Federal Reports

The SEC Missed Opportunities to Lower Contract Risk and More Effectively Manage Time-and-Materials Contracts, Report No. 582

Each year, increased mail volume and operational changes during the U.S. Postal Service’s peak season — Thanksgiving through New Year’s Eve — significantly strain the Postal Service’s processing and distribution network. As noted in prior audit reports, Postal Service management continued to develop a year-round strategy in preparation for peak season by implementing permanent operational changes.

We partially substantiated allegations that a senior DOI official violated ethics requirements and failed to disclose prohibited investments.

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

We audited the Boston Housing Authority’s Housing Choice Voucher (HCV) Program. We initiated this audit based upon our assessment of risks associated with public housing agencies' HCV Program units, as well as recent media attention and public concern about the conditions of subsidized housing properties. Our objective was to determine whether the physical conditions of the Authority’s HCV units complied with both the U.S. Department of Housing and Urban Development’s (HUD) and the Authority’s requirements.The Authority did not always ensure that its HCV Program units met HUD’s housing quality standards (HQS). Specifically, we reviewed a sample of 87 units that had passed a recent HQS inspection and determined that 50 units had 193 deficiencies. Of the 50 units, 15 units had 53 deficiencies that existed at the time of the Authority’s last inspection. In addition, the Authority did not (1) consistently stop housing assistance payments (HAP) to owners for uncorrected unit deficiencies and (2) comply with HUD’s monitoring and data collection requirements of the Lead Safe Housing Rule (LSHR) for cases of children with elevated blood lead levels (EBLL).These conditions occurred because the Authority's inspectors did not thoroughly inspect housing units in a consistent manner and the Authority’s quality control process for HQS inspections had weaknesses. Further, (1) the Authority’s information system did not have controls in place to stop payments properly and (2) the Authority did not consistently follow its own established procedures to take appropriate actions to address unit deficiencies. Additionally, although the Authority was aware of HUD’s EBLL requirements, it (1) was uncertain about its authority to require owners to comply with those requirements and (2) believed that coordinating with the vast number of local health departments would have been challenging. As a result, families participating in the Authority’s HCV Program resided in housing units that were not always decent, safe, and sanitary. Based on our statistical sample, we estimate that over the next year, the Authority will pay owners more than $34 million in housing assistance for units that do not meet HQS. Further, (1) the Authority paid $180,309 in housing assistance to owners for units with uncorrected deficiencies and (2) HUD lacked assurance that the Authority and owners appropriately addressed their responsibilities under the LSHR for cases of children with EBLLs in a timely manner.We recommend that the Director of HUD’s Boston Office of Public Housing require the Authority to (1) ensure that the owners correct the outstanding unit deficiencies; (2) recover or repay from non-Federal funds $106,477 for HAP that were not properly stopped; (3) review its records to confirm whether it had cases of children with EBLLs during our audit period and work with the owner(s) of the HCV Program units to provide required documentation to HUD; (4) update publications and educational materials to owners to ensure that they understand their reporting responsibilities to HUD regarding confirmed cases of children with EBLLs; (5) develop and implement procedures and controls for coordinating with public health departments and monitoring owners for compliance with the requirements of the LSHR; and (6) improve controls over its inspections, stop payments for uncorrected deficiencies, and monitor owners for compliance with the requirements of the LSHR. Additionally, we recommend that the Director of HUD’s Boston Office of Public Housing work with the Office of Lead Hazard Control and Healthy Homes to provide training to the Authority’s staff involved with managing lead‐based paint and technical assistance in developing and implementing new procedures and controls.

This review consisted of an examination of the office’s I&E policy as the CFTC OIG did not issue any I&E reports during the period under review. The AmeriCorps OIG identified instances in which the I&E policy was inconsistent with the updated Council of the Inspectors General on Integrity and Efficiency’s (CIGIE’s) Quality Standards for Inspection and Evaluation, December 2020 (Blue Book), and recommended that the CFTC OIG update its policy.

Our investigation of a company’s improper royalty estimates for oil and gas production led to the recovery of Federal mineral revenues.

The VA Office of Inspector General (OIG) reviewed the Veterans Crisis Line’s (VCL’s) preparation for implementation of the National Suicide Prevention Hotline three-digit dialing code “9-8-8 press 1” (988 press 1). The review focused on responder and supervisor staffing and training, including postvention support awareness; information technology equipment and support; and quality metrics data and oversight.VCL leaders collaborated with the Substance Abuse and Mental Health Services Administration to add the 988 press 1 option. VCL leaders expected an increase in call volume from the addition of 988 press 1 access. The OIG determined VCL leaders hired additional frontline staff in anticipation of the call volume increase. However, VCL had not increased the number of supervisors to meet the identified supervisor-to-staff ratio. Supervisors’ oversight ensures frontline staff provide adequate assessments of callers.The OIG identified a concern related to frontline staff’s awareness of and feelings of support from supervisors to use postvention resources. VCL staff would benefit from awareness and training regarding postvention resources.VCL leaders, in conjunction with the Office of Information and Technology leaders, assessed, planned for, and implemented technology changes related to 988 press 1. The VCL did not encounter technology concerns. The OIG also found quality metrics data were reported monthly to VCL leaders at Executive Leadership Committee meetings and reflected quality oversight.The OIG obtained and compared pre- and post-988 press 1 call volumes from July through December of each calendar year. From 2021 to 2022, call volume increased by 12.5 percent; from 2022 to 2023, call volume increased by 15.1 percent.The OIG made two recommendations to the VCL Director related to determining the optimal supervisor-to-staff ratio and ensuring staff are aware and trained on postvention resources available to them.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess whether leaders implemented corrective actions to address pharmacy-related concerns at the VA Central Western Massachusetts Healthcare System (system) in Leeds.In early 2023, the OIG received five allegations related to prescription processing delays and inadequate pharmacy staff training, and requested the Veterans Integrated Service Network (VISN) Director to respond to the allegations. According to the response, an external review, performed by individuals associated with another VISN, partially substantiated or substantiated four of the five allegations and made 12 recommendations. The System Associate Director (Associate Director) adopted the recommendations as corrective actions and, in July, tasked the chief of pharmacy with implementation. The OIG opened a hotline in September to determine whether system leaders had implemented the 12 corrective actions.The OIG determined that 11 of the 12 corrective actions were incomplete. The OIG found the chief of pharmacy perceived the corrective actions as a disciplinary tool rather than an opportunity to improve pharmacy services and that this impacted implementation of the corrective actions.Further, the Associate Director and the acting Associate Director, as the chief of pharmacy’s supervisors, did not provide effective and timely oversight to ensure completion of the corrective actions. Although not required, they also missed opportunities to involve the VISN Pharmacist Executive earlier, rather than waiting until corrective action deadlines had passed, diminishing the effectiveness of the VISN Pharmacist Executive to assist the system with timely intervention.The OIG made three recommendations to the VISN Director related to the completion of the corrective actions; training of pharmacy staff and supervisors; and ensuring that leaders receive administrative action, as appropriate.

The Science and Technology Directorate (S&T) can improve management of its research, development, testing, and evaluation (R&D) activities related to critical infrastructure security and resilience. Although S&T is actively making efforts to improve processes, it:• does not use a risk-based, holistic approach to prioritize critical infrastructure R&D programs and projects department-wide;• does not follow established project management principles and its own project management policies and procedures; and• relies on inaccurate and incomplete information to manage its critical infrastructure R&D projects.These problems occurred because S&T relies on component-based R&D prioritization processes instead of establishing and updating department-wide strategic priorities. Additionally, S&T does not ensure adherence to project management best practices, such as integrating program and project plans, using standard terminology and abbreviations, and tailoring its processes to fit the project needs. Finally, S&T has no formal data validation process to ensure the quality of R&D project management data

What We Looked At    This report presents the results of our quality control review (QCR) of an attestation examination of the Department of Transportation’s (DOT) Enterprise Services Center (ESC) controls. ESC provides financial management services to DOT and other agencies and operates under the direction of DOT’s Chief Financial Officer. The Office of Management and Budget requires ESC, as a service organization, to either provide its user organizations with independent audit reports on the design and effectiveness of its internal controls or allow user auditors to perform tests of its controls.We contracted with KPMG LLP to conduct this examination subject to our oversight. The objectives of the review were to determine whether (1) management’s description of ESC’s systems is fairly presented, (2) ESC’s controls are suitably designed, and (3) ESC’s controls are operating effectively throughout the period of October 1, 2023, through June 30, 2024. We performed a QCR on KPMG’s report and related documentation.What We FoundOur QCR disclosed no instances in which KPMG did not comply, in all material respects, with generally accepted Government auditing standards.Our RecommendationsKPMG made no recommendations.   

Amtrak notified our office February 16, 2024, of a potential data‐sharing incident. Our investigation found that an employee granted two third‐party email accounts access to an Amtrak OneDrive/SharePoint folder which contained 369 company files related to an Amtrak program. As a result of our investigation into the incident, the company took remedial action to optimize Microsoft tools for data loss prevention, conducted routine auditing and removal of guest accounts, completed additional security enhancements, and provided alerts for risky file sharing.

Although U.S. Customs and Border Protection (CBP) responded to CBPOne™ application weaknesses after implementation, it did not formallyassess and mitigate the technological risks involved with expanding theapplication to allow undocumented noncitizens (noncitizens) to scheduleappointments to present themselves for processing at Southwest BorderPorts of Entry (POEs). We found that CBP did not initially consider criticalfactors such as the design of the CBP One™ Genuine Presencefunctionality, adequacy of supporting application infrastructure,sufficiency of language translations, and equity of appointmentdistribution. As a result, noncitizens initially using the new featureexperienced application crashes, received frequent error messages, facedlanguage barriers, and may not have always had an equal opportunity tosecure an appointment.

What We Looked AtThe locks, channels, and accompanying infrastructure of the St. Lawrence Seaway are perpetual transportation assets that require periodic and regular capital reinvestment in order to continue to operate safely, reliably, and efficiently. The Great Lakes St. Lawrence Seaway Development Corporation (GLS) Seaway Infrastructure Program (SIP), previously the Asset Renewal Program, addresses the long-term capital asset renewal needs of the U.S. seaway infrastructure. Adequate internal controls are critical for GLS to generate high-quality cost estimates for its SIP projects and accurately track accumulated SIP project costs. Previously, the Government Accountability Office (GAO) identified issues with GLS’ cost estimating process. Given GAO’s previous findings and the importance of complete and accurate cost estimates, we initiated this audit. Accordingly, our audit objective was to evaluate the reliability of GLS’ cost-estimating process for SIP projects completed during fiscal years 2021 and 2022. As part of our review, we also evaluated GLS’ controls for determining the costs of completed projects.What We FoundGLS has not established adequate internal controls to effectively manage its estimating process for SIP projects. Specifically, GLS does not follow a formal process for developing reliable cost estimates. Also, GLS does not have policies and procedures for ensuring cost estimates are performed when required. In addition, we determined that GLS lacks adequate documentation of controls over determining the total costs for completed SIP projects. Specifically, GLS does not have a suitable mechanism in place to track the accumulated costs of completed SIP projects.Our RecommendationsWe made four recommendations to improve GLS’ internal controls over the SIP cost estimating process. GLS concurred with our recommendations. We consider the recommendations resolved but open pending completion of planned actions. 

Our objective was to determine whether Defense Intelligence Agency (DIA) managed its Research, Development, Testing, and Evaluation (RDT&E) funds to align with Agency mission priorities and optimize their use. To achieve the objective, we conducted a review of RDT&E budget requests and assessed the alignment of funds with DIA strategy and mission priorities. Additionally, we reviewed DIA’s obligation and expenditure performance against Office of the Secretary of Defense goals and unliquidated obligations to assess fund optimization. We also conducted interviews with Agency officials to gain insight into DIA’s processes for monitoring funds. We issued the results of our evaluation, along with four recommendations, in a final report dated August 21, 2024.

U.S. Immigration and Customs Enforcement (ICE) could not monitor the location and status of all unaccompanied migrant children (UCs) or initiate removal proceedings as needed. During our ongoing audit to assess ICE’s ability to monitor the location and status of UCs who were released or transferred from the custody of the Department of Homeland Security and U.S. Department of Health and Human Services (HHS), we learned ICE transferred more than 448,000 UCs to HHS from fiscal years 2019 to 2023. However, ICE was not able to account for the location of all UCs who were released by HHS and did not appear as scheduled in immigration court. ICE reported more than 32,000 UCs failed to appear for their immigration court hearings from FYs 2019 to 2023.

The Postal Accountability and Enhancement Act of 2006 (PAEA) requires the U.S. Postal Service to produce an Annual Compliance Report (ACR) and provide the report to the Postal Regulatory Commission (PRC) within 90 days of the end of each fiscal year (FY). In support of the ACR, the Postal Service provides billing determinant spreadsheets to the PRC. Postal Service management prepares billing determinant spreadsheets quarterly and at the end of each fiscal year. Billing determinants report the volume by rate, weight, and calculated revenue and compares the result to the reported Revenue Pieces and Weight volume. In its annual report to the PRC, the Postal Service is required to use only accepted analytical principles.

We audited the Housing Authority of the City of Los Angeles’ management of lead-based paint and lead-based paint hazards in its public housing units. We selected the Authority based on our assessment of the risks of lead‐based paint in public housing agencies’ (PHA) housing developments, including the age of buildings, the number of units, household demographics, and reported cases of childhood lead poisoning. The audit objectives were to determine whether the Authority (1) complied with HUD’s requirements for children with elevated blood lead levels (EBLL) and (2) adequately managed lead‐based paint and lead‐based paint hazards in its public housing units. The Authority appropriately managed a case of a child with an EBLL. It also maintained lead-based paint inspection reports for the 69 units reviewed. However, the Authority did not adequately manage lead-based paint and lead-based paint hazards in its public housing units. Specifically, for all 69 units reviewed, the Authority did not complete visual assessments in a timely manner. The Authority also did not conduct risk assessments and reevaluations for lead-based paint stabilization projects at 5 of the 10 developments reviewed, which included work at approximately 200 buildings. These issues occurred because the Authority (1) misapplied HUD’s waiver of the requirement for physical inspections during the coronavirus 2019 pandemic to visual assessments and (2) misinterpreted HUD’s requirements for visual assessments. The Authority also used standard treatments for remediating lead-based paint hazards; however, that method for remediating lead-based paint hazards does not apply to public housing, and it incorrectly believed that work performed was for lead maintenance in preparation for exterior painting rather than hazard reduction. Further, the Authority lacked adequate policies, procedures, and controls to ensure that it appropriately managed its housing units that contained lead-based paint. As a result, households that participated in the Authority’s program were at an increased risk of exposure to lead-based paint hazards, particularly families with children under 6 years of age.We recommend that the Director of the Los Angeles Office of Public Housing require the Authority to (1) implement adequate procedures and controls to ensure that visual assessments for lead-based paint are completed at least every 12 months; (2) implement adequate procedures and controls to ensure that risk assessments and reevaluations are conducted in accordance with HUD’s requirements; (3) obtain lead-based paint risk assessments and applicable reevaluations for its developments as applicable; and (4) coordinate with HUD’s Office of Lead Hazard Control and Healthy Homes to obtain training for the Authority’s employees on the management of lead-based paint, including the requirements for visual assessments, risk assessments, reevaluations, and hazard reduction.

The Office of the Inspector General performed an audit of costs billed to the Tennessee Valley Authority (TVA) by Service Electric Company (SEC) for transmission construction services provided under Contract No. 16986. The contract provided for TVA to compensate SEC on either a fixed price or cost reimbursable basis. Our audit objectives were to determine (1) if costs were billed in accordance with contract terms, (2) the reasonableness of TVA’s process for evaluating and awarding proposed fixed price tasks issued under the contract, and (3) if tasks were issued using the most cost-efficient pricing methodology. Our audit scope included approximately $28.2 million in costs billed to TVA from March 8, 2022, through November 30, 2023. This included $24.4 million for fixed price projects and $3.8 million for cost-reimbursable projects. Our audit primarily focused on the fixed price projects under the contract. We determined the $24.4 million in fixed price billings from our audit period had been billed and paid in accordance with purchase order approval limits. Although TVA generally had a good process in place for evaluating and awarding fixed price tasks issued to SEC under the contract, we determined (1) the use of fixed price compensation terms for tasks caused TVA to pay more than it would have if the tasks had been issued under cost-reimbursable payment terms, and (2) there were opportunities to strengthen the process when fixed price tasks are used. Specifically,• The use of fixed price compensation terms for tasks caused TVA to pay at least $3.7 million more than it would have if the tasks had been issued under cost-reimbursable payment terms. Additionally, we estimated TVA could potentially avoid up to $4.69 million in future costs by issuing tasks under cost reimbursable payment terms for the remaining contract spend.• TVA did not always receive price proposals from bidders other than SEC. Without adequate competition TVA is less able to ensure it is paying a fair fixed price amount. Additionally, TVA did not receive detail cost breakouts when changes of scope resulted in significant price changes. Without a price breakout, TVA is less able to determine the reasonableness of the price increase.We also noted opportunities to improve contract administration by TVA. Specifically, (1) the contract contained incomplete terms, (2) Supply Chain was not integrated into business level processes related to procurement, and (3) the contract’s monetary limit was increased without a formal amendment as required by the contract.

The Office of the Inspector General (OIG) audited Help America Vote Act (HAVA) grants administered by the Georgia Secretary of State’s Office (GSoS), totaling $46.3 million. This included federal funds, state matching funds, and interest earned on the reissued Section 101, reissued Section 251, Election Security, and Coronavirus Aid, Relief, and Economic Security (CARES) Act grants.

The Denali Commission has implemented effective privacy and data protection policies and procedures because it has implemented a majority of the NIST Privacy Framework to achieve effective privacy and data protection policies and procedures.

The Federal Emergency Management Agency (FEMA) did not ensure that it closed out disaster declarations in a timely manner. We reviewed 79 disaster declarations and identified 26 programs with nearly $9.4 million in unliquidated funds that remained open beyond their approved periods of performance. These programs included public assistance, individual assistance, and hazard mitigation grant programs that were awarded in 2012 or earlier. This situation is problematic because costs incurred after the period of performance ends are not reimbursable.

The Office of Inspector General (OIG) Care in the Community program evaluates selected performance elements of the Veterans Health Administration (VHA) Veterans Community Care Program. The resulting report describes selected care coordination activities required to initiate and process referrals for non-VA care (community care). The OIG reviewed community care processes in five VISN 9 medical facilities with a community care program from June 12 through July 13, 2023. The OIG evaluated the facilities’ processes for community care referral and care coordination in the following domains:
1. Leadership and Administration of Community Care
2. Community Care Diagnostic Imaging Results
3. Administratively Closed Community Care Consults
4. Community Care Provider Requests for Additional Services
5. Care Coordination: Scheduling and Communication with Veterans Referred for Community Care

The OIG issued 14 recommendations for improvement across all five domains as follows:
1. Leadership and Administration of Community Care
• Operating model staffing tool reassessment
• Patient safety event reporting
• Briefing the oversight council
• Document scanning
2. Community Care Diagnostic Imaging Results
• Diagnostic imaging result attachment to required note
• Significant findings alert use for abnormal results
3. Administratively Closed Community Care Consults
• Obtaining medical documentation
• Significant findings alert use when closing consults without documentation
4. Community Care Provider Requests for Additional Services
• Requests for services processing
5. Care Coordination: Scheduling and Communication with Veterans Referred for Community Care
• Level of care assignments
• Care coordination documentation
• Timely update of consult status to active
• Timely appointment scheduling
• Appointment attendance confirmation

Declining mail volume and a growing share of parcels in the mail mix have impacted the composition of the Postal Service’s workforce in recent years. Additionally, the U.S. labor market experienced dramatic swings, cratering in the early days of the COVID-19 pandemic, then tightening considerably as organizations struggled to recruit, hire, and retain employees.The USPS OIG found the Postal Service added 8,105 employees between FYs 2019 and 2023, a 1.3 percent increase over the 5-year period. In percentage terms, the number of mail handlers grew the most, increasing by 18.8 percent. Clerks rose by 1.9 percent, while the number of city carriers fell by less than half of one percent, rural carriers declined by 3.1 percent, and building and equipment maintenance employees fell by 6.1 percent.

This U.S. Small Business Administration Office of Inspector General (SBA OIG) report presents the results of our audit of the U.S. Small Business Administration’s (SBA) oversight of the Historically Underutilized Business Zone (HUBZone) program. The program provides small businesses that are located in economically distressed communities access to federal contracting opportunities to stimulate their local economies. In fiscal year (FY) 2022, SBA reported that federal agencies awarded over $16.3 billion, or 2.7 percent of prime federal contracting dollars, to 5,818 HUBZone businesses.We found SBA completed almost all 1,252 triennial program examinations timely and correctly validated 18 of the 20 firms we reviewed (90 percent) met eligibility requirements. Notwithstanding, we have identified some opportunities to further improve eligibility review practices and enhance functionality of the HUBZone information system that notifies participants of their annual recertification requirements.We made four recommendations for SBA to establish authoritative guidance for verifying that firms met eligibility requirements at the time of the triennial program examinations and improve system functionality for sending timely recertification notifications to all HUBZone firms. The agency partially agreed with three recommendations and disagreed with one.

The independent public accounting firm of Brown & Company CPAs and Management Consultants, PLLC, under contract with the Office of Inspector General, audited Help America Vote Act (HAVA) grants administered by the Michigan Department of State (MDOS), totaling $49.88 million. This included federal funds, state matching funds, and interest and program income earned on the reissued Section 101, reissued Section 251, Election Security, and Coronavirus Aid, Relief, and Economic Security (CARES) Act grants.

The Veterans Health Administration (VHA) purchases community healthcare services by contracting with third-party administrators (TPAs), which in turn contract with community providers. When prescribing drugs, community providers submit prescription requests to be filled at VA pharmacies and must consider VA’s approved formulary drugs before others, which require special authorization (usually a justification for its use). The VA Office of Inspector General (OIG) conducted this audit to determine if VHA’s oversight of TPAs ensured that community providers prescribed special-authorization drugs as required.The OIG determined that community providers rarely submitted initial prescriptions for special-authorization drugs with required justifications, partly because the electronic prescription system lacked the means to include justifications. VA pharmacies reported that ongoing staffing challenges and increased community care prescriptions required additional processing time and caused a backlog. However, VA pharmacies sometimes did not record receipt dates for these prescriptions accurately, which made it difficult for VHA to track delayed processing. The OIG found that community care prescription processing often exceeded VHA’s four-day standard, with an average of about 11 days for processing.These issues occurred partly because of ineffective oversight at multiple levels. VHA did not hold TPAs accountable for making certain that community providers followed formulary procedures for special-authorization drugs. Although TPAs developed formulary training, less than 2 percent of community providers completed it. The OIG questioned about $200.2 million in prescription costs that lacked justification from community providers.The OIG made seven recommendations to the under secretary for health to improve community providers’ compliance when prescribing special-authorization drugs, such as enhancing prescription system capabilities, addressing training requirements, improving VA pharmacies’ documentation of justifications, and clarifying requirements for VA pharmacies to report community providers that are not compliant.

The inspection sought to determine whether the Federal Student Aid office (FSA) established performance measures and indicators for returning borrowers to repayment. We found that FSA needed to establish effective performance measures and indicators to evaluate its performance for returning borrowers to repayment. Although FSA and the Office of the Undersecretary established operational and strategic objectives and operational goals for returning borrowers to repayment, they were not written in specific and measurable terms. In addition, although FSA identified several data metrics as performance measures and indicators for returning borrowers to repayment, they did not include clearly defined targeted percentages, numerical values, milestones, or measurements. Without effective performance measures and indicators, FSA is unable to assess whether it has made progress toward achieving its goals and objectives or if adjustments are needed to improve its performance. Overall, the lack of effective performance measures and indicators may negatively impact FSA’s ability to effectively identify, analyze, and respond to risks related to returning borrowers to repayment.

The Inflation Reduction Act appropriated $500 million for NPS to hire employees in National Park System units or national historic or scenic trails.

The VA Office of Inspector General (OIG) conducted a select review of Veterans Health Administration’s (VHA's) implementation of the 2022 United States Department of Veterans Affairs Sustainability Plan, which describes priority actions for achieving federal environmental sustainability goals outlined in Executive Order 14057. The review consisted of three healthcare delivery objectives to estimate VHA’s progress toward environmental sustainability. Objective 1 broadly looked at VHA’s approach to implementing the plan; objective 2 focused on a foundational priority action to help VHA’s sustainability efforts; and objective 3 examined the sustainability of VHA’s healthcare activities by analyzing purchased inhalational anesthetics to determine their contribution to greenhouse gas emissions, waste stream processes and tracking, and ethylene oxide use for sterile processing.Although VHA has started planning and implementing environmental sustainability actions, the OIG identified areas that would benefit from further evaluation. Most facility leaders reported that Green Environment Management System program managers are responsible for leading the implementation of the sustainability plan but the corresponding national program office reported program manager workload capacity as a barrier. VA, inclusive of VHA, implemented training focused on climate change but did not “incorporate environmental stewardship values,” as the executive order required. VHA increased attention to the use of inhalational anesthetics and the impact on greenhouse gas emissions, but the long-term cumulative environmental impact of inhalational anesthetics warrants consideration of a comprehensive mitigation strategy. VHA tracks waste streams and diversion rates from landfill but prohibits repurposing single-use medical devices, which impedes improvement of diversion rates. VHA reported elimination of ethylene oxide usage in sterile processing for healthcare operations.The OIG made one recommendation to the Secretary of Veterans Affairs to incorporate required training content, and four recommendations to the Under Secretary for Health related to position responsibilities, training content, and sustainable health care practices.

Every year, U.S. Postal Service employees risk illness and injury while working in extreme hot or cold temperatures. Mail carriers, especially, experience daily weather challenges and when exposed to extreme heat may be at risk of heat stress. Heat stress can result in heat stroke, heat exhaustion, heat cramps, or heat rashes. Employees can also face cold stress while performing their daily duties in cold environments, which can potentially lead to frostbite or hypothermia. Employers must take steps to prevent illnesses, injuries, or fatalities by controlling these hazards in workplaces impacted by extreme temperatures.

What We Looked AtWe queried and downloaded 60 single audit reports prepared by non-Federal auditors and submitted to the Federal Audit Clearinghouse between January 1, 2024, and March 31, 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 23 incidents of significant noncompliance with Federal guidelines, related to 16 grantees, that require prompt action from DOT’s Operating Administrations. Of the 23 significant findings, 8 were repeat findings related to 5 grantees. The auditors also identified questioned costs totaling $2,682,526 for nine grantees. Of this amount, $993,739 was related to the Logan County Commission, Logan, WV, and $1,106,389 was related to the Yolo County Transportation District, Woodland, CA. Additionally, we identified nonmonetary repeat findings that caused modified opinions for the State of Illinois, Springfield, IL, the Joint Programs of the Shoshone and Arapaho Tribes of the Wind River Reservation, and the Greater Roanoke Transit Company, Roanoke, VA.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 $2,576,852, if applicable. Finally, we recommend that OST work with FTA to determine the allowability of the questioned tribal transactions and recover $105,674, if applicable.

An Amtrak conductor based in Los Angeles, California, was terminated from employment on August 13, 2024, following an administrative hearing. Our investigation found that the employee violated company policies by failing to report his arrest for driving under the influence.

An Amtrak train attendant based in Charlotte, North Carolina, signed a civil settlement agreement on August 13, 2024, with the U.S. Attorney’s Office, Eastern District of North Carolina. The employee agreed to pay a total of $10,800 in settlement, restitution, and penalties to the Railroad Retirement Board (RRB). Our investigation found that the employee worked a second job while receiving RRB sickness benefits. We found that between July 19, 2021, and January 16, 2022, the employee submitted at least 13 false claims to the RRB for sickness benefits. As a result, the employee received $8,282 in benefits to which she was not entitled.

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA Eastern Colorado Health Care System (facility) in Aurora to review telemetry medical instrument technician (MIT) actions and leaders’ response to allegations that an MIT (MIT A) changed patient alarm settings and placed a communication device on “DO NOT DISTURB” for long periods. The OIG identified an additional MIT (MIT B) who possibly engaged in similar practices.The OIG found that while monitoring a telemetry patient (Patient A), MIT A failed to document notifying nursing staff of Patient A's oxygen desaturation alarms (patient event A) and a registered nurse failed to document a change in Patient A’s condition after staff found Patient A unresponsive and pulseless. Further, the OIG found another patient (Patient B) reported experiencing cardiac symptoms (patient event B) to nursing staff. There was a delayed notification of the event to nursing staff due to reports that MIT B turned off the audio of patient B’s monitoring alarms.The OIG found that telemetry nursing leaders failed to ensure and document MITs adherence to clinical alarm monitoring expectations.The OIG found that facility staff did not enter a patient safety report in the Joint Patient Safety Reporting system for patient event A despite the event involving a patient death. Although a patient safety report was entered for patient event B, a patient safety manager rejected the event, which inhibited further investigation by patient safety staff.The OIG found the Associate Director Patient Care Services failed to provide oversight of clinical alarm management, which could result in an increased risk for the occurrence of patient safety events.The OIG made six recommendations to the Facility Director related to medical record documentation, review of the telemetry program, patient safety event reporting, institutional disclosure, and clinical alarm management.

We found that the bureaus generally did not properly inventory or inspect radio infrastructure as required by the DOI OCIO directive.