Federal Reports

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 Louis A. Johnson VA Medical Center, which includes multiple outpatient clinics in West 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. Medical staff privileging• Professional Practice Evaluation reviews and recommendations2. Environment of care• Safe and clean patient care areas• Mental health inpatient unit: • Panic alarm testing • Maintaining a safe environment• Safe environment for mental health patients in the Emergency Department3. Mental health• Comprehensive Suicide Risk Evaluation completion

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review the high usage of community care services for primary care by the VA Loma Linda Healthcare System (system), the impact of that use, and system leaders’ oversight of VA outpatient clinics (clinics).The OIG found that a new company responsible for managing the system’s five non-VHA-operated clinics experienced challenges staffing the clinics, which increased the number of patients assigned to the panels of patient aligned care team providers. As a result, system leaders paused enrollment of new patients at all five non-VHA-operated clinics. The OIG learned that VHA-operated clinics’ inability to absorb the volume of additional patients, and insufficient staffing at the non-VHA-operated clinics contributed to an increase in the system’s use of community care for primary care.Despite adequate staffing levels in the community care department, the system did not meet VHA expectations for the timely processing of consults and scheduling of appointments for care in the community. While there was an increase in patients receiving primary care in the community and delays in processing and scheduling community care consults, the OIG did not identify patients who experienced poor outcomes.The lack of a formal oversight structure of the non-VHA-operated clinics, coupled with staff turnover in leadership positions at the system and the new company, created a vulnerability in the management of primary care services provided at the system’s clinics.The OIG made three recommendations to the System Director related to monitoring primary care staffing and panel sizes, timeliness of community care consult processing, and oversight of all the system’s clinics.

This letter to Congress reports on NCUA OIG's assessment of the NCUA's 2023 compliance under the Payment Integrity Information Act of 2019 (PIIA).

During our unannounced inspection of U.S. Immigration and Customs Enforcement’s (ICE) Golden State Annex (Golden State) in McFarland, California, we found that Golden State complied with ICE’s Performance-Based National Detention Standards 2011 (PBNDS 2011), as revised in December 2016, for use of force, the voluntary work program, access to the law library and legal services, and detainee segregation with one noted exception.

The Small Business Innovation Research (SBIR) program was established under the Small Business Innovation Development Act of 1982 and the Small Business Technology Transfer (STTR) program was established under the Small Business Technology Transfer Act of 1992. These programs encourage domestic small businesses to engage in federal research/research and development (R/R&D), with the potential for commercialization.The Office of Inspector General (OIG) is issuing this management advisory in accordance with requirements in the SBIR and STTR Extension Act of 2022 (the Act) for the U.S. Small Business Administration’s Office of Inspector General (OIG) to conduct an audit related to small business verification of sales and investments. Specifically, we address our ability to determine whether small businesses are verifying sales and investments in the program and how the Act’s requirements were established.We found limited assurance that small businesses verified sales and investments as outlined in the Act. According to SBA, to determine whether small businesses met increased minimum performance standards, it reviewed the business’ self-reported information on the SBIR website. SBA then performed “spot checks,” or limited reviews, of federal sales against two publicly available databases, Federal Procurement Data System (fpds.gov) and USAspending.gov. The combination of SBA spot checking supporting documentation, along with the Act excluding supporting documentation for federal sales and not requiring supporting documentation for investments, was not sufficient to make such a determine whether small businesses subject to increased minimum performance standards verified covered sales and investments.To address concerns with procedures for assessing whether small businesses are verifying sales and investments in the SBIR and STTR programs and to address risks associated with SBA’s reliance on self-certifications, we recommended the agency establish formal procedures for obtaining and reviewing appropriate supporting documentation to ensure sales and investments are accurately reported. The agency agreed with our recommendation.

An Amtrak electrical journeyman based in Miami, Florida, resigned from his position on April 19, 2024, as a result of our investigation. We found that the former employee violated company policies by failing to disclose a felony criminal conviction on his background investigation questionnaire when he was hired in 2014. In addition, he violated company policies by failing to notify the company of his pending deportation order that resulted from his arrest for alien inadmissibility per the Immigration and Nationality Act and his ineligibility to legally work within the United States since 2019.

Providing consistent, high‐quality customer service has been a longstanding strategic priority for Amtrak (the company).1 To that end, the company uses customer satisfaction surveys and other tools to collect data to help identify issues, inform business decisions, and ultimately improve the customer experience.Our objective was to assess how the company uses the data it collects to improve the customer experience. To address our objective and assess the company’s use of these data, we collected and analyzed its outbound communications to customers; 2 late train reports; call center data,3 including hold times; and reports documenting inbound communications from customers. We also interviewed company executives about customer service goals and initiatives, as well as key officials responsible for providing customer service, including those in charge of call centers and those responsible for analyzing customer feedback from surveys. We reviewed commonly accepted management standards for organizations, including standard practices in the call center industry. Additionally, we interviewed management officials who oversee employees providing front‐facing customer service, such as onboard and station staff.

We audited the Federal Housing Administration (FHA), Office of Asset Sales’ U.S. Department of Housing and Urban Development (HUD)-Held Vacant Loan Sales (HVLS) program. The audit objective was to assess the extent to which HUD achieved its mission objectives for a 2022 vacant loan sale. We noted deficiencies in 52 of 53 HUD-approved applications within the reviewed vacant loan sale. These deficiencies occurred in transactions for all seven purchasers that purchased loans in the sales. HUD risks not achieving its mission objectives to promote sales first to mission-driven entities or to encourage mission outcomes by allowing purchasers that submitted deficient applications to purchase distressed FHA loans.

The Cybersecurity and Infrastructure Security Agency’s (CISA) planned activities funded by the Infrastructure Investment and Jobs Act (IIJA) appear related to CISA’s cross-sector role. CISA had only spent a small amount of IIJA funds by the start of fieldwork, limiting our ability to assess how the use of IIJA funding impacted CISA’s cross-sector role. However, CISA has plans for spending all of the $35 million IIJA appropriated funds covered by this report by fiscal year 2026 and had obligated over 45 percent of the funds by the end of FY 2023. CISA’s planned use of these IIJA funds aligns with CISA’s standard financial controls processes and general appropriations requirements.

VA Office of Inspector General (OIG) Vet Center Inspection Program staff evaluated aspects of the quality of care at six randomly selected vet centers throughout Southeast District 2 zone 2: Ft. Lauderdale, Ft. Myers, Gainesville, Lakeland, and Naples in Florida; and San Juan in Puerto Rico. This inspection focused on four review areas: suicide prevention; consultation, supervision, and training; outreach; and environment of care. For the suicide prevention review, the OIG evaluated vet center staff participation on VA medical facility mental health executive councils and High Risk Suicide Flag SharePoint Site client dispositions, which resulted in two recommendations across all six vet centers inspected. In the consultation, supervision, and training review, the OIG identified concerns with external clinical consultation, vet center director monthly chart audits, and completion of select trainings, which resulted in five recommendations across five of the six vet centers inspected. The OIG’s outreach review evaluated outreach plan completion, inclusion of strategic components, and tailoring of outreach activities to cultural background information, which resulted in three recommendations across all six vet centers inspected. During the environment of care review, the OIG evaluated vet centers’ physical environment and general safety, which resulted in seven recommendations across five of the six vet centers inspected.The OIG issued 17 recommendations for improvement.

The VA Office of Inspector General (OIG) Vet Center Inspection Program evaluated aspects of the quality of care delivered at six randomly selected vet centers throughout Southeast district 2 zone 1: Augusta, Marietta, and Savannah in Georgia; Johnson City, Tennessee; Charleston, South Carolina; and Bay County, Florida.This inspection focused on four review areas: suicide prevention; consultation, supervision, and training; outreach; and environment of care. For the suicide prevention review, the OIG evaluated vet center staff participation on VA medical facility mental health executive councils and High Risk Suicide Flag SharePoint Site client dispositions, which resulted in one recommendation across three of the six vet centers inspected. In the consultation, supervision, and training review, the OIG identified concerns with external clinical consultation and completion of select trainings, which resulted in two recommendations across all six vet centers inspected. The OIG’s outreach review evaluated outreach plan completion, inclusion of strategic components, and tailoring of outreach activities to cultural background information, which resulted in three recommendations across all six vet centers inspected. During the environment of care review, the OIG evaluated vet centers’ physical environment and general safety, which resulted in seven recommendations across four of the six vet centers inspected.The OIG issued 13 recommendations for improvement.

The VA Office of Inspector General (OIG) Vet Center Inspection Program evaluated aspects of the quality of care delivered throughout Readjustment Counseling Service (RCS).This inspection evaluated four review areas within Southeast District 2 including leadership stability, morbidity and mortality reviews, high risk suicide flag (HRSF) SharePoint site, and consultation and safety plans.There were no findings in leadership stability. For the morbidity and mortality review, the OIG identified that district leaders did not complete reviews timely for clients who died by suicide based on the active policy at the time of the inspection. Leaders also did not follow established tracking methods and had different processes, as well as unclear criteria, when evaluating the need for morbidity and mortality reviews for clients who had serious suicide attempts. In the HRSF SharePoint Site review, the OIG identified noncompliance with timely documentation by vet center staff in RCSNet and highlighted concerns with the accuracy of information in, and utilization of, the HRSF SharePoint site. Additionally, the OIG found care coordination practices in violation of RCS client confidentiality requirements. In the consultation and safety plan review, the OIG found vet center staff noncompliant with seeking consultation and completing and providing safety plans to clients.The OIG issued six recommendations to the District Director and one to the RCS Chief Officer for improvement.

EAC OIG requested that the Department of Interior OIG investigation allegations that the Executive Director of the EAC improperly obtained a pay increase, failed to report annual leave on his time and attendance records, and expensed unapproved training courses.

The Tennessee Valley Authority’s (TVA) Executive Policy 37.000, Real Property, states that a strategic guiding principle for management of TVA’s real-property portfolio is to “manage real property from an enterprise perspective and invest in core assets to improve condition, safety, and utilization.” TVA’s real property database lists 3,247 active buildings. Additionally, TVA has 75 bridges that it inspects on a routine basis. Due to the importance of proper maintenance to the safe, efficient, and effective operation of assets, we performed an evaluation to determine if TVA has (1) assessed its facilities for safety risks and (2) developed plans or completed actions to address the identified risks.We found all buildings and infrastructure have not been formally assessed to identify safety risks. Specifically for fiscal years 2022–2023, we found only 111 of 3,247 (approximately 3 percent) active buildings had condition assessments and 376 (approximately 12 percent) had roof inspections. All 75 bridges had required inspections. Additionally, actions were not taken or planned for all identified risks. Building and infrastructure safety risks could go unidentified without performing formal assessments at all facilities and risks could increase if actions are not taken to address assets in poor and failed condition.

Objective: To determine whether the Social Security Administration properly updated payment records to prevent improper payments when individuals changed their name because of marriage.

The comments are in response to Impact of Undetected Marriages on Social Security Administration Payments, 012317, that was submitted by The National Association for Public Health Statistics and Information Systems on May 20, 2024, pursuant to Pub. L. No. 117- 263, § 5274.

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 Jesse Brown VA Medical Center, which includes multiple outpatient clinics in Illinois and Indiana. 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 eight recommendations for improvement in three areas:1. Quality, safety, and value• Peer review committee improvement actions 2. Environment of care• Environment of care inspections• Medical equipment maintenance per manufacturers’ recommendations• Medication access by approved individuals using the pneumatic tube system• Clean and orderly patient areas• Mental health inpatient unit: • Over-the-door alarm testing • Sally port entrance 3. Mental health• Comprehensive Suicide Risk Evaluation completion

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the G.V. (Sonny) Montgomery VA Medical Center and multiple outpatient clinics in Mississippi. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (focusing on suicide prevention initiatives)The OIG issued one recommendation for improvement in the Mental Health area of review regarding ensuring the Suicide Prevention Coordinator conducts at least five outreach activities each month.

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 Edward Hines, Jr. VA Hospital, which includes 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 five recommendations for improvement in three areas:1. Medical staff privileging• VISN oversight of privileging process2. Environment of care• Environment of care inspections3. Mental health• Suicide prevention outreach activities• Monthly reporting of suicide-related events• Comprehensive Suicide Risk Evaluation completion

Why We Did This ReportThe U.S. Environmental Protection Agency Office of Inspector General conducted this evaluation to determine whether the EPA adhered to federal laws, regulations, and EPA guidance pertaining to community engagement standards and practices at the Findett Corp. Superfund Site. Contamination of the groundwater at the Findett Corp. Superfund Site and the EPA’s response to that contamination has long been an issue of concern in the St. Charles, Missouri community. Summary of FindingsEPA Region 7 did not effectively engage with the community affected by the Findett Corp. Superfund Site. The region’s public-facing documents and presentations were too technical for the public to easily understand. The region also distributed information in newspapers with low circulation to reduce costs. As a result, members of the St. Charles, Missouri community, which is near the Findett Corp. Superfund Site, were unaware of opportunities for public participation and confused about the cleanup process. Further, after the discovery of an additional source of contamination, Region 7 did not promptly develop a new or updated community involvement plan for St. Charles. In addition, Region 7 did not effectively facilitate community involvement by providing timely technical assistance or other tools to the St. Charles community. It also did not use available mediation services in a timely manner to mitigate the contentious relationships among the Findett Corp. Superfund Site stakeholders, resulting in cleanup delays and community mistrust in the EPA.

During our unannounced inspection of Krome North Service Processing Center (Krome) in Miami, Florida, we found that Krome’s staff complied with Performance-Based National Detention Standards 2011, as revised in December 2016, for classification, voluntary work program, recreation, facility conditions, and non-medical grievances. However, they did not comply with use of force standards for several incidents.

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 Tuscaloosa VA Medical Center in Alabama. 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• Ongoing Professional Practice Evaluation activities2. Environment of care• Safe and clean patient care areas

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 Boise VA Medical Center and multiple outpatient clinics in Idaho and Oregon. 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 four recommendations for improvement in two areas:1. Environment of care• Inpatient Psychiatry Unit panic and over-the-door alarm testing2. Mental health• Monthly reporting of suicide-related events to mental health leaders and quality management staff• Comprehensive Suicide Risk Evaluation completion

UI was already a strained system, but the pandemic exacerbated existing challenges and created new ones which lead to massive fraud. We sampled 45 cases and learned about the schemes and methods fraudsters used. Find out what can be done to improve UI for the future. Read our report to find out more.

An Amtrak customer service representative based in Miami, Florida, signed a civil settlement agreement on April 16, 2024, with the U.S. Attorney’s Office, Southern District of Florida. The employee agreed to pay a total of $25,400 to the Small Business Administration (SBA), which includes damages, fees and a fine. Our investigation found that the employee submitted a Paycheck Protection Program (PPP) loan application to the SBA that included false statements and information. As a result, the employee received a PPP loan in the amount of $20,810 to which she was not entitled.

The Help America Vote Act of 2002 (HAVA) required states to establish an interest-earning election fund, in to which grant funds are deposited and maintained. OIG, through the independent public accounting firm of McBride, Lock & Associates, LLC, audited compliance with these requirements. The audit included open Election Security and Section 251 grants at 34 states and territories, as of September 30, 2022.

Our office remains committed to investigating and prosecuting fraud cases, and identifying opportunities to improve related internal controls. Ultimately, the company is responsible for preventing, detecting, and reporting fraud and instituting the controls necessary to do so. To help inform the company’s efforts to combat this persistent threat, we issued a report in May 2023 that identified four fraud risk areas facing the company: contracts and procurements, health care, employee wrongdoing, and cybercrime. That report highlighted indicators of potential fraud as well as mitigation activities the company could undertake to address these risks. This follow‐on report provides deeper insights on a specific fraud risk area—contracts and procurements—for the company’s consideration as it continues its unprecedented expansion in mission and federal funding. Accordingly, the purpose of this report is to share insights from industry practices and our own observations about collecting and analyzing data to monitor for and detect contract and procurement fraud.

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

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 Bay Pines VA Healthcare System, which includes the C.W. Bill Young VA Medical Center and eight outpatient clinics in Florida. 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 eight recommendations for improvement in four areas:1. Leadership and organizational risks• Institutional disclosures for sentinel events2. Quality, safety, and value• Root cause analysis for patient safety events3. Environment of care• Clean and orderly patient care areas• Furnishings and walls in good repair• Solid bottom shelves in storage areas• Medical equipment inspection, testing, and maintenance • Mental health inpatient unit panic alarm testing4. Mental health• Monthly reporting of suicide events to quality management staff

Why We Did This Report We conducted this evaluation to determine whether the EPA’s oversight and implementation of institutional controls will support effective use of Infrastructure Investment and Jobs Act, or IIJA, funding at the American Creosote Works Inc. (Pensacola Plant) Superfund site in Pensacola, Florida. The EPA allocated approximately $40 million in IIJA funds for the final remediation of this site. Summary of Findings The institutional controls that the EPA has established at the American Creosote Works Inc. (Pensacola Plant) Superfund site in Pensacola, Florida, related to contaminated groundwater and soil are not sufficient to prevent potential exposure to contamination. For contaminated groundwater, the institutional control that the EPA relied on did not prevent well drilling or require groundwater well plugging and abandonment. The EPA also did not plan to secure permission from private property owners to plug and abandon any wells that the EPA encountered during remediation, potentially wasting at least $1.3 million in remediation funds from the IIJA. For contaminated soil, the EPA did not implement institutional controls to prevent potential exposure to off-facility parcel contamination or to inform the wider public of the extent of contamination. Further, the EPA does not plan to implement institutional controls on these parcels after remediation to prevent the disturbance of unremediated soil, potentially wasting $5.4 million in IIJA funds allocated for the parcels’ remediation.

The U.S. Postal Service is working to leverage technology to improve visibility and tracking of mail and packages in near real time for the Postal Service, its customers, and mailers. As it moves through the surface transportation network, mail and packages are assigned to a container equipped with barcodes. Surface Visibility provides real-time scanning of barcodes and reports mail movement from origin to final destination allowing the Postal Service to measure its performance. Oversight of scanning processes performed by logistics and processing employees helps ensure all scans are performed accurately. Scanning accuracy is critical to achieving real-time visibility and providing the Postal Service with a competitive market advantage and long-term stability within the mailing industry.

The Postal Service deployed a major change to operations within the Richmond, VA, area on October 28, 2023, when it implemented its Local Transportation Optimization initiative. The initiative is designed to reduce the overall number of transportation trips to and from select Post Offices and increase the amount of mail transported on each trip. In this new initiative, the Postal Service will no longer transport mail collected at select delivery units to the Richmond Regional Processing and Distribution Center (RPDC) the same day it is collected. Rather, the mail will remain at the unit until the next day, delaying its entry into sorting operations.

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

The U.S. Postal Service’s mission is to provide timely, reliable, secure, and affordable mail and package delivery to more than 160 million residential and business addresses across the country. The U.S. Postal Service Office of Inspector General (OIG) reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission.This interim report presents the results of our self-initiated audit of delivery operations and property conditions at the Ward Place Carrier Annex in Washington, D.C. The Ward Place Carrier Annex is in the Maryland District of the Atlantic Area and services ZIP Codes 20006, 20036, 20037, and 20052. These ZIP Codes serve 26,780 people, which are considered living in urban communities.

The U.S. Postal Service’s mission is to provide timely, reliable, secure, and affordable mail and package delivery to more than 160 million residential and business addresses across the country. The U.S. Postal Service Office of Inspector General (OIG) reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission.This interim report presents the results of our self-initiated audit of delivery operations and property conditions at the Lammond Riggs Station in Washington, D.C. The Lammond Riggs Station is in the Maryland District of the Atlantic Area and services ZIP Code 20011. This ZIP Code serve 66,425 people in an urban area.

The U.S. Postal Service needs effective and productive operations to fulfill its mission of providing prompt, reliable, and affordable mail service to the American public. It has a vast transportation network that moves mail and equipment among approximately 330 processing facilities and 31,100 post offices, stations, and branches. The Postal Service is transforming its processing and logistics networks to become scalable, reliable, visible, efficient, automated, and digitally integrated. This includes modernizing operating plans and aligning the workforce; leveraging emerging technologies to provide world-class visibility and tracking of mail packages in near real time; and optimizing the surface and air transportation network. The U.S. Postal Service Office of Inspector General (OIG) reviews the efficiency of mail processing operations at facilities across the country and provides management with timely feedback to further the Postal Service’s mission.This report presents the results of our self-initiated audit of the efficiency of operations at the Curseen- Morris Processing and Distribution Center (P&DC) in Washington, DC. We judgmentally selected this P&DC based on a review of first and last mile failures; workhours; scanning compliance; and late, canceled, and extra trips. The Curseen-Morris P&DC is in the Chesapeake Division and processes letters, flats, and packages. The Curseen-Morris P&DC services multiple 3-digit ZIP Codes in urban communities.

The U.S. Postal Service’s mission is to provide timely, reliable, secure, and affordable mail and package delivery to more than 160 million residential and business addresses across the country. The U.S. Postal Service Office of Inspector General (OIG) reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission.This interim report presents the results of our self‑initiated audit of delivery operations and property conditions at the Brookland Station in Washington, D.C. The Brookland Station is in the Maryland District of the Atlantic Area and services ZIP Codes 20017 and 20064. These ZIP Codes serve 21,062 people in an urban area.

Why This Report Was DoneThe Office of the Special Inspector General for Afghanistan (SIGAR) conducted a required external peer review of the EPA OIG’s compliance with the Council of Inspectors General on Integrity and Efficiency Quality Standards for Inspection and Evaluation, December 2020 (Blue Book). Summary of FindingsSIGAR determined that the EPA OIG’s policies and procedures generally were consistent with the Blue Book standards addressed in the external peer review.

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 Martinsburg VA Medical Center and multiple outpatient clinics in Maryland, Virginia, and West 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 three recommendations for improvement in two areas:1. Medical staff privileging• Ongoing Professional Practice Evaluations2. Environment of care• Expired/outdated inventory in clean and sterile stockrooms

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 Bedford Healthcare System, which includes the Edith Nourse Rogers Memorial Veterans’ Hospital in Bedford and three outpatient clinics in Massachusetts. 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 four areas:1. Leadership and organizational risks• Institutional disclosures for applicable sentinel events2. Quality, safety, and value• Root cause analysis for patient safety events3. Environment of care• Patient care areas clean and free from undue wear• Inpatient mental health unit over-the-door alarm testing4. Mental health• Comprehensive Suicide Risk Evaluation completion

Our objective for this alert was to determine facility opening procedures and mail conditions at the South Houston Local Processing Center.Each year, increased mail volume during the Postal Service’s peak mailing season — Thanksgiving through New Year’s Eve1 — significantly strains the Postal Service’s processing and distribution network. The Postal Service opens peak season annexes to temporarily help with increased package volume at select processing facilities. As part of our peak season audit, we assessed the Postal Service’s acquisition and use of these peak season annexes. One such annex we identified was the South Houston Local Processing Center (LPC), which opened on November 18, 2023, and was associated with the North Houston Processing and Distribution Center (P&DC).

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 Salt Lake City Health Care System, which includes the George E. Wahlen VA Medical Center in Salt Lake City and multiple outpatient clinics in Idaho, Nevada, and Utah. 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. Medical staff privileging• Focused Professional Practice Evaluation results2. Environment of care• Environment of care inspections• Inpatient Psychiatry Unit: • Panic and over-the-door alarm testing • Maintaining a safe environment3. Mental health• Comprehensive Suicide Risk Evaluation completion

The Office of the Inspector General performed an audit to determine the effectiveness of the Tennessee Valley Authority’s (TVA) business application retirement process. Our scope included application retirement requests in TVA’s ticketing system as of December 6, 2023. We determined TVA's business application retirement process was ineffective. Specifically, the application retirement process did not (1) have clear ownership and accountability, (2) have effective controls to prevent duplicate requests and incomplete data, and (3) align with best practices. As a result of the ineffective process, only one application had been retired since September 28, 2022, and 631 business application retirement requests were between 1 and 434 days outstanding. TVA management agreed with our recommendations.

The AmeriCorps Office of Inspector General (AmeriCorps OIG) investigated allegations that a contractor submitted invoices under its Blanket Purchase Agreement (BPA) with AmeriCorps that included unallowable and/or unsupported costs. AmeriCorps OIG’s investigation foundevidence that the contractor billed AmeriCorps $167,714.42 in unallowable charges in violation of acquisition regulations and policies, including, Federal Acquisition Regulation (FAR) 31.201-2(d) Determining allowability, FAR 5.503(c) Proof of advertising, and AmeriCorps Acquisition Policy5.1304(c) Invoice Certification, and the contractor lacked supporting documentation required by the BPA. In addition, the investigation found that the contractor both overbilled and underbilled AmeriCorps, the net of which favored the contractor.

The AmeriCorps Office of Inspector General (AmeriCorps OIG) investigated allegations that the former Executive Director (ED) of the Volunteer and Community Service Commission of Puerto Rico (Commission) attempted to use AmeriCorps funds to award a sole-source contract to a close friend, required prayers before AmeriCorps events, and requested subgrantees allow AmeriCorps members to perform service outside the scope of their grant. AmeriCorps OIG’s investigation confirmed the allegations regarding the sole-source contract and that the former ED required a prayer before the start of multiple AmeriCorps events. The investigation also found that the Commission was not reimbursing its subgrantees in a timely manner and that a former Commission Program Coordinator was improperly paid $2,825.

The Office of Inspector General (OIG) is issuing this inspection report to present the results of our assessment of the U.S. Small Business Administration’s (SBA) initial response to Hurricanes Fiona and Ian, including staffing adequacy, loan application volume, and timeliness of disaster loan approvals.We found SBA’s initial response to Hurricanes Fiona and Ian was timely and effective. The agency established a field presence within 3 business days and opened a Business Recovery Center within 10 business days for both hurricanes, meeting its strategic goal. Additionally, SBA successfully addressed initial staffing concerns and maintained adequate staffing levels throughout its response to both hurricanes.The agency reacted to anticipated resource needs by implementing a hiring initiative and providing advanced specialty training. These actions addressed a projected staffing shortfall, including the need for bilingual staff who were brought in to assist from other SBA offices.

The Veterans Community Care Program allows the Veterans Health Administration (VHA) to purchase care for veterans through Community Care Network (CCN) contracts or veterans care agreements. While the CCN groups VA medical facilities into regions managed by third-party administrators (TPAs), the Office of Integrated Veteran Care (IVC) is responsible for overseeing execution of CCN contracts.The VA Office of Inspector General (OIG) conducted this audit to determine whether VHA provided effective oversight of its TPAs and VA medical facilities. The review team evaluated IVC’s oversight of the TPAs’ adherence to four contract requirements designed to ensure facilities have enough community providers to administer care within the timeliness and drive-time standards established in the contracts. The OIG found that IVC did not hold TPAs accountable for implementing these contract requirements, causing staff to struggle to convince TPAs to add community providers to their networks at the eight facilities the audit team visited.While IVC provided proof of TPA discussing community care needs with three facilities, similar evidence for other facilities was not provided. Furthermore, IVC did not conduct any analyses of facilities’ network adequacy needs to help TPAs build provider networks and did not ensure TPAs maintained provider networks that were accepting VA patients. IVC also did not position itself to defend facilities’ needs for additional community care providers.The OIG recommended to the undersecretary for health that the IVC holds future TPAs accountable for operational readiness and provider network adequacy; develop processes to update and maintain CCN data, challenges, and needs; conduct Advanced Medical Cost Management Solution training on evaluating network adequacy through the tool for community care staff; and not only develop its own network adequacy performance reports but also evaluate TPAs’ reports, holding them accountable for resolving identified issues.

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 Syracuse VA Medical Center, which includes multiple outpatient clinics in New York. 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 12 recommendations for improvement in four areas:1. Quality, safety, and value• Peer review committee • Peer review level reassignments • Review of data by medical executive committee2. Medical staff privileging• Ongoing Professional Practice Evaluation completion• Specialty-specific criteria for professional practice evaluations3. Environment of care• Environment of care inspections• Safe and clean patient care areas• Mental health inpatient unit: • Panic and over-the-door alarm testing • Maintaining a safe environment • Ceiling tiles checked semiannually• Biomedical staff inspection and testing of medical equipment• VISN oversight of biomedical program4. Mental health• Comprehensive Suicide Risk Evaluation completion

The VA Office of Inspector General (OIG) conducted a focused national review to assess concerns with Veterans Health Administration’s (VHA’s) process to identify providers who have been removed from VA employment due to violations of policy “relating to the delivery of safe and appropriate care” and exclude those providers from the VA Community Care Program (VCCP), as required by the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 (MISSION Act).The OIG found that VHA’s process failed to identify all healthcare providers removed from VA employment. The OIG determined that VHA’s process also failed to accurately identify personnel actions that indicate healthcare providers were removed for violating policies relating to the delivery of safe and appropriate care. Furthermore, VHA did not consider whether a provider was removed for reasons related to delivery of safe and appropriate care. These process failures resulted in both inclusion of ineligible providers and exclusion of eligible providers from the VCCP.Deficiencies in VHA’s process to identify providers who should be excluded precluded a complete evaluation of the exclusion process. As a result, this inspection focused on the initial steps to identify ineligible providers for exclusion. The OIG remains concerned about VHA’s inability to exclude and prevent ineligible healthcare providers from delivering care to veterans through the VCCP. The OIG issued this brief report to provide timely oversight and share concerns to facilitate VA action.The OIG made two recommendations to the Under Secretary for Health related to the criteria and processes used to identify and exclude ineligible healthcare providers from the VCCP, and to review previous personnel actions to determine whether the reason(s) for those removals were for violation of policy related to the delivery of safe and appropriate care.

Jason Chan and Jamar Rogers, both California residents, were sentenced on April 8, 2024, and March 27, 2024, respectively, in the U.S. District Court, Eastern District of California, for Wire Fraud and Aiding and Abetting. Chan was sentenced to 3 years’ probation and Rogers was sentenced to 12 months and one day in prison followed by 3 years’ probation. The men were also ordered to pay a total of $43,518.32 in joint restitution.Our investigation found that Rogers purchased Amtrak tickets with stolen credit cards and exchanged the tickets for vouchers that he then advertised for sale. Chan purchased the vouchers from Rogers at a discounted rate, used them to buy new tickets, cancelled those tickets to obtain new vouchers, and then offered Amtrak tickets for sale at a discount. As a result of the scheme, Rogers and Chan caused Amtrak to issue approximately $38,000 in ticket vouchers and caused losses of over $45,000 to Amtrak, card-issuing banks, and card holders.

Why We Did This ReportThe U.S. Environmental Protection Agency Office of Inspector General conducted this audit to determine to what extent (1) the EPA is providing guidance and reviewing states’ clean water state revolving fund intended use plans, or IUPs, to ensure that the plans, as they relate to climate change resiliency, meet the intent of the presidential policy directive to strengthen and maintain secure, functioning, and resilient critical infrastructure; and (2) the states, in their clean water state revolving fund planning, are considering climate change resiliency to safeguard federal investments, including funding provided by the Infrastructure Investment and Jobs Act. Summary of FindingsThe EPA prioritized climate adaptation and provided guidance to states during the development of their annual clean water state revolving fund intended use plans, or CWSRF IUPs. Despite these EPA actions, the EPA had limited success in getting states to include climate adaptation or related resilience efforts, such as those addressing natural disasters, in their IUPs. Just 13 states included this in their 2020 IUPs. After passage of the Infrastructure Investment and Jobs Act and after the federal government established its climate adaptation priority in 2021, the number increased to 25 states for the 2022 IUPs, an increase of 12 states over two years. In addition, only 13 states included climate adaptation or related resilience efforts as part of the project prioritization criteria documented in their 2022 IUPs. In federal fiscal year 2022, the EPA awarded $1.2 billion out of the available $3 billion CWSRF funds—which included annual and Infrastructure Investment and Jobs Act appropriations—to states that did not include resilience in their IUPs. Funded projects may become inoperable if the impacts of climate change are not considered.