Federal Reports

This document provides an update to our plan for oversight of the EPA’s implementation of the IIJA.We have divided this Year 3 oversight plan into three time-based sections that describe planned and ongoing IIJA-related audit and evaluation projects for FY 2024 and beyond. The first section includes planned and ongoing projects for Year 3 of our IIJA oversight, the second section details planned projects for Years 4–5, and a third section summarizes our planned approaches for oversight work expected in Year 6 and beyond. Each of the planned and ongoing projects summarized in this plan relates to the EPA’s IIJA implementation work; however, some projects identified in this oversight plan will receive partial support from annual appropriations.

The Bemidji Post Office provides standard delivery and retail operations in a predominantly rural community in Northern Minnesota. The office also has some mail processing operations typically found inside a processing and distribution center. It processes, and subsequently, dispenses mail to 37 other delivery units in the region for delivery. In November 2023, community members and Postal Service employees in the Bemidji, MN, area contacted their congressional representatives and the media to express concerns about increased package volume disrupting mail service. Delivering and processing all mail timely is critical to the Postal Service meeting its service standards and providing the public with the service it deserves.

Results of the FEC OIG annual improper payment review

EAC OIG performed this review to determine whether EAC complied with the Payment Integrity Information Act of 2019 reporting requirements for fiscal year 2023.

Our objective was to assess the company’s efforts to support New Jersey Transit (NJ Transit) and oversee company interests as construction advances.We found that the project is both on budget and on schedule, as of January 2024, but we also found that the company has opportunities to improve its support to NJ Transit, the lead sponsor of the project, and better oversee its own interests. Specifically, it did not anticipate the demand for track outages and company labor, it had differing expectations with NJ Transit related to information sharing, and it did not initially staff its project team to effectively manage its work on the project.We recommend improvements to the company’s process for identifying outage, labor, and information needs at the outset of future projects. Further, for the Portal North Bridge project, we recommend that the company assess and address where information-sharing expectations may continue to vary with NJ Transit.

The Additional Supplemental Appropriations for Disaster Relief Act, 2019, provided DOI with approximately $327 million to support disaster response.

To learn how communities across the nation responded to the pandemic, we initiated a multi-part review of six communities—two cities, two rural counties, and two Tribal reservations. This report is the first community-specific report and focuses on our work in Springfield, Massachusetts, where we previously identified that recipients, including city government, small businesses, and individuals, received almost $1.88 billion from 52 pandemic relief programs and subprograms. This report provides a closer look at nine pandemic programs and subprograms provided to Springfield by eight federal departments.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Maryland Health Care System, which includes the Baltimore VA Medical Center (central Baltimore), Loch Raven VA Medical Center (northern Baltimore), Perry Point VA Medical Center (Perry Point), and multiple outpatient clinics in Maryland. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued five recommendations for improvement in three areas:1. Medical staff privileging• Ongoing Professional Practice Evaluation recommendations and results2. Environment of care• Biohazard sign posting• Safe and clean patient care areas• Panic alarm testing in the inpatient mental health unit3. Mental health• Comprehensive Suicide Risk Evaluation completion

The OIG received a hotline complaint about delays by staff at the Martinsburg VA Medical Center in processing and scheduling veterans’ community care consults. These consults are referrals to non-VA providers for clinical services. The OIG substantiated that as of February 28, 2023, there were over 5,000 active consults (meaning staff were working to process them), that staff took more than 100 days to make the first contact attempt with the veteran, and that staff took longer than 45 days on average to schedule veterans for care in the community (well in excess of the seven-day requirement). While evaluating the merits of the specific complaints, the OIG learned that, in an effort to make staff aware of the repercussions of untimely scheduling, the chief of community care had sent her whole team a list of veterans who had passed away with unscheduled consults. The list contained personally identifiable information. The OIG determined that community care scheduling delays occurred because of (1) ineffective processes used to manage community care consults, (2) shortages of specialty care providers, such as in otolaryngology, gastroenterology, radiology, orthopedics, and cardiology, and (3) a lack of controls to ensure manager accountability for consult timeliness. The OIG recommended ensuring that personal information of veterans is only shared on a need-to-know basis, evaluating alternative workflows to improve consult processing and scheduling, exploring ways to increase the availability of specialty care providers, and adding to the community care chief’s performance plan standards related to the metrics for community care.

Endo Health Solutions Inc. (EHSI) was ordered May 2, 2024, to pay $1.086 billion in criminal fines and an additional $450 million in criminal forfeiture—the second-largest set of criminal financial penalties ever levied against a pharmaceutical company—for violations of the federal Food, Drug and Cosmetic Act (FDCA), according to the U.S. Department of Justice.EHSI pleaded guilty April 18, 2024, to one misdemeanor count of introducing misbranded drugs into interstate commerce. In its plea, EHSI admitted that from April 2012 through May 2013, some of its sales representatives marketed Opana ER with INTAC (Opana ER) to prescribers by touting the drug’s purported abuse deterrence, tamper resistance, and/or crush resistance despite a lack of clinical data supporting those claims. In addition, approved labeling for Opana ER did not provide adequate information for healthcare providers to safely prescribe Opana ER for use as an opioid that is abuse deterrent. According to the plea agreement, EHSI was responsible for the misbranding of Opana ER by marketing the drug with a label that failed to include adequate directions for its claimed abuse deterrence, in violation of the FDCA. EHSI withdrew Opana ER from the market in 2017. The investigation, supported by our office, found that some Amtrak employees and dependents were prescribed the misbranded drug.

16th Quarterly Report to Congress

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Harry S. Truman Memorial Veterans’ Hospital, which includes multiple outpatient clinics in Missouri. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued seven recommendations for improvement in three areas:1. Medical staff privileging• Ongoing Professional Practice Evaluationo Completiono Service-specific criteria• Professional practice evaluation data2. Environment of care• Mental health inpatient unit over-the-door alarm testing3. Mental health• Comprehensive Suicide Risk Evaluation completion• Suicide prevention outreach activities• Reporting suicide behaviors to the suicide prevention team

With the Artemis campaign, NASA intends to return humans to the Moon and build a sustainable lunar presence as a foundation for human exploration of Mars. Given the high stakes of the first crewed flight, the Agency is working to identify and mitigate any risks and challenges to ensure the safe return of the Artemis II crew and safeguard NASA’s significant investment in Artemis vehicles and systems.

This report summarizes work we initiated and completed during this semiannual period on a number of critical U.S. Department of Commerce (Department) activities. Over the past 6 months, our office issued 10 products related to our audit, evaluation, and inspection work. These products addressed programs and personnel associated with the U.S. Census Bureau, U.S. Economic Development Administration (EDA), National Oceanic and Atmospheric Administration (NOAA), National Telecommunications and Information Administration, United States Patent and Trademark Office, and the Department itself. This report also describes our investigative activities addressing programs and personnel associated with the Census Bureau, EDA, NOAA, and the Department.

I am pleased to submit this Semiannual Report to Congress highlighting the activities of the EqualEmployment Opportunity Commission (EEOC), Office of Inspector General (OIG) for the sixmonths ending on March 31, 2024.

Semiannual Report to Congress for the period October 1, 2023 – March 31, 2024

To view the report, please click on the link below

KPMG made 29 recommendations that are intended to strengthen DOI’s information security program as well as those of DOI’s bureaus and offices.

The VA Office of Inspector General (OIG) conducted an inspection at the Raymond G. Murphy VA Medical Center (facility) in Albuquerque, New Mexico, to assess allegations regarding deficiencies in the reprocessing and quality control of reusable medical devices (RMDs). The OIG also reviewed Veterans Integrated Service Network (VISN) 22 oversight of the facility Sterile Processing Service (SPS) leaders’ management of RMD reprocessing. The OIG substantiated that high-level disinfection (HLD) documentation was missing for endoscopes used in gastroenterology procedures for four patients. Three patients underwent procedures with anal manometers that lacked HLD documentation. In review of electronic health records, the OIG did not find adverse clinical outcomes for these seven patients. Patients were at risk for infection when RMDs used in patient care lacked HLD documentation. While the OIG could not determine if any RMDs were improperly cleaned prior to use, SPS leaders did not inform the Gastroenterology Service when HLD documentation was missing and precluded facility clinical staff from ensuring risks to patient safety were immediately addressed.Deficiencies in HLD quality assurance processes persisted into March 2023, despite facility leaders’ awareness of HLD findings from a May 2022 VISN audit. Specifically, SPS supervisors did not consistently complete daily quality assurance reviews of HLD documentation. The VISN failed to ensure facility leaders’ completion of action plans related to HLD findings from the VISN audit. The lack of VISN oversight resulted in delayed implementation of sustainable, corrective action, which did not occur for over a year from the original audit findings. The OIG made seven recommendations regarding VISN oversight of SPS audit findings, as well as facility identification, resolution, and quality assurance of HLD documentation and communication of SPS staff roles and responsibilities.

A former Alamo Navajo School Board member was sentenced for stealing Federal funds and receiving kickbacks for an IT services contract.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Finger Lakes Healthcare System, which includes the Bath and Canandaigua VA Medical Centers and multiple outpatient clinics in New York and Pennsylvania. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued three recommendations for improvement in three areas:1. Medical staff privileging• Ongoing Professional Practice Evaluations - equivalent specialized training and similar privileges2. Environment of care• Environment of care inspections3. Mental health• Comprehensive Suicide Risk Evaluation completion

What We Looked At Section 502 of the Federal Aviation Administration (FAA) Reauthorization Act of 2018 mandated that FAA report on the Agency’s progress in implementing Next Generation Air Transportation System (NextGen) programs and that Department of Transportation (DOT) Office of Inspector General (OIG) review the accuracy of FAA’s report. NextGen is an infrastructure effort aimed at modernizing our Nation’s aging air traffic system to provide safer and more efficient air traffic management. As a complex multibillion-dollar, multi-year undertaking, NextGen encompasses multiple programs, procedures, and systems at differing levels of maturity intended to benefit airspace users. Our objectives were to (1) assess FAA’s report on its implementation of NextGen and (2) report the status of OIG’s NextGen recommendations.   What We Found FAA’s Section 502 NextGen report states that all major NextGen systems will be in place by 2025; however, FAA plans to deploy each major system to at least one location by 2025, with full deployment going beyond 2025. The report states that NextGen’s vision has remained constant over time, but our analysis and other stakeholder reports have found that NextGen will be less transformational than originally promised. The report does not include all NextGen expenditures, nor the challenges posed by increasing sustainment and operating costs. The report also projects $100 billion in benefits by 2030, even though FAA had previously acknowledged that this amount was not achievable within that timeframe. In addition, FAA reported that the Agency remains committed to working with industry on NextGen programs, but industry representatives stated that transparency and collaboration with the Agency declined starting in 2018. Finally, of the over 200 NextGen recommendations we made between 2005 to 2022, DOT and FAA have successfully closed all but 3 recommendations. Our Recommendations We made three recommendations for FAA to meet FAA Reauthorization Act of 2018 Section 502 requirements as well as improve communication and transparency on the status of NextGen. FAA concurred with all three of our recommendations and provided acceptable planned action and completion dates.

Semiannual Report to the Congress October 1, 2023 - March 31, 2024

This report was issued in conjunction with the Office of Inspector General for the Railroad Retirement Board's Semiannual Report to the Congress. It was incorporated by reference in the corresponding Semiannual Report which is available at the link below.

The report summarizes the FTC OIG’s activities and accomplishments during the first half of the FY 2024 reporting period.

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

Why We Did This ReportThe U.S. Environmental Protection Agency Office of Inspector General conducted this audit to assess the U.S. Chemical Safety and Hazard Investigation Board’s compliance with the FY 2023–2024 Inspector General Federal Information Security Modernization Act of 2014 Reporting Metrics. We contracted with SB & Company LLC to perform this audit under our direction and oversight. Summary of FindingsSB & Company concluded that the CSB achieved an overall maturity of Level 2, Defined, in fiscal year 2023. This means that the CSB’s policies, procedures, and strategies are formalized and documented but not consistently implemented. While the CSB has improved its overall maturity from the Level 1, Ad Hoc, rating it achieved in fiscal year 2022, SB & Company identified that improvements are still needed in the Incident Response domain within the Respond Function Area. Specifically, SB & Company concluded that the CSB should formally document the results of and the lessons learned during its disaster recovery testing scenarios. Because the CSB only has an informal process for documenting testing results and lessons learned, it did not fully document the results of its disaster recovery testing in a manner that was consistent with the National Institute of Standards and Technology guidelines.

The Office of the Inspector General performed an audit to determine if TVA’s security controls were appropriately configured to protect corporate Wi-Fi networks. Our scope was limited to Wi-Fi networks maintained by TVA’s Technology and Innovation organization. We determined TVA’s security controls related to overall architecture design and implementation were generally configured appropriately to protect corporate Wi Fi networks. However, we identified several areas that should be addressed to further improve the security of corporate Wi-Fi networks. Specifically, we identified:• Internal controls for specific types of attacks were ineffective.• Wireless software and hardware were unsupported by the manufacturer.• Data in transit (electronic transmission of information) was not properly secured.• Primary accounts improperly provided privileged user access.• Service account usage was not in accordance with TVA policy.• Baseline configuration management process was not designed or implemented properly.TVA management agreed with our recommendations.

The VA Office of Inspector General (OIG) conducted a review to evaluate (1) VHA and medical center leaders’ awareness and incorporation of social determinants of health (SDOH) and health-related social needs (HRSN) into inpatient medical unit discharge assessments, planning, policies, and templates; and (2) VHA’s efforts to address SDOH/HRSN with tools and community resources. The OIG determined there were no national policies or procedures that integrated SDOH/HRSN into discharge assessment and planning. Although the OIG found three national reference documents incorporating SDOH/HRSN, these documents were not considered formal guidance and were largely unknown to leaders responsible for discharge assessment and planning within inpatient units. Most medical center staff developed their own discharge policies and procedures addressing SDOH/HRSN, according to an OIG survey. The OIG also identified national templates incorporating SDOH/HRSN for primary care social workers but no template for discharge planning within medical units. VHA leaders recognized the impact of incorporating SDOH/HRSN into a screening tool and launched the Assessing Circumstances and Offering Resources for Needs initiative. The templated screening expands VHA’s capability to collect and capture SDOH/HRSN data in the electronic health record. As of July 2023, only two medical centers used the tool within inpatient medical units. The VHA Office of Health Equity developed health mapping tools to assist staff in identifying and addressing health disparities within their communities; however, few medical center leaders reported using these tools. Almost half of the surveyed leaders did not participate in formal partnerships with community resources to address SDOH. The OIG made five recommendations to the Under Secretary for Health regarding the development of national policy on incorporating SDOH/HRSN into discharge assessment and planning, implementation of a standardized template, evaluation of barriers to assessing SDOH/HRSN at discharge, use of health equity tools, and establishment of community resource partnerships to address SDOH.

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

NASA’s Office of STEM Engagement is making progress managing and coordinating a diverse group of STEM engagement activities across the Agency and continues to operate against a backdrop of uncertainty, with its efforts challenged by a history of budget cuts and proposed elimination of the office.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Central Virginia VA Health Care System, which includes the Richmond VA Medical Center and multiple outpatient clinics in Virginia. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued six recommendations for improvement in three areas:1. Quality, safety, and value• Recommendations and improvement actions for Level 3 peer reviews2. Medical staff privileging• Recommendations for privileges based on professional practice evaluation results3. Environment of care• Temperature- and humidity-controlled storage of reusable medical equipment• Clean and safe storage rooms and patient areas• Medication access limited to approved staff• Availability of feminine hygiene products in restrooms at no cost

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Kansas City VA Medical Center, which includes multiple outpatient clinics in Kansas and Missouri. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued five recommendations for improvement in three areas:1. Leadership and organizational risks• Institutional disclosures for sentinel events2. Environment of care• Environment of care inspections• Electrical receptacles covered with metal plates in the Inpatient Mental Health Unit3. Mental health• Comprehensive Suicide Risk Evaluation completion• Suicide behaviors reported to suicide prevention team

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Eastern Kansas Health Care System, which includes the Colmery-O’Neil VA Medical Center (Topeka), Dwight D. Eisenhower VA Medical Center (Leavenworth), and multiple outpatient clinics in Kansas and Missouri. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued three recommendations for improvement in the Environment of Care area of review:• Walls in good repair• Panic and over-the-door alarm testing in the inpatient mental health unit

This semiannual report summarizes the GPO OIG's activities and accomplishments from October 1, 2023, through March 31, 2024.

The Office of Inspector General (OIG) is issuing this management advisory to present the results of our review of the U.S. Small Business Administration’s (SBA) processing of Coronavirus Disease 2019 (COVID-19) Economic Injury Disaster Loan (EIDL) funds that were returned to the agency by borrowers, banks, or other sources.We found significant delays in the decision process related to returned COVID-19 EIDL funds. The majority of these COVID-19 EIDLs were eventually made available to small business owners, including the original borrowers. However, SBA canceled $3.1 billion of these loans, part of the returned COVID-19 EIDL funds, over several months.SBA also canceled $8.1 billion of undisbursed COVID-19 EIDLs. The agency had not disbursed these loans because of inaccurate applicant information or other reasons, including fraud indicators that had not yet been resolved. The returned and undisbursed COVID-19 EIDLS, totaling $11.2 billion, were canceled after the program closed, so the funds could not be made available to other eligible COVID-19 EIDL borrowers.On June 3, 2023, the Fiscal Responsibility Act of 2023 was enacted, which rescinded unobligated COVID-19 EIDL subsidy balances.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Nebraska-Western Iowa Health Care System, which includes the Grand Island and Omaha VA Medical Centers and multiple outpatient clinics in Nebraska, as well as one outpatient clinic in Iowa. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued two recommendations for improvement in two areas:1. Leadership and organizational risks• Institutional disclosures for sentinel events2. Medical staff privileging• Focused Professional Practice Evaluation results

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Illiana Health Care System, which includes the Danville VA Medical Center and multiple outpatient clinics in Illinois. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued two recommendations for improvement in two areas:1. Medical staff privileging• Service-specific criteria in professional practice evaluations2. Mental health• Comprehensive Suicide Risk Evaluation completion

The Making Advances in Mammography and Medical Options for Veterans Act of 2022 requires the VA Office of Inspector General (OIG) to report on mammography services and breast cancer care provided to veterans. In accordance with this requirement, the OIG conducted an evaluation of mammography services delivered through the outpatient settings of randomly selected VA medical facilities and community providers. The OIG also assessed the performance of VA’s Women’s Oncology System of Excellence and patients’ accessibility to a comprehensive care team, for those diagnosed with breast cancer, as required by the legislation.Because veterans receive mammography services and breast cancer care through VA and community providers, the OIG deployed teams from both its Comprehensive Healthcare Inspection Program (CHIP) and Care in the Community (CITC) program to gather data for this inspection.The OIG issued three recommendations for improvement to the Under Secretary for Health, VISN directors, facility leaders, and National Oncology Program staff to ensure:1. Facility leaders and staff are aware of the services offered to veterans diagnosed with breast cancer through the Women’s Oncology System of Excellence.2. The Under Secretary for Health and National Oncology Program staff offer a range of services for patients diagnosed with breast cancer, including rehabilitative services, through the Women’s Oncology System of Excellence.3. Staff enter data into the local cancer registry database in a timely manner.

The U.S. Postal Service has experienced issues with hiring and retaining employees, particularly among pre-career employees. This is due, in part, to the national unemployment rate overall being low, impacting most employers as they compete for talent. In September 2019, the Postal Service adopted a new centralized hiring process. The goals of this hiring initiative included shortening the time to hire by promptly extending job offers, getting applicants on the payroll, and eliminating interviews for most bargaining positions. The Postal Service measures the time it takes to hire an applicant (time to hire) from the date the job posting closed to the date an employee’s personnel and payroll records are created. Addressing unnecessary or prolonged steps with the goal of streamlining the hiring process will allow the Postal Service to timely hire external applicants.