Federal Reports

This report contains information about recommendations from the OIG's audits, evaluations, reviews, and other reports that the OIG had not closed as of the specified date because it had not determined that the Department of Justice (DOJ) or a non-DOJ federal agency had fully implemented them. The list omits information that DOJ determined to be limited official use or classified, and therefore unsuitable for public release.The status of each recommendation was accurate as of the specified date and is subject to change. Specifically, a recommendation identified as not closed as of the specified date may subsequently have been closed.

As part of our annual audit plan, we performed an audit of costs billed to the Tennessee Valley Authority (TVA) by Emerson Process Management Power and Water Solutions, Inc., (Emerson) under Contract No. 14688 for distributed control systems products and services. Our audit objective was to determine if costs billed to TVA under Contract No. 14688 were in accordance with the contract's terms. Our audit scope included about $8.2 million in costs billed to TVA by Emerson during fiscal years 2022 and 2023.In summary, we reviewed $6,039,332 in invoices billed under the largest 14 purchase orders (POs), all of which were for fixed price projects, and determined the fixed price POs were billed in accordance with the milestone payment schedules that had been authorized. However, we determined Emerson did not comply with the contract requirements to build up its fixed price POs using the contract pricing, resulting in an overstatement of $702,108 to the fixed price POs. Further, about $1.3 million of the pricing was not from Emerson’s pricing books. In addition, we determined (1) TVA project managers did not have enough information to effectively review the fixed price proposals to verify compliance with the contract prior to the issuance of the POs, which could have prevented Emerson’s noncompliance, and (2) the fixed price projects were not competed, although the contract stated it was TVA’s intent to compete any fixed price work awarded under the contract.

The U.S. Consumer Product Safety Commission (CPSC) OIG retained Williams, Adley, & Co.-DC LLP (Williams Adley, we), an independent public accounting firm, to perform the independent evaluation of the CPSC’s implementation of FISMA for FY 2024 and to determine the effectiveness of its information security program. This report documents the results of the OIG’s FISMA evaluation. Specifically, we assessed the CPSC’s compliance with the annual Inspector General (IG) FISMA reporting metrics set forth by the DHS and OMB. Agency efforts are scored against a five level maturity model ranging from level one, “ad hoc,” to level five, “optimized,” with level four, “managed and measurable,” generally considered effective.

The Federal Emergency Management Agency (FEMA) did not fullyimplement the State-Administered Direct Housing Grant Programrequired by Section 1211(a) of the Disaster Recovery Reform Act of2018 (DRRA). Specifically, as of March 2024, FEMA had not issuedfinal regulations to fully implement the program. This occurredbecause FEMA . Additionally,FEMA did not implement an effective pilot program. The DRRA hadauthorized FEMA to carry out a pilot program for up to 2 years untilfinal regulations were issued. However, during the pilot period,FEMA only issued one narrowly focused grant award that did notauthorize the recipient state to administer direct housingassistance on FEMA’s behalf. This occurred because FEMA did notissue timely guidance for the pilot program, leaving only 10 weeksto implement the pilot program before it expired. As a result, FEMAmissed opportunities for state, territorial, and tribal (STT)governments to play a greater role in identifying and implementingdisaster housing solutions to best meet their communities’ needs.

Objective: To determine whether the Social Security Administration followed policies and used available tools to prevent, detect, and recover Supplemental Security Income overpayments.

The U.S. Postal Service is responsible for processing, transporting, and delivering the nation’s Election and Political Mail. The Postal Service is committed to fulfilling its role in the electoral process when policy makers choose to use the mail as a part of their election system. The Postal Service has specific policies and procedures on the proper acceptance, processing, delivery, and documentation of Election and Political Mail.

We audited HUD’s management of its FHA appraiser roster to determine whether the roster was accurate and reliable. We selected this review because a prior audit identified weaknesses related to roster oversight and because this topic aligns with HUD’s strategic goals related to promoting home ownership and strengthening its internal capacity, as well as increased interest in the appraisal process. HUD’s FHA appraiser roster was generally reliable. HUD’s system controls prevented ineligible appraisers from being assigned appraisals on FHA-insured properties. Though it did not affect the assignment of appraisals, HUD could improve its data management by timely removing ineligible appraisers with expired licenses or disciplinary actions within specified timeframes, and better maintain historical information and supporting documentation. Additionally, HUD’s processes, policies, procedures, and regulations for maintaining the appraiser roster did not consistently align, were not clear, or were undocumented. HUD had begun to make several system enhancements to address the concerns identified, and it should continue to improve its guidance and data management to help ensure the integrity of the roster. We recommend that HUD (1) update policies and procedures for appraiser roster management so that they align with each other and with regulations and HUD practice; (2) maintain historical appraiser roster data; and (3) improve quality assurance processes by adding steps to verify that the appraiser roster is accurate and reliable over time.

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

Objective: To determine whether the Social Security Administration and disability determination services conducted consultative examination (CE) oversight reviews, as required, and whether they took corrective actions based on the results of the CE oversight reviews completed.

The AmeriCorps Office of Inspector General (AmeriCorps OIG) conducted a proactive review of
AmeriCorps employees who may have improperly applied for and received unemployment
insurance (UI) payments while actively employed.
AmeriCorps OIG developed a list of potential matches of AmeriCorps employees and individuals
who had applied for UI benefits. AmeriCorps OIG identified ten potential matches for further
investigation.

OIG determined whether Farm Service Agency (FSA) employees would recognize and respond to phishing email. OIG made three recommendations to OCIO and reached management decision on each of them.

The U.S. Postal Service issued approximately 27,000 smartphones to its employees to provide telecommunication and connectivity to its information systems and work-related applications. Although smartphones offer opportunities to improve business productivity, they also introduce the risk of cyber threats that could compromise sensitive Postal Service data. Given the level of access a smartphone offers to its internal network, it is imperative the Postal Service appropriately secures its smartphones to mitigate the risk to its data and systems.

Purpose: This report summarizes the Office of the Inspector General’s audit work related to the Social Security Administration’s (SSA) efforts to prevent, detect, and recover improper payments, which we have identified as a major management challenge for SSA since Fiscal Year 2002.

This report presents the results of our audit of Service Performance of the New Sorting and Delivery Center in Binghamton, NY.

VA provides tax-free monthly compensation payments to veterans for service-connected disabilities, including special monthly compensation for certain serious disabilities or combinations of disabilities. As part of its Veterans Benefits Administration (VBA) oversight, the VA Office of Inspector General (OIG) identified instances where VBA did not properly implement annual disability compensation cost-of-living adjustments (COLA). First, the OIG team found that certain special monthly compensation amounts had been calculated incorrectly for each annual COLA since December 1, 2016. This resulted in some monthly payments to veterans being slightly higher or lower than they should have been.Second, the OIG team found that the increased amounts for disability compensation, additional compensation for dependents, and clothing allowance for the COLA effective December 1, 2022, were not published in the Federal Register, as required by law. VBA received the Federal Register notice signed by the VA Secretary containing the increased amounts; however, VBA did not forward the notice to the next office for publication. Although the increased amounts were available on VA’s website, including them in the Federal Register is important because it is the official publication for notices of federal agencies and organizations.In November 2023, the OIG team notified VBA representatives of the improper implementation of these compensation COLAs. The VA OIG issued the management advisory memorandum to formally and transparently convey this information so that VBA can determine if additional actions are warranted. The OIG requested that VBA inform the OIG of what action, if any, VBA takes regarding the incorrect special monthly compensation amounts identified in this memorandum and the increased disability compensation amounts effective December 1, 2022, that were not published in the Federal Register.

As required by FISMA, OIG reviewed USDA’s ongoing efforts to improve its information technology security program and practices during FY 2024.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess an allegation of inadequate clinical care of a patient who died by suicide on the inpatient medical unit.In summer 2023, a physician admitted the patient to the facility’s medical unit, placed an order for one-to-one observation status (1:1) for suicidal ideation, started a Clinical Institute Withdrawal Assessment of Alcohol Revised (CIWA-Ar) protocol for treatment of alcohol withdrawal symptoms, and entered a consult to the psychiatry service. Four days later, the patient was found in the bathroom hanging from a necklace, having died by suicide.The OIG found that staff did not follow policy requirements to remove the patient’s belongings or reduce environmental risks. Additionally, a nurse failed to conduct a warm handoff as required for the completion of a Comprehensive Suicide Risk Evaluation (CSRE) after completing a positive suicide risk screening. The psychiatrist completed a telemental health evaluation of the patient but did not complete the required CSRE. On the third day of admission, the psychiatrist did not reassess the patient before changing the patient’s 1:1 order to every 15-minute checks and did not sign the evaluation note within the required 24-hour time frame, leaving the assessment unavailable to other providers.Nursing staff documented CIWA-Ar assessments every 1–4 hours and administered lorazepam as ordered except for one error. The medical unit nurse manager reported addressing the error, and the error had no impact on the patient’s outcome.Facility leaders evaluated processes related to the care of the patient through actions that included a root cause analysis in accordance with Veterans Health Administration policy. The resulting action plans addressed concerns identified in this report.The OIG made four recommendations to the Facility Director related to clinical screenings and evaluations, timely documentation, and removing environmental risks.

The VA Office of Inspector General (OIG) reviewed an allegation that a patient experienced a delay in receiving basic life support (BLS) during a medical emergency on the grounds of the Carl T. Hayden VA Medical Center (facility) in Phoenix, Arizona, and later died at a community hospital.The OIG determined the patient experienced a delay in receiving BLS. The OIG learned of deficiencies related to the initiation of emergency medical care, including (1) conflicting facility policies that were inconsistent with Veterans Health Administration (VHA) requirements, (2) lack of layperson cardiopulmonary resuscitation (CPR) training, and (3) lack of an automatic external defibrillator (AED).Quality of care concerns were also identified, which included a discrepancy between the documented plan for a wearable cardioverter defibrillator (WCD) and the absence of an order for the device, and a failure to assess vital signs at an appointment preceding the medical emergency. The OIG was unable to determine whether a change in care would have resulted in a different outcome for the patient.Facility leaders’ lack of response upon awareness of the event did not align with high reliability organization (HRO) principles and I CARE values. The OIG identified the patient safety manager did not facilitate a thorough investigation of the related patient safety report, which resulted in an inaccurate harm assessment. Additionally, the patient safety manager and Facility Director failed to ensure a timely review of the report and investigation.The OIG made 10 recommendations to the Facility Director related to congruence of facility policies and their alignment with VHA Directives, layperson CPR training, placement of AEDs at the facility, outpatient clinic compliance with vital signs completion, complaint review processes, communicating in alignment with HRO and I CARE values, training on patient safety reporting, and investigation and closure of patient safety reports.

We conducted a review to determine the Federal Student Aid office’s (FSA) actions to mitigate risks associated with the verification of identities in the FSA ID account creation process. Although we found that FSA had implemented controls to address identity verification risks associated with FSA ID account creation, it could take further actions by implementing preventive controls to better protect Title IV funds and the public from fraudulent activity. We found that approximately $27.3 million in Title IV funds was disbursed to suspected fraudulent FSA ID accounts. Further, although FSA has taken several steps to mitigate other risks to FSA ID accounts, these controls mitigate risks after the FSA ID account has been created and do not mitigate risk associated with the creation of the FSA ID account. We also identified a data reliability issue with the National Student Loan Data System data.

Peer Review: System Review Report on the U.S. Securities and Exchange Commission's Office of Inspector General Audit Organization

The Inflation Reduction Act (IRA), enacted in August 2022 as Public Law 117-169, appropriated $3 billion to the U.S. Postal Service to assist with its delivery fleet modernization. The Act provides the Postal Service $1.29 billion in funding for the procurement of zero-emission delivery vehicles (electric vehicles) and $1.71 billion in funding for the purchase, design, and installation of the necessary charging infrastructure at Postal Service facilities.

The Clean Air Act requires delegated agencies to work with the EPA to reduce air pollution from stationary sources. From at least 2006, the EPA did not ensure that two large, delegated agencies, the Texas Commission on Environmental Quality, or the TCEQ, and California's South Coast Air Quality Management District, identified a subset of synthetic-minor sources of air pollution, or SM-80s. The permit limitations on SM-80s need to be clear and enforceable because, if the limitations are not adhered to, the source may operate at major source levels and should be subject to more stringent requirements. The EPA's Office of Enforcement and Compliance Assurance's lack of in-depth evaluations of Regions 6 and 9, lack of SM-80 requirements, and reliance on unenforceable guidance contributed to deficiencies we identified in the regional offices' oversight.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review surgical service and quality management concerns at the Hampton VA Medical Center (facility) in Virginia.The OIG found facility leaders conducted three focused clinical care reviews (FCCRs) in response to concerns about the assistant chief of surgery’s surgical care. However, facility leaders failed to report the results of two FCCRs and delayed reporting the results of one FCCR to the Medical Executive Committee, and did not use multiple reviewers for interrater reliability in any of the FCCRs to ensure the reviews were “fair and objective.” Facility leaders took several privileging actions against the assistant chief of surgery. However, the OIG found multiple deficiencies with notification letters and processes, including failure to adhere to VHA policy, send extension letters, include required language within the letters, and use clear terminology. Leaders also failed to report the assistant chief of surgery to the state licensing board after identifying six cases of substandard care.Surgical staff did not complete required patient safety reports. Morbidity and mortality conferences were held in a manner that compromised the formal peer review process and resulted in negative staff experiences. The chief of surgery did not recognize the need for three substandard cases to be considered for peer review. The VISN Chief Medical Officer and the facility chief of quality, safety, and value failed to prevent a management review from including two cases that were being peer reviewed concurrently. The OIG determined that facility leaders generally did not communicate and document required institutional disclosure elements.Eleven recommendations were made to the facility director regarding FCCRs, privileging actions, state licensing board reporting, professional practice evaluations, patient safety reporting, morbidity and mortality conferences, peer review, and institutional disclosures. One recommendation was made to the VISN Director.

On December 19, 2023, the Office of Special Counsel referred a whistleblower disclosure in which a Social Security Administration (SSA) employee alleged that, “SSA Claims Examiners are not informing claimants about the potential detriment of electing to apply for spousal benefits prior to full retirement age.” The Agency referred that allegation to the Office of the Inspector General for review.

What We Looked At The Office of Inspector General (OIG) maintains a hotline for receiving allegations of fraud, waste, abuse, or mismanagement affecting U.S. Department of Transportation (DOT) programs or operations. OIG received a hotline complaint alleging a hostile work environment in the Federal Aviation Administration’s (FAA) Acquisition and Fiscal Law Division (AGC-500). The Division provides legal support to FAA regarding Government contract and acquisition, fiscal, and real property laws. We initiated an audit after reviewing the hotline complaint because its concerns extended beyond a matter for human resources to having potential programmatic effects that could impact the Division’s ability to conduct its mission. Accordingly, our audit objective was to determine if the work environment impacts AGC-500’s ability to fulfill its mission to provide legal support for the NAS.What We Found AGC-500’s work environment impacts its ability to meet its mission and provide legal support to FAA as the Division is experiencing high attorney turnover, employee dissatisfaction, and inefficient decision making. These issues are partly because of attorney dissatisfaction with AGC senior leadership. As a result, FAA faces unanticipated costs, potential safety burdens, and potential challenges meeting its mission. Furthermore, AGC-500 cases are not formally tracked and lack transparency. While FAA has made improvements to address issues with its documentation system, the tool will not be effective until all AGC-500 attorneys are trained on and use the system to share program information and formally document their work. In addition, AGC-500 adopted guidelines in 2022 that could conflict with employees’ whistleblowing rights and could interfere with OIG’s investigations. In November 2023, after discussion with OIG’s legal counsel, AGC-500 drafted an improved business rules document. However, until the Division officially updates its business rules, employees’ ability to fulfill their mission with the protections afforded to all Federal workers will remain at risk.Our Recommendations We made six recommendations to enhance the AGC-500’s operating environment and ability to complete its mission efficiently. The Agency concurred with all six recommendations, which we consider resolved but open pending completion of planned actions.

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

Summary
The U.S. Environmental Protection Agency prepared the Semiannual Report on Purchase Charge Card Violations for the period of October 1, 2023, to March 31, 2024, which is attached to this letter. The EPA reported no violations for the period. No additional information inconsistent with the EPA's violation report for the reporting period came to our attention. Additionally, we received no allegations of misuse of the government purchase card for the semiannual period.

Report Type
Audit
Report sub-type
Congressional Reporting
Office
Business Operations (BOD)

In response to the terror attacks of 9/11, the First Responder Network Authority (FirstNet Authority) was established in 2012 as an independent authority within the National Telecommunications and Information Administration (NTIA) to oversee a national communications network dedicated to emergency responders and public safety.In March 2017, FirstNet Authority signed a 25-year contract with AT&T for the construction and operation of the Nationwide Public Safety Broadband Network (NPSBN). The contract requires the NPSBN (commonly known as FirstNet) to be a resilient, secure, and highly reliable broadband service with availability 99.99 percent of the time.On February 22, 2024, AT&T customers, including FirstNet customers, experienced a nationwide outage of services. According to FirstNet Authority, the NPSBN was affected by the outage for about 3 hours. We met with 10 public safety agencies from fire, police, and emergency medical services disciplines to determine the impact of the outage. Although impacts to public safety agencies across the country varied, 9 of 10 agencies we spoke with were not contacted by AT&T or FirstNet Authority when the outage occurred. We also found that the impacted agencies had to rely on their own contingency plans to maintain communication during the approximately 3-hour NPSBN outage.Notification of an outage and transparency regarding network performance are essential to maintaining confidence in the NPSBN within the public safety community. Without a reliable communication network during the outage, the safety of our nation’s first responders was jeopardized and their ability to perform their critical mission was compromised.We proposed two actions for change to NTIA and FirstNet Authority to address the concerns presented in this management alert.

We found USGS lacks sufficient internal controls in laboratories to prevent losses associated with breaches of scientific integrity and misconduct.

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

I am pleased to present the Defense Intelligence Agency (DIA) Office of the Inspector General (OIG) Semiannual Report (SAR) to Congress covering the period from October 1, 2023, to March 31, 2024.

When a veteran is unable to secure and maintain a substantially gainful occupation because of service-connected disabilities, VA policy states that the veteran should be rated totally disabled—also referred to as total disability based on individual unemployability (TDIU)—for monthly compensation. The VA OIG conducted this review to determine if claims processors were following policies and procedures and accurately deciding claims for individual unemployability. After reviewing two statistical samples of individual unemployability claims (granted and denied claims), the team found claims processors did not consistently follow policies and procedures when processing these claims, resulting in at least $100 million in improper payments (underpayments and overpayments) to veterans from May 1, 2022, to April 30, 2023. The team estimated that 74 percent of granted TDIU claims and 76 percent of denied TDIU claims completed during the review period had at least one claims processing error. These errors occurred because of inadequate system controls, inconsistent interpretations of VBA’s procedures manual by VBA staff, and claims processors’ limited exposure to individual unemployability claims. The OIG made seven recommendations to the under secretary for benefits to help VBA improve the accuracy of individual unemployability claims decisions. These recommendations included updating guidance, enhancing information systems, improving training, and evaluating workload distribution.

During our ongoing audit of the Department of Homeland Security’s learning management system (DHSLearning), we identified a significant risk to the operations, assets, and individuals at the Cybersecurity and Infrastructure Security Agency (CISA) and Federal Law Enforcement Training Centers (FLETC). We are issuing this management alert to advise CISA and FLETC to take immediate action to mitigate risks associated with using a high-risk contractor (Contractor A) to supply their learning management systems. A DHS internal investigation identified Contractor A as having poor cybersecurity practices. By not taking action to mitigate the control deficiencies, CISA and FLETC may be putting sensitive personally identifiable information (PII) and sensitive law enforcement training information stored and processed by CISA and FLETC’s learning management systems at risk of compromise.

In October 2023, we conducted on-site, unannounced inspections at five U.S. Customs and Border Protection (CBP) facilities in the ElPaso area, specifically three U.S. Border Patrol (Border Patrol) facilities and two Office of Field Operations ports of entry. At the time of our on-site inspection, CBP held 1,426 detainees in custody in the five facilities. We found that Border Patrol held some detainees in both the El Paso Hardened Facility and Santa Teresa station longer than specified in the National Standards on Transport, Escort, Detention, and Search, which generally limits detention to 72 hours. Additionally, Border Patrol experienced challenges staffing El Paso sector centralized processing centersduring migrant surges. Overall, CBP generally met other applicable standards related to food, water, hygiene items, and availability of bedding, toilets, sinks, showers, and medical support to detainees. However, we found a few instances of non-compliance related to medical support, hygiene, and bedding. For example, at the Santa Teresa station, we found Border Patrol did not always refer detainees to onsite contract medical staff, make hygiene items available, or provide clean sleeping mats. In addition, we found data integrity issues with information in Border Patrol’s electronic system of record, e3.

Front-line supervisors are the first layer of management directly above craft employees and are the leaders who oversee day-to-day operations. Their interactions with employees and customers can influence productivity and morale. Additionally, they significantly contribute to the accomplishment of Postal Service goals, including ensuring customers receive quality service and their mail and parcels on time. When supervisor vacancies are not filled timely, there are risks of an increase in staff shortages — negatively affecting operations — and additional workload may strain existing supervisors.

What We Looked At The Federal Aviation Administration’s (FAA) Next Generation Air Transportation System aims to modernize the Nation’s air traffic system and provide safer and more efficient air traffic management. The Terminal Flight Data Manager (TFDM) program, an almost $1 billion part of this modernization effort, will address a top FAA and industry priority to improve airport surface operations. FAA is currently testing and implementing key TFDM capabilities at airports across the Nation, introducing electronic flight strips and surface management tools to improve efficiency at airports. Given the large investment in TFDM, as well as concerns about program deployment cost and schedule, the Chairmen and Ranking Members of the House Committee on Transportation and Infrastructure and its Subcommittee on Aviation requested that we review FAA’s current implementation plan for TFDM. Specifically, we assessed FAA’s progress in implementing TFDM, including its core capabilities. What We Found While FAA has begun to deploy TFDM, it has experienced significant delays of nearly 3 years in its deployment. A nearly 20 percent cost increase since 2016 has also caused a reduction in deployment sites from 89 to 49; therefore, increasing the estimated cost per site while decreasing planned system consolidations and functionality. Although FAA significantly reduced the program’s scope, the Agency retained the large deployment sites that are expected to provide over 90 percent of the original anticipated monetized benefits. However, funding uncertainty will remain which could impact the number of future deployment sites. Additionally, FAA and airspace users will not realize major benefits, such as fuel and carbon emissions savings, until at least 2025 and FAA continues to face implementation risks in areas such as system integration, airline participation, future cybersecurity requirements, and air traffic controller human factors and training.  Our Recommendations We made three recommendations to improve FAA’s TFDM program. The Agency concurred with all three of our recommendations and provided appropriate planned actions and completion dates. 

District of Columbia Workmen’s Compensation Act Special Fund Financial Statements and Independent Auditors’ Report September 30, 2023, and 2022

As part of its Delivering for America plan, the U.S. Postal Service is purchasing and deploying approximately 66,000 electric vehicles and charging stations to support its delivery fleet modernization. The Postal Service generally combined this rollout with its efforts to convert plants into consolidated sorting and delivery centers. It planned to use excess power from converted plants to reduce power upgrades and scheduling risks. The Postal Service expects to complete construction at 130 sites by the end of 2024 and to deploy electric vehicles at an estimated 800 sites by 2028. As of March 26th, 2024, the Postal Service confirmed it completed construction and commissioning at six sites.

To see our report, click on the link below

The OIG received a hotline allegation in June 2022 concerning delays of over 30 days to complete burials at the Santa Fe National Cemetery. In August 2022, the executive director of the National Cemetery Administration (NCA) Pacific District substantiated the delays and attributed them to limited permanent committal shelter space (only one was available), the number of burials feasible per day (no more than nine), family preference, and COVID 19 restrictions.The OIG analyzed data for all NCA burials completed from January 1, 2022, through March 31, 2023. On average, the time from notification to burial was 33 days with a range of 1 to 799 days. Although NCA policy does not set a time requirement, the OIG conducted this audit to determine whether NCA’s oversight ensures the preferences of families are appropriately considered when scheduling burials and can identify potential burial delays.The OIG found that NCA does not have sufficient data to determine if it is scheduling burials in accordance with family preferences and identifying potential burial delays. The two information systems that contain data on burials do not log family preferences. Therefore, the OIG team listened to recorded scheduling phone calls to the National Cemetery Scheduling Office (NCSO) for a sample of burials. The team projected those results to all 5,200 burials that took place in the audit period. The team estimated that for some 2,800 burials with a recorded call scheduling a burial, family preferences were met for about 97 percent. The other 3 percent lacked sufficient information because the scheduled burial was subsequently changed without documentation to indicate whether the changes were at the family’s or NCA’s request.The OIG recommended NCA obtain the capability to identify and monitor potential scheduling delays and ensure family preferences are being met at national cemeteries.