Federal Reports

A primary goal of the National Telecommunications and Information Administration (NTIA) is to expand U.S. broadband Internet access and adoption. To help meet this goal, NTIA administers six broadband programs, including the Tribal Broadband Connectivity Program (TBCP). Our objective for this audit was to determine whether NTIA properly disbursed the federal funds provided for the TBCP. We reviewed awards made under NTIA’s first round of TBCP funding. Between September 1, 2021, and December 31, 2022, NTIA awarded about $1.73 billion. Overall, we found that NTIA did not adequately design and implement the award process to ensure that TBCP funds were awarded only for eligible proposed service areas. For the awards we reviewed, we determined that NTIA did not (1) independently verify that grant recipients needed funding for broadband infrastructure deployment and (2) consistently document its process for reviewing TBCP applications. As a result of these issues, the TBCP’s fraud risk is higher, and NTIA could not provide assurance that TBCP awards were made to tribes that did not have access to broadband and actually needed the funds.

We found that the Government email address of a former BIE employee was spoofed to change the employee’s direct deposit information.

On February 29, 2024, an Amtrak sheet metal worker based in Miami, Florida, signed a civil settlement agreement with the U.S. Attorney’s Office, Southern District of Florida, to pay a total of $18,750, including $16,537.34 in restitution. Our investigation found that the employee applied for and received two fraudulent Paycheck Protection Program (PPP) Loans for an alleged automotive repair business in the amount of $5,746 each. The employee claimed to have made over $25,000 in gross revenues from his business that qualified him for the loan. We interviewed the employee who admitted that the business had no reported income in 2019 or 2020 and that the PPP loan applications were false.

On March 11, 2024, an Amtrak customer service representative based in Miami, Florida, signed a civil settlement agreement with the U.S. Attorney’s Office, Southern District of Florida, and agreed to pay a total of $15,000, including $10,000 in restitution. Our investigation found that the employee falsified an application for a COVID-19 Economic Injury Disaster Loan (EIDL), and he received a EIDL loan advance in the amount of $10,000 from the Small Business Administration. While the employee claimed the loan was for a t-shirt making business, when we interviewed the employee, he admitted that the loan application was fraudulent.

The VA Office of Inspector General (OIG) evaluated the Veterans Health Administration’s (VHA’s) attention deficit hyperactivity disorder (ADHD) diagnostic assessment practices, stimulant medication (stimulant) prescribing practices, training expectations, and policies. A diagnosis of ADHD must be established by a qualified provider based on diagnostic criteria. Stimulants are approved to treat ADHD and classified as controlled substances because of the risk for abuse. ADHD diagnoses and stimulant prescribing to treat adult ADHD have increased in recent decades.Prescribers insufficiently documented support for ADHD diagnoses corresponding to new stimulant prescriptions. Additionally, most electronic health records included documentation of a diagnostic interview, while fewer documented other assessment methods.The OIG found that prescribers inadequately assessed the risks and contraindications of stimulants prescribing, such as cardiac risks and urine toxicology testing. Prescribers assessed risks through the prescription drug monitoring program queries consistent with VHA expectations of 75 percent for new and 95 percent for active controlled substance prescriptions. The OIG would expect the query goal for new controlled substance prescriptions to meet or exceed the goal established for active prescriptions.The OIG found deficiencies in prescribers’ reported ADHD diagnostic and stimulant-prescribing training and knowledge. Among survey respondents, 13 percent of mental health and 65 percent of primary care respondents reported being somewhat or not knowledgeable about prescribing stimulant medication for the treatment of ADHD. The OIG determined that VHA has no established policies or clinical practice guidance related to ADHD assessment, diagnosis, and treatment. The lack of ADHD-related policies may contribute to limited awareness of clinical expectations and resources.The OIG made five recommendations to the Under Secretary for Health related to diagnostic assessment, assessment of risks and contraindications, prescription drug monitoring program goals, the referral process for complex mental health conditions, and ADHD policy and clinical practice guidance.

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 Northern Indiana Health Care System, which includes the Fort Wayne and Marion VA Medical Centers, multiple outpatient clinics in Indiana, and an outpatient clinic in Ohio. 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 10 recommendations for improvement in three areas:1. Medical staff privileging• Focused Professional Practice Evaluation time frames• Privileges based on Ongoing Professional Practice Evaluation activities2. Environment of care• Corrugated containers• Clean and free of dust and soiling• Clean patient care areas• Expired commercial products• Clean and dirty equipment storage• Walls allow thorough cleaning• Inpatient Mental Health Unit over-the-door alarm testing3. Mental health• Comprehensive Suicide Risk Evaluation completion

We contracted with the Institute for Defense Analyses (IDA), an independent firm, to perform this evaluation. Our office oversaw the evaluation’s progress to ensure that IDA performed it in accordance with the Council of the Inspectors General on Integrity and Efficiency’s Quality Standards for Inspection and Evaluation (December 2020) and contract terms. However, IDA is solely responsible for the attached report and the conclusions expressed in it. The evaluation objective was to determine whether NOAA Fisheries grantees and subrecipients accounted for and expended pandemic relief funds provided under the Coronavirus Aid, Relief, and Economic Security Act and subsequent funding authorizations in accordance with federal laws and regulations. IDA found that (1) a dashboard helped NOAA monitor execution progress of most funding; however, NOAA had little to no oversight of CAA funding for the Tribes; (2) some states and territories employed more rigorous processes and internal controls to identify potential incorrect payments; and (3) some states, Tribes, and territories were slower to distribute funds and less effective at targeting fishery participants with greater than 35 percent loss.

What We Looked AtIn 2023, we conducted a quality control review (QCR) of Crosslin PLLC’s single audit of the Metropolitan Transit Authority (MTA) of Nashville, TN, for the fiscal year that ended June 30, 2022 (OIG Report Number QC2023046, dated September 25, 2023). In that QCR, we found that Crosslin’s audit work did not comply with the requirements of the Single Audit Act, the Uniform Guidance, and the U.S. Department of Transportation’s (DOT) major program. Specifically, Crosslin found a noncompliance that it decided not to report. Auditing guidelines require auditors to include in their work papers reasonable bases for not reporting noncompliance, but we found that Crosslin’s basis was not reasonable. As a result, Crosslin had to either include in its work papers a reasonable basis for not reporting the noncompliance or reissue its report on the single audit. On February 7, 2024, Crosslin reissued its single audit report that included MTA’s Procurement and Suspension and Debarment noncompliance, and questioned costs totaling approximately $68,000 that resulted from the noncompliance.We performed a follow up QCR on Crosslin’s revised single audit of MTA. Our objectives were to determine whether (1) the revised audit work complied with the Single Audit Act of 1984, as amended, the Office of Management and Budget’s Uniform Guidance, and the extent to which we could rely on the auditors’ revised work on DOT’s major program and (2) MTA’s revised reporting package complied with the reporting requirements of the Uniform Guidance.What We FoundCrosslin complied with the requirements of the Single Audit Act, the Uniform Guidance, and DOT’s major program. We found nothing to indicate that Crosslin’s opinion on DOT’s major program was inappropriate or unreliable. In addition, we did not identify deficiencies in MTA’s reporting package that required correction and resubmission. Accordingly, we assigned Crosslin a rating of pass.

Objective: To determine the risk of illegal, improper, and erroneous purchases made through the Social Security Administration’s charge card programs.

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 Hurricane Idalia, including staffing, loan application volume, and timeliness of disaster loan approvals.We found SBA’s initial response to Hurricane Idalia 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 Florida and Georgia. Additionally, SBA was responsive to the increase in loan applications that resulted from the hurricane.Residents reported positive experiences with the customer service received at the recovery centers.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the Oscar G. Johnson VA Medical Center, which includes multiple outpatient clinics in Michigan and Wisconsin. 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. Leadership and organizational risks• Identification of sentinel events for home oxygen fires• Veterans Integrated Service Network tracking and monitoring of root cause analyses2. Mental health• Completion of Comprehensive Suicide Risk Evaluations

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 Maine Healthcare System, which includes the Togus VA Medical Center and multiple outpatient clinics in Maine. 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 all five areas:1. Leadership and organizational risks• Sentinel events and institutional disclosures2. Quality, safety, and value• Root cause analysis for patient safety events3. Medical staff privileging• Ongoing Professional Practice Evaluation data• Focused Professional Practice Evaluation reporting• VISN oversight of credentialing and privileging processes4. Environment of care• Environment of care inspections• Panic and over-the-door alarm testing• Maintaining a safe environment• Hazard warning signs• Safe and clean patient care areas5. Mental health• Comprehensive Suicide Risk Evaluation completion

An Amtrak Assistant Passenger Conductor based in Philadelphia violated company policy by altering her company paystub for July 2022 and submitting it to a financial institution for the purpose of securing a mortgage loan. On April 2, 2024, the employee received a final warning after she waived her right to a hearing and accepted responsibility for the charges.

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 the Maui wildfire disaster, including staffing, loan application volume, and timeliness of disaster loan approvals. We found SBA’s initial response to the Maui wildfire disaster was timely and effective. On the day of the Presidential disaster declaration, SBA placed personnel in locations throughout Hawaii to support businesses and residents impacted by the wildfires. Within 6 days of the Presidential disaster declaration, SBA representatives were stationed at the first Disaster Recovery Center and Business Recovery Center on Maui and provided timely disaster loan assistance to survivors.While SBA successfully navigated disaster assistance challenges such as increased customer service calls and loan applications, we identified an opportunity for improvement that may be beneficial in future disasters – specifically, a standard way to quickly adjust staffing levels as the volume of activity shifts at each center. We suggested SBA management routinely conduct a staffing needs assessment throughout a disaster to ensure recovery centers are adequately staffed based on customer demand and workload.SBA management disagreed with our suggestion and stated that SBA regularly examines staffing levels and will continue to do so as it navigates future disaster assistance challenges. Management further stated that a new system is not needed because of the existing system that is in place.

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 Central Iowa Health Care System, which includes the Des Moines VA Medical Center and multiple outpatient clinics 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 three recommendations for improvement in two areas:1. Medical staff privileging• Ongoing Professional Practice Evaluations by providers with equivalent specialized training and similar privileges• Ongoing Professional Practice Evaluation activities2. Mental health• Comprehensive Suicide Risk Evaluation completion

As required by the Inspector General Act of 1978 (as amended), this Semiannual Report summarizes the activities of the Department of Transportation Office of Inspector General for the preceding 6-month period.

OIG reviewed the Forest Service to determine the likely level of sophistication an attacker would need to compromise selected USDA systems or data. OIG made one recommendation to FS and reached management decision on it.

2024 Peer Review Results of the Office of the Inspector General for the U.S. Nuclear Regulatory Commission and Defense Nuclear Facilities Safety Board, Investigations Division

What We Looked AtThe Federal Highway Administration (FHWA) oversees approximately $350 billion appropriated for FHWA programs and activities by the Infrastructure Investment and Jobs Act (IIJA) of 2021. To ensure proper planning and budgeting, each State Department of Transportation (State DOT) must submit a Statewide Transportation Improvement Program (STIP) that includes all projects planned for implementation over a period of at least 4 years. Given the amount of funding under IIJA, we initiated this audit. Our objectives were to assess whether FHWA (1) issued guidance to support States’ STIP planning, (2) provided timely technical assistance to support States’ STIP development, and (3) provided continued monitoring and oversight of the Division Offices’ updated STIP standard operating procedures.What We FoundFHWA has not finalized all planned guidance to help State DOTs administer IIJA programs and develop STIPs. As of November 2023, the Agency was working on 4 of 22 guidance areas related to IIJA. Federal control standards call for agencies to communicate the information necessary to achieve objectives. FHWA’s lack of complete guidance may increase the risk that IIJA funding will not achieve intended benefits and cause increased project costs. Furthermore, FHWA’s delays in technical assistance to State DOTs on IIJA-funded projects can impact States’ administrative efficiency. It took the Agency up to 5 months to fulfill two requests from one State DOT. Such delays in other States may increase the risk of adverse effects on STIP development for IIJA-funded projects. FHWA has provided guidance to Division Offices on standard operating procedures (SOPs) for STIP reviews and approvals but lacks policy on reviews of updated SOPs. This lack of policy can increase the Agency’s oversight risks.Our RecommendationsWe made three recommendations to help FHWA improve oversight of STIPs that include IIJA-funded projects. FHWA concurred with one recommendation and partially concurred with the other two. We consider all three recommendations resolved but open pending completion of planned actions.

The Office of Inspector General (OIG) is issuing this management advisory to bring to your attention concerns regarding how the U.S. Small Business Administration (SBA) manages its Information Technology (IT) systems. OIG has reported on significant IT investment internal control issues over the last 6 years, which the agency has also identified without taking meaningful action to resolve. These issues include:• The governance board did not meet as required to oversee IT investments,• Performance against established baselines was not reported,• Critical system capabilities were missing, and• Corrective actions were not taken for underperforming investments.These issues require immediate attention as a strong IT governance framework enables the agency to achieve mission goals and objectives while safeguarding taxpayer funds. An efficient IT framework will help the agency better deliver SBA programs and services, particularly in times of crisis.SBA management agreed with five recommendations and partially agreed with one. To address these recommendations, the agency is planning to implement corrective measures, including updating applicable policies, procedures, and evidentiary documentation.

This inspection concluded that the FCC has effectively implemented five of the nine privacy requirements in Title 42 U.S.C. § 2000ee-2. Four of the nine requirements had not been effectively implemented for the period covered by our review. The final report includes four findings and offers seven recommendations intended to improve the Commission’s privacy and data protection policies and procedures

To see our report, click on the link below

The audit of AmeriCorps grants awarded to the Puerto Rico Commission for Volunteerism and Community Service (the Commission) and two of its subgrantees found that the Commission and subgrantees did not comply with Federal regulations and AmeriCorps grant terms and conditions resulting in $625,446 in questioned Federal and match costs, and education awards. Specifically, the Commission did not adequately document or appropriately report costs. We also found the Commission insufficiently monitored its subgrantees’ compliance with grant terms and conditions and the Commission’s and a subgrantee’s financial management system did not properly track grant and report expenditures.We made recommendations for the Commission and AmeriCorps that focus on improving the Commission’s and its subgrantees’ administrative and management procedures for monitoring AmeriCorps grants. The Commission concurred with all findings within the report and noted that it had begun implementing corrective actions consistent with the auditor’s recommendations. AmeriCorps acknowledged working with the Commission on its management response and noted it will make its final determination for all findings, recommendations, and questioned costs after receiving the final report and reviewing the auditor’s working papers and the Commission’s corrective action plan.

We found that Indian Affairs was unable to effectively manage deferred maintenance at school facilities funded by the Bureau of Indian Education.

The Inflation Reduction Act authorizes $4 billion in appropriations for the Bureau of Reclamation to mitigate drought in the Reclamation States.

We audited costs claimed by the Louisiana Department of Wildlife and Fisheries under WSFR grants awarded by FWS.

We found the Interagency Working Group on Mining Regulations, Laws, and Permitting did not fully meet IIJA Section 40206 reporting and performance metric requirements. 

The audit of AmeriCorps grants awarded to YouthBuild USA found that AmeriCorps was aware of inconsistencies between Federal Statute and Federal Regulations concerning limitations on Federal share of member living allowance and member support costs beginning in 2009 and neither updated its Federal regulations nor effectively explained the inconsistencies to grantees. In addition, YouthBuild did not comply with Federal or AmeriCorps requirements, resulting in $3,604,355 of questioned Federal and match costs. The audit identified an additional $3,087,791 in funds put to better use. The questioned costs and funds put to better use stem from YouthBuild’s ineffective system of internal controls over timekeeping that failed to provide reasonable assurance that it and its subgrantees are adequately managing AmeriCorps funds. YouthBuild’s weak internal controls allowed a subgrantee to recruit prospective and existing employees as AmeriCorps members and permit them to earn and receive education awards for the same hours worked fulfilling their normal employment duties. In addition, YouthBuild’s timekeeping and member training hours policies significantly deviated from Federal regulations and AmeriCorps’ policy; and YouthBuild did not sufficiently monitor its subgrantees to detect instances of non-compliance with its policies. AmeriCorps agreed to disallow $3,083,528 in questioned costs due to the YouthBuild subgrantee recruiting employees as AmeriCorps members and other instances of subgrantee non-compliance undetected by YouthBuild’s monitoring. However, AmeriCorps did not agree with recommendations to disallow the remaining $520,827 of questioned costs related to noncompliant timekeeping practices and to require YouthBuild to pay $3,087,791 in outstanding education awards. These decisions by AmeriCorps increase the likelihood that grantees will adopt fraudulent timekeeping practices and put a significant amount of AmeriCorps funds at risk.

As required by the Charge Card Abuse Prevention Act of 2012, Public Law 112-194, we performed risk assessments of the U.S. Department of Housing and Urban Development’s (HUD) purchase and travel card programs. In our risk assessments, we analyzed and identified the risks of illegal, improper, or erroneous purchases. Using information provided by HUD, we assessed risk for eight different risk factors and ranked each risk factor as low, medium, or high, based on predetermined criteria. We determined that the overall risk for both programs was low and at this time, an audit is not warranted. However, we did identify areas of medium risk in which HUD could make improvements to strengthen its charge card controls related to three risk factors for the purchase card assessment and one risk factor for the travel card assessment. The risks in both programs centered around weaknesses in procedures and monitoring. Specifically, in the purchase card program, the Office of the Chief Procurement Officer (OCPO) used and relied on an outdated policy implementation guide that did not reflect OCPO’s current processes and lacked standard operating procedures outlining the specific steps taken to execute the controls. Further, the monthly monitoring review process did not always ensure that potential improper use transactions were cleared with adequate documentation. In the travel card program, HUD program offices did not always follow up on potentially improper transactions identified by the Office of the Chief Financial Officer (OCFO) in a timely manner, and OCFO lacked the authority to act when reviews were untimely. We also noted that HUD did not sufficiently monitor for employees who did not use their government travel card when required for official travel-related purchases. To improve its processes and oversight for the purchase card and travel card programs, we made recommendations to develop and implement policies and procedures in the areas that we assessed as medium risk. While we assessed risks of illegal, improper, or erroneous purchases as low in both charge card programs, implementation of these recommendations will enhance and further strengthen HUD’s controls and oversight activities in this area.

The PRAC along with 10 of our member Offices of Inspectors General conducted this second phase of our review in order to provide insights on the experiences of the two cities, two rural counties, and two Tribal reservations that, during the first part of our review, received a combined $2.65 billion in pandemic relief funding across 89 pandemic programs and subprograms. We found that the six communities shared similar experiences even though their populations, demographics, locations, and contexts were unique. Specifically, we identified four themes which provide valuable insights to policymakers, program officials, and the American public regarding the federal government’s COVID-19 response and how to prepare for the next major emergency. These themes focus on Program Administration and Guidance, Knowing Your Community, Pre-Existing Challenges, and Sustaining Lives and Recovering from the Pandemic.

The Postal Service relies almost entirely on the revenue generated from postage to fulfill its public mission and cover the costs of delivering mail. As mail volumes decline and operational costs increase, USPS has sought to cover its costs by generating more revenue through increases in the price of postage. Record levels of inflation and additional pricing authorities have recently led to notable increases in the price of Market Dominant mail, including the highest revenue generating class of mail, First-Class Mail. Specifically, First-Class Mail has seen more frequent price increases and a higher percentage of price increases since August 2021.

The U.S. Postal Service is redesigning its processing network with the goal of creating a best-in-class mail and package processing network as part of its 10-year strategic Delivering for America plan. The Postal Service plans to create a modernized network based around Regional Processing and Distribution Centers (RP&DC), local processing centers, and sorting and delivery centers. The Richmond Processing and Distribution Center became the first RP&DC, in July 2023, consolidating operations from nearby facilities. According to the Postal Service, the effectiveness of these new facilities is critical to the success of its strategic initiatives.

This audit was performed in accordance with the Accountability of Tax Dollars Act of 2002, which requires the U.S. Chemical Safety and Hazard Investigation Board to prepare, and the Office of Inspector General to audit, the agency’s financial statements each year. The EPA OIG, which also serves as the OIG for the CSB, contracted with an independent auditor, Allmond & Company LLC, to perform the audit of the CSB’s FYs 2023 and 2022 financial statements.

The AmeriCorps Office of Inspector General (AmeriCorps OIG) investigated allegations that AmeriCorps Volunteers in Service to America (VISTA) members were paid as employees of the Mississippi Center for Re-Entry (MSCRE) while simultaneously receiving an AmeriCorps living allowance for service at the organization, and that MSCRE’s founder instructed VISTA members to not disclose their employment relationship to AmeriCorps. AmeriCorps OIG’s investigation confirmed that one VISTA member was required to perform duties both within and outside their VISTA Assignment Description (VAD), while simultaneously receiving living allowance payments from AmeriCorps and paychecks from MSCRE. AmeriCorps OIG also confirmed that MSCRE’s founder directed VISTA members to not disclose their employment relationships with the organization to AmeriCorps.

The Veteran Readiness and Employment (VR&E) Service and Veteran Employment Through Technology Education Courses (VET TEC) programs support veterans seeking education or training for employment. VR&E focuses on disabilities that directly impact employment, and participants must attend GI Bill approved programs (or obtain a waiver). VET TEC was created for veterans pursuing high technology training. VET TEC programs must meet less stringent approval requirements, are not approved for use under the GI Bill, and require a waiver from the executive director for VR&E participants to use them.The VA Office of Inspector General (OIG) conducted this review to assess the allegation that a VET TEC training provider was knowingly enrolling VR&E participants with improper authorizations. The allegation also stated that some VR&E counselors have worked with the training provider while others have not.Upon review, the OIG substantiated the allegation that VR&E staff improperly authorized 31 participants to attend courses offered by the VET TEC training provider mentioned by the complainant. The team also identified 11 additional VR&E participants attending courses at eight other VET TEC training providers that VR&E staff improperly authorized. Because 33 of 42 VR&E participants were improperly enrolled to attend VET TEC courses, the OIG considers the $387,000 spent on those courses between April 1, 2019, and December 31, 2022, as improper payments.The improper authorizations occurred because VR&E staff were not adequately informed about VET TEC and were generally unaware the program could not be used by VR&E participants. VR&E controls also did not prevent participants from being authorized for and enrolled in unapproved courses.The OIG made the following two recommendations to the undersecretary for benefits: develop and implement polices and system controls to verify programs approved meet requirements; and provide training for all appropriate VR&E regional office staff.

The AmeriCorps Office of Inspector General (AmeriCorps OIG) investigated an allegation that the President of the Great Lakes Community Conservation Corps (GLCCC) misused personal identifiable information provided by prospective AmeriCorps members at recruitment sessions to enroll them in AmeriCorps' Education Award Program, even though the members did not provide service. It was also alleged that these prospective members were enrolled in the MyAmeriCorps portal with the GLCCC President’s email address. AmeriCorps OIG’s investigation found that the GLCCC President used his email address to enroll 55 individuals as AmeriCorps members, and that at least one of the individuals was unaware that they were enrolled into an AmeriCorps program. AmeriCorps OIG further determined that the GLCCC President attended enrollment sessions of a partner organization that did not receive AmeriCorps funding in order to enroll members into GLCCC’s AmeriCorps program, and that hours members served for the partnership organization were counted as AmeriCorps service hours.

We make recommendations to provide clarity and updated guidance regarding the operation of childcare centers on NPS lands.

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.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report evaluates notification and surveillance for patients with mammogram results requiring action during the COVID-19 pandemic. The inspections involved interviews with key staff and evaluations of clinical processes. The OIG reviewed providers’ notification of mammogram results requiring action to patients within VHA’s defined time frame and patients’ completion of the recommended actions.The OIG issued no recommendations for improvement.

The objectives of the audit were to determine whether the Illinois State Board of Education (Illinois) had an adequate oversight process in place to ensure that (1) local educational agencies’ (LEA) American Rescue Plan (ARP) Elementary and Secondary School Emergency Relief (ESSER) plans met applicable requirements and (2) LEAs use ARP ESSER funds in accordance with applicable requirements and their approved LEA ARP ESSER plans.We found that Illinois generally had adequate processes to ensure that LEA ARP ESSER plans met applicable requirements. However, it did not communicate accurate guidance to LEAs regarding when to submit their ARP ESSER plans according to U.S. Department of Education (Department) guidance. As a result, 434 (54 percent) of 801 LEAs did not submit their ARP ESSER plans within a reasonable timeframe as provided for in Department guidance, with one LEA submitting its plan to Illinois more than 540 days after receiving its allocation. Further, six LEAs still had not submitted their ARP ESSER grant application and plan to Illinois as of January 11, 2024, more than 2.5 years after the LEAs received their ARP ESSER allocations. Thus, some LEAs may not have received critical ARP ESSER funds timely or early enough to adequately respond to the impacts of the coronavirus pandemic by addressing students’ academic, social, emotional, and mental health needs, which was the purpose of the ARP ESSER program. We also found that Illinois’ process for reviewing LEA ARP ESSER reimbursement requests could be strengthened in a key area to provide additional assurance that LEAs use ARP ESSER funds for allowable purposes, and although Illinois has been consistent in how it oversees LEAs’ use of ARP ESSER funds, it does not request a listing of expenditures or review any supporting documentation from LEAs as part of its review of LEA reimbursement requests. Without supporting documentation to verify that the expenditures are allowable and properly accounted for, there is an increased risk that Illinois will not identify or become aware of significant compliance issues involving the ARP ESSER program.

System Review Report

The AmeriCorps Office of Inspector General (AmeriCorps OIG) received an allegation that a former Federal Emergency Management Agency (FEMA) Corps member with the National Civilian Community Corps (NCCC) was sexually assaulted while on deployment. It was further alleged that NCCC failed to investigate the allegation or report the allegation to law enforcement, failed to take disciplinary action against the alleged assailant, and removed the member from the NCCC program. AmeriCorps OIG did not investigate or render any findings regarding the validity of the complainant’s sexual assault allegations because complaints of sexual assault fall under the jurisdiction of local law enforcement. However, AmeriCorps OIG conducted an assessment of NCCC’s sexual assault prevention and response program.

We completed this informational report on a review of the Infrastructure Investment and Jobs Act (IIJA) Reconnect Program - Rural Utilities Service consideration and balance of broadband needs, as conducted by an independent certified public accounting firm.

For the independent program evaluation of National Institute of Standards and Technology (NIST) Pandemic Relief Program, the evaluation objective was to determine whether NIST grantees and subrecipients accounted for and expended pandemic relief funds provided under the Coronavirus Aid, Relief, and Economic Security Act and subsequent funding authorizations in accordance with federal laws and regulations. We contracted with the Institute for Defense Analyses (IDA), an independent firm, to perform this evaluation. Our office oversaw the evaluation’s progress to ensure that IDA performed it in accordance with the Council of the Inspectors General on Integrity and Efficiency’s Quality Standards for Inspection and Evaluation (December 2020) and contract terms. However, IDA is solely responsible for the attached report and the conclusions expressed in it.In its evaluation, IDA identified that multiple recipients spent more than the approved budgeted amounts by category or in new budget categories without receiving the required prior approval, resulting in questioned costs of approximately $2.55 million.In addition, IDA made the following observations:• NIST’s technical oversight of awards encouraged process efficiencies where possible. • NIST leveraged existing processes to expedite awards, program objectives were aligned with award activities, and NIST can improve oversight by tracking quantitative goals and progress toward goals in progress reports.

What We Looked AtThe Federal Railroad Administration’s (FRA) recent data show that human factors, which include fatigue, remain the leading cause of reportable non-grade crossing train accidents. In particular, the rate of human factor-caused train accidents reached a 14-year high of 1.43 per million train miles in 2022. According to FRA, overseeing railroad fatigue management and compliance with Federal Hours of Service (HOS) requirements is part of the Agency’s ongoing efforts to address the adverse impacts and underlying causes of fatigue in the railroad industry. Given these factors, we assessed FRA’s (1) oversight of HOS compliance, (2) pursuit of civil penalties for HOS violations, and (3) oversight of passenger railroad compliance with fatigue management requirements. What We Found Three FRA staff in two divisions—the HOS subject matter expert (SME) and two fatigue SMEs—oversee HOS compliance and fatigue management for the entire railroad industry. However, the oversight processes and analyses are not fully documented and there is no evidence of risk-based planning. Specifically, there are no detailed procedures documenting how FRA’s staff plan or perform oversight of HOS compliance or required analyses of passenger railroad work schedules and fatigue mitigation plans. FRA also lacks guidance for many HOS violation penalty amounts as well as procedures for producing accurate Annual Enforcement Reports. As a result, FRA does not have the procedures and accurate data necessary to effectively target its limited resources to the highest risk areas or adequately oversee different railroad types. Our Recommendations FRA concurred with all 19 of our recommendations to improve its oversight of HOS and fatigue management and provided appropriate actions and completion dates. We consider these recommendations resolved but open, pending completion of planned actions.

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 Black Hills Health Care System, which includes the Fort Meade and Hot Springs VA Medical Centers and multiple outpatient clinics in Nebraska, North Dakota, South Dakota, and Wyoming. 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 three areas:1. Medical staff privileging• Completion of Ongoing Professional Practice Evaluations• Review of Ongoing Professional Practice Evaluation data and documents2. Environment of care• Completion of environment of care inspections3. Mental health• Completion of Comprehensive Suicide Risk Evaluations

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the VA Ann Arbor Healthcare System, which includes the Lieutenant Colonel Charles S. Kettles VA Medical Center and multiple outpatient clinics in Michigan and Ohio. 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 providers complete the Comprehensive Suicide Risk Evaluation on the same calendar day as a patient’s positive suicide risk screen in all ambulatory care settings.

Review of the Federal Labor Relations Authority's Implementation of the Remote Work Pilot Program

We conducted this work as part of our ongoing inspection with the objective to conduct integrated oversight of the funding provided to Forest Service's Restoration Projects on Federal and Non-Federal Land from Infrastructure Investment and Jobs Act (IIJA).

As part of the Delivering for America 10-year plan, the U.S. Postal Service is making significant investments in Regional Processing and Distribution Centers (RP&DCs) to modernize its network. The goal of this initiative is to standardize and modernize mail and package processing and improve service reliability and cost efficiency across the nation. The Postal Service opened one RP&DC in calendar year 2023 and is projecting to open about 60 through calendar year 2028. With the implementation of these new facilities nationwide, it will be important for the Postal Service to have a standardized process to relocate mail processing equipment timely and verify accurate accountability of its assets.

This SBA OIG pandemic oversight report reviewed the U.S. Small Business Administration’s Restaurant Revitalization Fund application review and approval process. The objective of this review was to determine whether the controls SBA implemented to award RRF program funds in accordance with the Act and other applicable guidance were effective. SBA developed an implementation plan including a risk framework that was intended to reduce the risk of making improper payments and awarding Restaurant Revitalization Funds (RRF) to ineligible recipients. However, the plan did not include all program requirements and SBA did not always adhere to the plan or have sufficient controls to ensure program and statutory requirements were met by RRF applicants.Beginning in May 2021, SBA received 278,300 RRF applications requesting $72.2 billion in relief payments. SBA approved approximately 101,000 applications and disbursed all $28.6 billion authorized for the program. After accounting for award amounts that we questioned for more than one eligibility requirement, we determined that SBA disbursed nearly $6.7 billion to applicants without sufficiently verifying they were eligible for award.We made five recommendations for SBA to improve the use of data to reduce risks of making improper payments, and to review and recover funds awarded to applicants that did not meet eligibility requirements or received funds that exceeded statutory limits. SBA management agreed or partially agreed with all five recommendations.

The AmeriCorps Office of Inspector General (AmeriCorps OIG) investigated allegations that multiple AmeriCorps Seniors Senior Companion Program (SCP) volunteers submitted falsified timesheets during their service at Kansas City Shepherd’s Center (KCSC). The investigation substantiated that three SCP volunteers submitted falsified timesheets and received a combined total of $7,769.82 in Federal funds as a result. One of the volunteers, Manuel Benson Jr., pled guilty to one count of 18 U.S.C. § 641, Theft of Government Money, and was sentenced to two years’ probation and ordered to pay $4,727.55 in restitution. The other volunteers entered into repayment agreements with KCSC and the United States Attorney’s Office declined to prosecute them. AmeriCorps OIG referred the matter to AmeriCorps and recommended it disallow the funds KCSC paid to the volunteers less the amount of Benson’s restitution. AmeriCorps OIG also recommended that AmeriCorps provide training and technical assistance to KCSC to ensure volunteer supervisors are adequately supervising volunteers.

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 Cheyenne VA Medical Center and multiple outpatient clinics in Colorado, Nebraska, and Wyoming. 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• Focused Professional Practice Evaluation results review• Ongoing Professional Practice Evaluation completion2. Environment of care• Environment of care inspections3. Mental health• Suicide-related event reporting• Comprehensive Suicide Risk Evaluation completion

We found that DOI was not taking sufficient action to ensure the contractor met all contract terms and conditions.

We audited the Arizona Game and Fish Department’s use of grants awarded by the U.S. Fish and Wildlife Service under the Wildlife and Sport Fish Restoration Program.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin. 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 providers complete the Comprehensive Suicide Risk Evaluation on the same calendar day as a patient’s positive suicide risk screen in all ambulatory care settings.

This report summarizes the results of the fiscal year 2023 Federal Information Security Modernization Act (FISMA) of 2014 evaluation and assessment of the Denali Commission's information security systems policies, procedures, and practices. The objectives were to determine whether the Denali Commission complied with FISMA and assess the maturity of controls used to address risks. During this review period the Commission completed corrective actions recommended in the FY 2021 review.