual independent evaluation to determine the effectiveness of the information security program (ISP) and practices of its respective agency. Our objective was to determine the effectiveness of the Tennessee Valley Authority’s (TVA) ISP and practices as defined by the FY 2023 – 2024 IG FISMA Reporting Metrics. Our audit scope was limited to answering the fiscal year (FY) 2024 IG metrics, which include 20 core IG metrics and 17 supplemental IG metrics. The FISMA methodology considers metrics at a level 4 (managed and measurable) or higher to be at an effective level of security. Based on our analysis of the FY 2024 IG metrics and associated maturity models, we determined TVA's ISP and practices were operating in an effective manner as defined by the FY 2023 – 2024 IG FISMA Reporting Metrics. However, we identified areas for improvement in both the core and supplemental metrics to further improve TVA’s ISP and practices.
We found that the Person in Charge failed to stop a pollution event, ordered platform operators to lie to BSEE inspectors, and falsified inspection logs.
This report presents the results of our audit of Mail Theft Mitigation and Response at the Parkside Station, Rincon Finance Center Station, and Townsend Carrier Annex Station in San Francisco, CA. The stations are in the California 1 District of the Retail and Delivery Operations, Western- Pacific Area. Our objective was to assess the U.S. Postal Service’s actions taken to mitigate and respond to mail theft in San Francisco, CA.
Assessment of a Hotline Complaint: GSA’s Public Buildings Service Faces a Significant Backlog of Open Occupational Safety and Health, and Fire Risk Conditions
Deficiencies in Facility Leaders’ Summary Suspension of a Provider and Patient Safety Reporting Concerns at the VA Black Hills Health Care System in Fort Meade, South Dakota
The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate facility leaders’ response to an alleged impairment of a general surgeon (subject provider) and assess concerns with patient safety event reporting at the VA Black Hills Health Care System (facility) in Fort Meade, South Dakota. The OIG found facility leaders failed to issue a summary suspension of the subject provider’s privileges when removing the provider from patient care. Factors that may have contributed to the facility leaders’ failure to issue a summary suspension included misunderstandings of policy regarding summary suspensions; an initial presumption that the subject provider’s actions were conduct related and that privileging actions were not indicated; and facility leaders were waiting for upcoming changes to the Veterans Health Administration’s (VHA’s) privileging policy for privileging actions. Because the concern for patient safety reached the level of removing the subject provider from patient care, the Facility Director was obligated to issue a summary suspension when the concerns were identified. The OIG is concerned that the misunderstanding of policy and failure to suspend privileges allowed the subject provider to engage in patient care, potentially placing patients at risk of harm. The OIG found that facility leaders failed to complete a focused clinical care review. Since facility leaders did not conduct a comprehensive review of the care provided by the subject provider, there were limited opportunities to identify additional incidents of potential clinical care concerns and to assess for harm.It was also determined by the OIG that facility surgical staff did not consistently report patient safety events in the joint patient safety reporting system.The OIG made three recommendations to the Facility Director related to VHA policy for conducting summary suspensions and related privileging actions, focused clinical care reviews, and evaluation of patient safety reporting processes.
Financial Audit of USAID Resources Managed by Maternal, Adolescent and Child Health Institute NPC in South Africa Under Multiple Awards, October 1, 2022, to September 30, 2023
Financial Audit of Strength CTIP-P Managed by Partnership for Development Assistance in the Philippines, Cooperative Agreement 72049219CA00011, April 1, 2022, to March 31, 2023
Financial Audit of USAID Resources Managed by Centre for Infectious Disease Research in Zambia Under Multiple Awards, October 1, 2022, to September 30, 2023
Investigative Summary: Findings of Misconduct by a Federal Bureau of Prisons Warden for Inappropriate Sexual Relationship with a Subordinate Employee and Sexual Harassment of Another Subordinate Employee
The VA Office of Inspector General (OIG) conducted a healthcare inspection at the North Florida/South Georgia Veterans Health System to assess an allegation that a patient was “misled” by staff and incorrectly involuntarily admitted to the inpatient mental health unit, and that VA staff actions led to the patient's disengagement from VA mental health care and eventual death by suicide. The OIG reviewed the patient's care in accordance with the Veterans Health Administration (VHA) policy and Florida Mental Health Act (the Baker Act), which provides criteria for involuntary mental health care. The OIG identified deficiencies in staff adherence and leaders’ oversight pertaining to VHA policy and the Baker Act, but was unable to determine whether a change in care would have altered the patient’s outcome.The OIG substantiated that system staff admitted the patient under involuntary status despite the patient’s request for voluntary admission and that staff incorrectly applied the involuntary inpatient Baker Act examination hold criteria.The OIG found that during outpatient mental health appointments prior to admission, the patient was not offered evidence-based psychotherapy for posttraumatic stress disorder (PTSD) or informed of available treatment options. The OIG determined that turnover in mental health providers was a contributing factor in the patient's decision to withdraw from mental health care and that despite the patient voicing concerns about being involuntarily admitted, staff did not document a response to the patient’s concerns, likely contributing to feelings of being “misled” by staff.
The attached final report summarizes Ernst & Young LLP’s (Ernst & Young) review of the information technology security controls of common control providers. Under a contract the Office of Audit monitored, Ernst & Young, an independent certified public accounting firm, reviewed the security of common control providers. Ernst & Young interviewed Social Security Administration staff and management and reviewed evidence the Agency provided.
In March 2021, the Veterans Benefits Administration (VBA) began transitioning to a Digital GI Bill platform designed to improve education benefits delivery. The original plan called for implementing the new platform through a contractor for 10 years at a projected cost of $453 million. The VA Office of Inspector General (OIG) conducted this audit to assess VBA’s progress in implementing the platform.The OIG found VBA encountered delays due to unclear contract requirements and unrealistic expectations. The original contract required VA to provide three test environments by October 2022, but resource and infrastructure limitations resulted in only one test environment, which was undergoing testing in January 2024. Further, the platform relies on the decommissioning of older systems such as the Benefits Delivery Network (BDN); however, BDN’s decommissioning has been pushed back from September 2023 to as late as spring 2025, which will delay platform completion and may increase costs.The OIG found VBA did not follow the Government Accountability Office’s best practices for a project’s integrated master schedule, which plots a project’s entire scope. Until February 2023, the platform project had no overall master schedule, and once one was established, it was not consistently shared with the contractor. The OIG also found that poor communication contributed to failures in the critical path—a schedule’s continuous sequence of activities—that resulted in delays and increased costs.VBA has renegotiated the original contract, further delaying implementation and increasing project costs by $479 million, more than doubling the original contract to $932 million.The OIG made three recommendations to the under secretary for benefits to increase the chances of successful implementation under the new contract through better monitoring, stronger communication with the platform contractor, a consistent and updated master schedule, strategies to address critical path failures, and a clear timeline.
2024 Peer Review Results of the Office of the Inspector General for the U.S. Nuclear Regulatory Commission and Defense Nuclear Facilities Safety Board, Audits & Evaluations Division
The U.S. Postal Service is redesigning its processing network with the goal of creating a best-in-class mail and package processing network as part of its 10-year strategic Delivering for America plan. The Postal Service plans to create a modernized network based around Regional Processing and Distribution Centers (RPDC), local processing centers, and sorting and delivery centers. The Atlanta RPDC is a new, one million square foot facility and one of the first RPDCs in the network.
South Carolina Did Not Always Invoice Rebates to Manufacturers for Physician-Administered Drugs Dispensed to Enrollees of Medicaid Managed-Care Organizations
What We Looked AtWe queried and downloaded 39 single audit reports prepared by non-Federal auditors and submitted to the Federal Audit Clearinghouse between April 1, 2024, and June 30, 2024, to identify significant findings related to programs directly funded by the Department of Transportation (DOT).What We FoundWe found that reports contained a range of findings that impacted DOT programs. The auditors reported 20 incidents of significant noncompliance with Federal guidelines related to 12 grantees that require prompt action from DOT’s Operating Administrations. Of the 20 significant findings, 9 were repeat findings related to 5 grantees. The auditors also identified questioned costs totaling $1,035,753 for seven grantees. Of this amount, $216,491 was related to the Indianapolis Airport Authority, Indianapolis, IN, and $590,403 was related to the Metropolitan Transit Authority of Harris County, Houston, TX. Additionally, we identified a nonmonetary repeat finding that caused a disclaimer of opinion for the Joint Programs of the Shoshone and Arapaho Tribes of the Wind River Reservation, Fort Washakie, WY.RecommendationsWe recommend that DOT coordinate with the impacted Operating Administrations to develop a corrective action plan to resolve and close the findings identified in this report. We also recommend that DOT determine the allowability of the questioned transactions and recover $919,266, if applicable. Furthermore, we recommend that OST work with the Federal Transit Authority to determine the allowability of questioned tribal transactions and recover $116,487, if applicable
Financial Audit of Generating Rural Opportunities by the Working with Cooperatives Project in the Philippines, Managed by AgriterraPhils Inc., Agreement 72049220CA00002, January 6, 2020, to December 31, 2021
NASA is developing a second mobile launcher (ML-2)—the ground structure used to assemble, transport, and launch the Space Launch System (SLS) rocket and Orion crew capsule—to support larger variants of the SLS beginning with the Artemis IV mission. ML-2’s cost and schedule are not sustainable despite NASA’s efforts to improve project performance.
The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered throughout Readjustment Counseling Service (RCS).This inspection evaluates four review areas within Continental District 4 including leadership stability, morbidity and mortality reviews, the high risk suicide flag (HRSF) SharePoint site, and safety plans.There were no findings in stability of leadership. Based on active policy at the time of the inspection, the OIG identified that district leaders did not complete timely morbidity and mortality reviews for clients who died by suicide. Inconsistent with requirements at the time, leaders also implemented a peer review process for all suicide attempts instead of the morbidity and mortality reviews. The OIG did not conduct the HRSF SharePoint site review due to concerns with data accuracy. In April 2024, the OIG made a recommendation to the RCS Chief Officer related to HRSF SharePoint site functionality. The recommendation remained open at the time of the inspection; therefore, the OIG will continue to monitor progress to closure and did not make a new recommendation. Vet center staff were noncompliant with completing and providing safety plans to clients.The OIG issued three recommendations for improvement to the District Director.
The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered at vet centers. The OIG inspected six randomly selected vet centers throughout Continental district 4 zone 1: Fort Collins, Colorado; Kalispell, Montana; Tulsa, Oklahoma; Abilene, Texas; Salt Lake City, Utah; and Cheyenne, Wyoming.The OIG inspection focused on four review areas: suicide prevention; consultation, supervision, and training; outreach; and environment of care. In the suicide prevention review, the OIG team evaluated vet center staff participation in VA medical facility mental health executive council meetings resulting in one recommendation across five of the six vet centers inspected. The consultation, supervision, and training review identified concerns with external clinical consultation, monthly client record reviews, and completion of select trainings resulting in three recommendations across all six vet centers inspected. The outreach review evaluated outreach plan completion, inclusion of strategic components, and tailoring of outreach activities to cultural background information identified in the plan which resulted in one recommendation across all six vet centers inspected. The environment of care review evaluated vet centers’ physical environment and general safety resulting in eight recommendations across five of the six vet centers inspected. The OIG issued a total of 13 recommendations for improvement.
A Lack of Program Management Controls and Attention to IT Security Threatens the Success of NOAA’s Effort to Implement a Cloud-Based Common Ground System
The National Oceanic and Atmospheric Administration’s (NOAA’s) National Environmental Satellite, Data, and Information Service (NESDIS) provides access to global environmental data from satellites and other sources. Current NESDIS ground systems process data from NOAA and non-NOAA satellites and other observing systems. The computing architecture for many of NESDIS’ ground systems is currently located “on premises” rather than in the cloud and was developed with unique designs specific to each mission.NESDIS is transitioning some functionality from its current satellite ground systems to its cloud-based NESDIS Common Cloud Framework (NCCF). The NCCF is intended to provide greater flexibility, efficiency, cybersecurity, and cost effectiveness for the next generation of NESDIS missions.Our audit objective was to assess NESDIS’ progress implementing the NCCF. We found that (1) NESDIS’ effort to implement the NCCF lacks fundamental project management practices set forth in Department of Commerce policy, (2) NOAA is not reporting the NCCF’s financial, project, and performance data to the federal IT dashboard, (3) NESDIS’ penetration testing of the NCCF has been inadequate, and (4) the NCCF is built on a cloud platform that cannot support its security requirements.We made 11 recommendations to help NOAA ensure that the NCCF has appropriate management controls, complies with policy requirements, and meets security requirements.
The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered throughout Readjustment Counseling Service (RCS).This inspection evaluates four review areas within Continental District 4 including leadership stability, morbidity and mortality reviews, the high risk suicide flag (HRSF) SharePoint site, and safety plans.There were no findings in stability of leadership. Based on active policy at the time of the inspection, the OIG identified that district leaders did not complete timely morbidity and mortality reviews for clients who died by suicide. Inconsistent with requirements at the time, leaders also implemented a peer review process for all suicide attempts instead of the morbidity and mortality reviews. The OIG did not conduct the HRSF SharePoint site review due to concerns with data accuracy. In April 2024, the OIG made a recommendation to the RCS Chief Officer related to HRSF SharePoint site functionality. The recommendation remained open at the time of the inspection; therefore, the OIG will continue to monitor progress to closure and did not make a new recommendation. Vet center staff were noncompliant with completing and providing safety plans to clients.The OIG issued three recommendations for improvement to the District Director.
Based on a preponderance of the evidence, our investigation found that in all four matters, EPA official Joseph Goffman failed to assess whether specific parties or industries posed a potential financial conflict-of-interest prior to participation. Our investigation also found that Goffman held financial interests in the MCM and Commercial sterilization rulemakings and failed to meet his ethical obligations under the federal financial conflicts-of-interest prohibition when he participated in both rulemakings. Our investigation was inconclusive as to whether Goffman met his ethical obligations under the federal financial conflicts-of-interest prohibition when he participated in the review of a request by a corporate entity. Finally, our investigation did not substantiate that Goffman failed to meet his ethical obligations under the federal financial conflicts-of-interest prohibition when he participated in preparations for a "Bipartisan Infrastructure Law and Inflation Reduction Act Roundtable."
Financial Audit of USAID Resources Managed by Lilongwe Diocese Catholic Health Commission in Malawi Under Multiple Awards, October 1, 2022, to September 30, 2023
Financial Audit of USAID Resources Managed by Center for Clinical Care and Clinical Research in Nigeria Under Multiple Awards, October 1, 2022, to September 30, 2023