Federal Reports

We performed a self-initiated audit at the Los Angeles Processing and Distribution Center (P&DC) and three delivery units serviced by the P&DC during the week of November 13, 2023. The delivery units included the Dockweiler Station, Downtown Long Beach Station, and Inglewood Carrier Annex.We issued individual reports for the three delivery units and the P&DC we visited. We will issue another report summarizing the results of our audits at all three delivery units with specific recommendations for management to address.

To see our report, click on the link below

We found that the DOI must improve its wildland fire fleet management to ensure readiness across bureaus and locations.

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 reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission.

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 reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission.

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 reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission.

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 280 processing facilities and 35,000 post offices, stations, and branches. The Postal Service is transforming its processing and logistics networks to become more 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 and packages in near real time; and optimizing the surface and air transportation network. The U.S. Postal Service Office of Inspector General 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.

The Postal Reorganization Act of 1970, as amended, established the Board of Governors (Board), which is generally comprised of nine governors appointed by the President of the United States, the postmaster general, and the deputy postmaster general. There was a full Board throughout fiscal year (FY) 2023. The Board reviews the U.S. Postal Service’s practices and policies and establishes objectives and goals in accordance with Title 39 of the U.S. Code. In FY 2023, the Board incurred $470,020 in salaries, travel, meeting fees, and professional service expenses. The Office of the Board of Governors’ policy requires annual audits of the Board’s expenses.

The VA Office of Inspector General (OIG) conducted an inspection at the VA Central Ohio Healthcare System (facility) in Columbus to review an allegation that implementation of the new electronic health record (EHR) led to a prescription backlog. While reviewing the allegation, the OIG determined facility leaders took timely and sustainable steps to manage the issue. However, the OIG identified other facility and national pharmacy-related patient safety issues.The OIG found implementation of the new EHR at the facility, despite known pharmacy-related patient safety and usability issues, contributed to ongoing patient safety risks and usability challenges at the facility. The new EHR contributed to pharmacy-related patient safety issues nationally as a software coding error resulted in inaccurate medication and allergy information transmission from new EHR sites to legacy EHR sites. Affected patients were not notified of their risk of harm and the OIG remains concerned for their safety. The OIG learned VHA communicated recommendations to providers to mitigate the risk of harm to affected patients; however, the recommendations were non-sustainable. Additionally, the new EHR's operational inefficiencies required increased clinical pharmacist staffing and development of workarounds and educational materials to complete pharmacy processes. The inefficiencies also led to pharmacy staff burnout, job dissatisfaction, and decreased morale.The OIG made three recommendations to the Deputy Secretary related to resolution of patient safety and usability issues. The OIG made six recommendations to the Under Secretary for Health. One recommendation focuses on accurate patient medication data and three recommendations address patient and provider awareness and evaluation of the risk of harm related to data transmission issues. Another recommendation is related to pharmacy staffing, and one focuses on the underlying technical and functional issues requiring workarounds and educational materials to perform pharmacy operations.

The objective of the audit was to determine whether the Mississippi Department of Education (MDE) implemented selected components of its statewide accountability system in accordance with Mississippi’s approved State plan and any approved amendments. Our audit covered MDE’s processes for implementing selected components of Mississippi’s statewide accountability system based on accountability data for school years 2017–2018, 2018–2019, and 2021–2022. The selected components were (1) establishment of long-term goals for improved academic achievement, (2) indicators used to measure student academic achievement and school success, (3) annual meaningful differentiation, and (4) identification of low-performing schools and schools with low-performing student subgroups. Our audit also covered the funding and support services that MDE provided to LEAs with schools identified in the fall of 2022 as needing comprehensive support and improvement (CSI), targeted support and improvement (TSI), and additional targeted support and improvement (ATSI). We found that MDE generally implemented the long-term goals, indicators, annual meaningful differentiation, and identification of low-performing schools’ components of its statewide accountability system in accordance with Mississippi’s approved State plan and amendment. However, its implementation of several aspects of the accountability system deviated from the plan. In several cases, the changes warranted the Department’s review and approval; however, MDE implemented the changes without (1) submitting amendments to the Department or (2) waiting for the Department to approve the amendments. In addition, found that MDE did not always calculate indicator scores, perform annual meaningful differentiation, and identify schools for CSI in accordance with Mississippi’s approved State plan and amendment. We also determined that MDE provided funding and additional support to all 236 Mississippi public schools that it identified in the fall of 2022 as needing additional support based on accountability data for school years 2017–2018, 2018–2019, and 2021–2022. Lastly, as noted in the “Other Matters” section of our report, MDE did not take corrective actions that were responsive to the Mississippi Office of the State Auditor’s recommendations for ensuring the accuracy and completeness of graduation rate data used in Mississippi’s statewide accountability system.

We audited costs claimed by the Wyoming Game and Fish Department under WSFR grants awarded by FWS and had no findings.

The AmeriCorps Office of Inspector General (AmeriCorps OIG) investigated an allegation that Teach for America (TFA) improperly exited an AmeriCorps member (member) for Compelling Personal Circumstances (CPCs) who allegedly provided a fictitious reason for a CPC exit in order to participate in a teacher strike and still earn her education award.

The new electronic health record (EHR) includes a scheduling system intended to enhance efficiency and user experience, minimize disruptions in the delivery of care, and standardize workflows that improve patient access. Having a scheduling system that routes patients to the appropriate providers in a timely manner is critical for the Veterans Health Administration (VHA) to effectively provide care for veterans. The VA Office of Inspector General (OIG) issued this management advisory memorandum to address the concern that scheduling system challenges experienced during deployment of the new EHR at smaller VA medical facilities could be exacerbated at larger, more complex medical centers.While VA has delayed additional EHR deployments until it is confident in the system’s functionality, the deployment at the Captain James A. Lovell Federal Health Care Center (Lovell FHCC) proceeded as planned. Lovell FHCC is the first large, complex VA facility to use the EHR, and the implementation presents an immediate challenge in connection with the scheduling system. This memo, provided to VHA ahead of that implementation, was meant to assist in determining whether additional actions are warranted prior to or during future deployments to mitigate scheduling system concerns.These concerns include the need for additional staffing and overtime to meet or exceed pre-deployment appointment levels, displaced appointment queue functionality, challenges related to providers and schedulers sharing information, inaccurate patient information, difficulties changing appointment type, and the inability to automatically mail appointment reminder letters. At facilities currently relying on the EHR, these issues have resulted in inconsistent workarounds and additional work, increasing the risk for scheduling errors. Consequently, at future go-live facilities, assessing staffing levels and overtime usage prior to deployment and preparing staff with approved workflow best practices may help to reduce employee resistance and facilitate successful adoption of the system.

The VA Office of Inspector General (OIG) reviewed concerns related to the care of a patient who died by accidental overdose approximately seven weeks after a missed appointment at the VA Central Ohio Healthcare System in Columbus (facility). The OIG evaluated staff’s failure to conduct minimum scheduling efforts due to an error in new electronic health record (EHR) functioning. The OIG reviewed the adequacy of mental health evaluations of the patient, supervision of a psychologist, caring communications management, and an internal review of the patient’s care.The OIG found that due to the EHR system error, the patient’s missed appointment was not routed to a queue to prompt rescheduling efforts. The OIG determined that, unlike established care standards, for sites using the new EHR, VHA required fewer patient contact attempts following missed mental health appointments. The OIG found that the nurse practitioner did not evaluate a request from the patient to restart medication nor obtain a comprehensive mental health history. The psychologist did not thoroughly evaluate or address the patient’s depression and failed to reconcile critical clinical information. The OIG would have expected a supervisory psychologist to identify concerns about the patient’s depression, substance use relapse risk, and suicidal behavior, and ensure follow-up regarding the medication request. The OIG found that staff failed to send the patient caring communications after high risk for suicide patient record flag inactivation. Facility leaders did not communicate a root cause analysis Lesson Learned to staff as expected.The OIG made one recommendation to the Deputy Secretary to monitor new EHR scheduling functionality. The OIG made two recommendations to the Under Secretary for Health to evaluate minimum scheduling effort requirements and establish Lessons Learned guidance. The OIG made two recommendations to the Facility Director to review the patient’s care and Caring Communication Program compliance.

CSO tank construction delays may increase taxpayer costs to complete the cleanup remedy at the Gowanus Canal Superfund site and prolong community exposure to contaminants.

In November 2021, Congress passed the VA Transparency & Trust Act of 2021 (Transparency Act) to provide oversight of VA’s spending of COVID-19–related emergency relief funding, including funding related to the Families First Coronavirus Response Act (FFCRA), Coronavirus Aid, Relief, and Economic Security (CARES) Act, and American Rescue Plan (ARP) Act of 2021. To comply, VA must provide a detailed plan to Congress outlining its intent and justification for obligating and expending funds covered by the act. Additionally, the Transparency Act requires VA to submit biweekly reports to Congress detailing its obligations, expenditures, and planned uses, as well as justification for any deviation from the plan. The act also requires the VA OIG to submit semiannual reports comparing how VA is obligating and expending covered funds to the planned obligations and expenditures. In this fifth report, the OIG found that VA’s last biweekly report was dated June 6, 2023; VA stated it received approval from Congress to deviate from the biweekly reporting requirement but has not been able to provide documentation to support this statement. VA’s reported obligations through the fourth quarter of fiscal year 2023 generally aligned with the ARP Act spend plan obligation schedule with few exceptions. Deviations to the spend plan did not affect VA’s compliance with the Transparency Act. However, the OIG found that VA’s lack of reporting does not provide sufficient documentation and precludes Congress and other external parties from determining if funds were properly obligated and expended as required.

The AmeriCorps Office of Inspector General (AmeriCorps OIG) investigated an allegation that College Possible staff and an AmeriCorps member were lobbying at the state capitol in Olympia, WA. AmeriCorps OIG’s investigation substantiated the allegation, and confirmed that only one member was in attendance and the lobbying activity was limited to one day. AmeriCorps OIG referred the matter to AmeriCorps State and National (ASN) and recommended it disallow the member’s service hours and a staff member’s hours that had been charged as matching expenditures for the date of the lobbying activity. AmeriCorps OIG also recommended that ASN provide additional training to College Possible on prohibited activities.

In March 2023, while conducting an audit of the Denver Logistics Center (DLC), the OIG found an employee recreation group was auctioning items that VA purchasers had requested through free offers associated with supply orders that met a minimum-dollar threshold. DLC staff auction winners took the items for personal use, and the proceeds were used to fund staff social events. The OIG initiated this administrative investigation to examine possible misconduct by VA senior leaders responsible for maintaining ethical procurement practices.DLC purchasing agents claimed free items for 32 purchases from February 2021 through May 2023. The employee recreation group then sold the items to staff through silent auctions. Under federal law, the items were government property because they were part of a purchase made by VA. Federal ethics regulations state, “employee[s] ha[ve] a duty to protect and conserve Government property and shall not use such property, or allow its use, for other than authorized purposes.” DLC leaders and staff had taken related VA ethics and purchase card training, which explained management of government property, ethical restraints on receiving free incentives, and purchase card prohibitions; however, no one at the DLC appeared to have questioned the propriety of the auctions.The OIG found the purchases associated with the free items constituted waste. Contrary to VA policy, which requires every effort be made to use government-wide or agency contracts, the DLC purchased these items without considering a preestablished government contract. The DLC director halted the auctions and the acceptance of free merchandise in June 2023. VA concurred with the OIG’s six recommendations that include a full accounting of losses and recoveries, enhanced guidance and training, and taking any other needed administrative actions. VA was also alerted to 168 other facilities that appeared to be receiving free incentives for further examination.

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Edward Hines, Jr. VA Hospital (facility) in Hines, Illinois, to assess an allegation that deficient quality of care resulted in a patient’s foot amputation.The patient told facility primary care staff about falling at home while wearing VA-issued diabetic shoes. At the time of the fall, the patient had temporarily stopped taking anticoagulation medication, as instructed, for a procedure. The patient told clinical staff of symptoms consistent with an arterial occlusion 11 and 12 days after the fall; staff referred the patient to an emergency department. The patient elected to wait and go to the facility for diagnostic testing, and later underwent a foot amputation due to an arterial occlusion. The facility’s vascular surgeon told the OIG that the arterial occlusion may have been caused when the patient stopped anticoagulation medication (prior to a bleeding-risk procedure) or possibly due to the fall.Pharmacy staff managed the patient’s anticoagulation medication in accordance with Veterans Integrated Service Network and facility guidance.The day of the fall, a podiatrist saw the patient for an annual evaluation and gave instructions to wear the previously provided VA-issued shoes, a type of shoe with known challenges related to fit and heel slippage. The OIG determined that the podiatrist missed an opportunity to provide reeducation or refit the patient with new VA-issued shoes.The patient attributed the fall to the shoes and reported concerns to the facility’s patient advocate. The OIG found that the patient advocate did not consult with the facility’s patient safety staff, as required, after receiving concerns from the patient alleging facility staff’s negligence led to the amputation.The OIG made two recommendations related to consulting with patient safety and refitting and reeducating patients on VA-issued shoes.

The United States Capitol Police (USCP or the Department) Office of Inspector General reviewed USCP nondisclosure policies, forms, agreements, and related documents for the inclusion of required “anti-gag” provisions.

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 Beckley VA Medical Center, which includes two 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 three recommendations for improvement in two areas:1. Medical staff privileging• Service-specific criteria in Ongoing Professional Practice Evaluations• Regular Ongoing Professional Practice Evaluations2. Mental health• Comprehensive Suicide Risk Evaluation completion

The AmeriCorps Office of Inspector General (AmeriCorps OIG) investigated allegations ofnoncompliance with grant terms and conditions stemming from the AmeriCorps Office ofMonitoring’s (OM) review of the Retired and Senior Volunteer Program – Volunteers in Service(RSVP-VIS)

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 Pittsburgh Healthcare System, which includes the H. John Heinz III and Pittsburgh VA Medical Centers, one outpatient clinic in Ohio, and multiple outpatient clinics in Pennsylvania. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (focusing on suicide prevention initiatives)The OIG did not issue recommendations for improvement related to the areas reviewed for this report.

Final Management Letter: Evaluation of the SEC’s FY 2023 Compliance With the Payment Integrity Information Act of 2019

To see our report, click on the link below

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

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

We audited the Puerto Rico Housing Finance Authority’s (PRHFA) Homebuyer Assistance Program (HBA), which provides eligible applicants with closing costs and downpayment assistance for the purchase of a primary residence. The U.S. Department of Housing and Urban Development (HUD) provided its grantee, the Puerto Rico Department of Housing (PRDOH), $495 million in Community Development Block Grant Disaster Recovery funds for HBA Our objective was to determine whether PRHFA was on track for delivering the expected program outcomes and the impact the program had on home ownership rates in Puerto Rico after Hurricanes Irma and Maria. We found that HBA program participants were mostly satisfied with the program and stated that it had a significant impact on their lives by helping them obtain a safe and stable home for themselves and their families. The program was on track to deliver the expected outcomes as defined in the subrecipient agreement, including, but not limited to, the number of program applications received, reviewed, and approved per month and monthly funds disbursed to assist participants obtaining housing. However, PRDOH, which is responsible for monitoring the progress of the program, did not have current and reliable data to measure the program’s effect on home ownership rates in Puerto Rico. In addition, PRHFA inappropriately allowed participating lending institutions to calculate financial assistance award amounts. Further, PRHFA did not have clear and consistent guidelines to determine household income and final HBA financial assistance awards. As a result, PRHFA cannot ensure that it distributed disaster recovery funds equitably among eligible program participants. We recommend that the Director of the Office of Disaster Recovery work with PRDOH and PRHFA to (1) update its action plan and program guidelines to reflect the current method(s) being used by the agency to measure the impact of the HBA program, (2) develop and implement clear and consistent guidance and procedures that establish a verifiable method for determining financial awards and provide necessary training to participating lending institutions, and (3) provide training and guidance to participating lending institutions related to the updated guidelines and procedures for determining the financial award granted to HBA participants to ensure that program funds are distributed in an equitable manner.

Promoting positive customer retail lobby experiences is a focus area in the U.S. Postal Service’s Delivering for America plan. Retail lobbies are where many customers interact with the Postal Service, such as when buying stamps or mailing packages. The Postal Service collects data on retail lobby customer experiences, such as cleanliness, transaction times, staff courtesy, and mailing supply availability, through mystery shoppers, surveys, and observations. The Postal Service’s New York 1 District — which includes Manhattan, the Bronx, Staten Island, and Brooklyn — recently had low retail lobby customer experience scores. When issues are identified, offices must implement corrective actions to promote customer experiences and service in a manner that reflects the Postal Service’s positive image and brand.

In July 2023, we conducted on-site, unannounced inspections of six U.S. Customs and Border Protection (CBP) facilities in the Rio Grande Valley area, specifically three U.S. Border Patrol facilities and three Office of Field Operations ports of entry. At the time of our on-site inspection, Border Patrol held 2,020 detainees in custody in the Donna and Ursula Centralized Processing Centers (CPC).

We audited costs claimed by the Indiana Department of Natural Resources, Division of Fish & Wildlife under WSFR grants awarded by FWS and had no findings.

On May 16, 2022, the Peace Corps notified the United States Congress that Peace Corps/Cambodia intended to resume operations as early as September 2022. The first intake of 2 reinstated Volunteers arrived in September 2022, and 36 two-year Volunteers arrived in October 2022. On July 7, 2023, the Office of Inspector General announced this review to assess Peace Corps/Cambodia’s compliance with specific agency policies and procedures related to Volunteer and trainee health and safety and the re-entry process.

The AmeriCorps Office of Inspector General (AmeriCorps OIG) investigated allegations of fraud, waste, and mismanagement at the Harrison County Council on Aging’s (HCCA) Retired and Senior Volunteer Program (RSVP) in Bethany, MO. HCCA was unable to produce financial records related to its RSVP program upon request. Information obtained during interviews indicated that HCCA did not provide adequate oversight of its RSVP program.

The Office of the Inspector General conducted an audit of the U.S. Government Publishing Office (GPO) Telework Program.Our objective was to determine if management has effective controls over the telework program, and if there are opportunities for cost savings and improvements to the telework program.

The purpose of this report is to summarize the results of six previously conducted post re-entry health and safety reviews (re-entry reviews), to include a subsequent review of nine additional posts, and bring to your attention needed improvements.

The VA Office of Inspector General (OIG) conducted a review of VA health care and benefits utilization by veterans who reported sexual assault to the Department of Defense Sexual Assault Prevention and Response Office (SAPRO) during military service or who later disclosed having experienced military sexual trauma (MST) to a VHA provider.The OIG found that veterans who reported sexual assault to SAPRO were more likely to be female, younger, and fall within the lowest pay grades at the time of discharge when compared with veterans who did not report sexual assault during military service. Veterans who reported to SAPRO were more likely to apply, and applied sooner after discharge, for VA health care, education, and readiness and employment benefits.Among VHA patients who did not report sexual assault to SAPRO, seven percent disclosed MST at VHA. VHA patients who reported sexual assault or MST were more likely to use and used VA health care more frequently, especially mental health care, compared with VHA patients who did not report. VHA patients who reported sexual assault or MST were more likely to be diagnosed with mental health disorders, particularly posttraumatic stress disorder and major depressive disorder. Veterans who reported to SAPRO were also more likely to use Vet Center counseling services than those who did not report.Veterans who reported sexual assault to SAPRO were more likely to have received a service-connected disability rating, have a higher service-connected disability rating, and have a mental health disorder component contributing to their service-connected disability rating than veterans who did not report to SAPRO.The OIG made one recommendation to the Under Secretary for Health regarding outreach and two recommendations to the Under Secretary for Benefits to evaluate the application and claims process and outreach for veterans who reported sexual assault during military service.

For decades, NASA has been a leader in High-End Computing, also known as supercomputing. But the Agency’s history of innovation is being stymied by disjointed management, as detailed in this report.

OIG evaluated USDA's transfers of funds into and out of the Shared Cost Programs and Working Capital Fund to determine if funds were used in accordance with their purpose.

Management Advisory Memorandum Regarding FLRA's Contract for Administrative Support Services

During fiscal year 2022 through 2026, the EPA will receive about $12.7 billion in Infrastructure Investment and Jobs Act funds for CWSRF grants, in addition to an estimated $4.2 billion in regular annual appropriations. Without proper oversight of the annual review process, these funds will be more susceptible to fraud, waste, and abuse, and the success of the CWSRF Program may be at risk.

This management advisory assesses the U.S. Small Business Administration’s (SBA) internal controls over purchase and travel card expenditures for fiscal year 2022. In August 2019, OMB issued a revised circular requiring federal agencies to develop a charge card management plan, which is a risk management policy containing an internal control system. SBA’s plan identifies key management officials and their roles and responsibilities and directs employees on how to use data analytics tools and techniques to support spend visibility and analysis. SBA participates in the General Services Administration (GSA) SmartPay government-wide charge card program, which is important to our assessment because this program includes data analytics and reporting tools to assist with oversight controls.Our objective was to perform a risk assessment of SBA’s government purchase card and travel card programs to identify any risks of illegal, improper, or erroneous purchases and payments. Our review focused on determining whether SBA implemented effective controls, policies, and procedures to mitigate the risk of charge card misuse, improper, or erroneous purchases and payments.Our assessment of SBA’s fiscal year (FY) 2022 purchase and travel card programs found the agency is at low risk of illegal, improper, or erroneous purchases and payments. We found SBA implemented effective internal controls to limit risks to prevent illegal, improper, and erroneous purchases and payments. SBA’s internal controls helped safeguard taxpayer funds against fraud, waste, or abuse. SBA established the use of bank card management analytical and audit tools to manage card program expenses, review cardholders spending patterns, and analyze transaction detail reports to monitor delinquency, potential fraud and misuse, performance metrics, and other noncompliance issues.

The VA Office of Inspector General’s (OIG’s) oversight function includes interpretation of Veterans Health Administration (VHA) policies. Unclear policies create challenges for oversight and may impact the services veterans receive. The purpose of this memorandum is to highlight concerns with facility-level expectations described in the VHA policy for conducting institutional disclosures of adverse events. The OIG identified unclear language and inconsistent application of VHA Directive 1004.08, Disclosure of Adverse Events to Patients, during various healthcare inspections that took place during fiscal years 2022 and 2023.The OIG determined that VHA policy language is unclear as to whether a sentinel event automatically triggers the need for institutional disclosure, in part because of The Joint Commission’s (TJC’s) evolving definition of a sentinel event, which now includes non-patient-care events. Based on a fiscal year 2023 hotline inspection involving a sentinel event, the OIG also discovered unclear criteria regarding the definition of suicide as a sentinel event, and whether all sentinel events require institutional disclosure.Unclear requirements may have resulted in VHA medical facility leaders’ confusion about when to make institutional disclosures. Additionally, the OIG found that VHA Directive 1004.08 does not provide leaders with discretion on whether to make an institutional disclosure of an event based on a delay in discovery of a serious adverse incident when, according to 1004.08, an institutional disclosure would otherwise be implemented.The OIG requested the Under Secretary for Health (1) more clearly specify in an amended or updated policy when a sentinel event, as defined by TJC, should trigger an institutional disclosure; (2) reinforce to VHA staff the indications for institutional disclosure; and (3) reinforce to staff that the present policy requires institutional disclosure for specific events, regardless of timeliness of discovery.

The objective of the Department of the Interior Office of Inspector General (DOI OIG) Qualitative Assessment Review was to determine whether the Office of the Special Inspector General for the Troubled Asset Relief Program (SIGTARP) had internal control systems in place that provided reasonable assurance that SIGTARP followed professional standards when conducting investigations. The professional standards were the Council of the Inspectors General on Integrity and Efficiency (CIGIE) Quality Standards for Investigations and the Attorney General Guidelines for Offices of Inspector General with Statutory Law Enforcement Authority.DOI OIG performed the review in accordance with the CIGIE Qualitative Assessment Review Guidelines for Federal Offices of Inspectors General. They used the questionnaires and checklists attached to these review guidelines. DOI OIG analyzed existing policies and procedures; spoke with staff; reviewed closed investigative case files; and tested compliance with SIGTARP’s internal control systems to the extent we considered appropriate. They conducted the review in January and February 2024.