Federal Reports

The U.S. Postal Service provides customers across the nation mail service six days a week as required by law. In December 2022, Winter Storm Elliott arrived in Western New York, and within minutes, winds went from 10 to 70 miles per hour and brought about 36 inches of snow over four days. During a winter storm emergency that may disrupt normal operations, the Postal Service may continue its mission of delivering services to the American public or decide to close facilities and cease operations. It is vital for the Postal Service to prepare for and respond to winter emergencies in a timely manner to safeguard employees. Additionally, it is critical for the Postal Service to capture lessons learned and address potential preparedness and response weaknesses following a weather emergency.

While conducting a risk assessment to inform our Fiscal Year 2024 Top Management and Performance Challenges Facing the Department of Commerce report, we concluded that the ship construction program the National Oceanic and Atmospheric Administration (NOAA) is currently undertaking is insufficient to fully meet the requirements outlined in the bureau’s fleet plan. Further, the lack of an up-to-date fleet plan has negatively impacted NOAA’s ability to communicate its capability needs and required funding. In addition, we highlight a significant challenge in ensuring that the agency has sufficient staff with the required skills to simultaneously acquire three new classes of ships. We also identify a need for increased programmatic oversight of these complicated and expensive acquisition programs.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Central Alabama Veterans Health Care System, which includes the Central Alabama VA Medical Center-Montgomery, Central Alabama VA Medical Center-Tuskegee, and multiple outpatient clinics in Alabama and Georgia. 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 the mental health area of review:• Comprehensive Suicide Risk Evaluation completion• Suicide-related event reporting

An annual update on the OIG’s oversight of the U.S. Environmental Protection Agency’s implementation of the IIJA, which appropriates over $60 billion to the EPA for fiscal years 2022 through 2026, representing the largest appropriation that the Agency has ever received.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations related to deficiencies in the communication with and care coordination for a post-stroke patient who died by suicide at the VA Maine Healthcare System (facility) outpatient clinic in Augusta, Maine. Although the OIG identified deficiencies in the quality of care and completion of quality reviews, the OIG was unable to determine whether a change in care would have resulted in a different outcome for the patient.After the patient had a stroke, facility staff communicated with the patient and scheduled a primary care appointment. However, following the patient’s suicidal statements, facility staff were unable to engage the patient to complete a formal suicide risk screening and did not document the inability to complete the screening per Veterans Health Administration policy or ensure a safety plan was in place. Furthermore, a staff member did not follow the facility policy of notifying suicide prevention staff to garner support for the patient.A primary care provider failed to assess the patient for post-stroke depression, conduct a neurological assessment to determine cognitive or neurological impairments, or consider all options for rehabilitation services and transportation to outpatient therapy.The OIG identified deficiencies with facility quality management reviews. The root cause analysis team did not follow the required process for facility leaders’ nonconcurrence with root cause analysis findings. Additionally, facility leaders did not recognize the need to conduct a peer review of the primary care provider as required by VHA policy.The OIG made seven recommendations to the Facility Director related to suicide screening, safety plans, suicide prevention staff engagement, root cause analyses, peer reviews, and quality management reviews.

We included an audit of the Tennessee Valley Authority’s (TVA) management of early payment discounts on vendor invoices in our annual audit plan as a follow up to audit 2017-15500, Early Payment Discounts on Vendor Invoices, dated May 30, 2018, where we reported TVA missed 19 percent of all early payment discount opportunities. Our audit objective was to determine if early payment discounts are appropriately managed by TVA. Our audit scope included invoices from Supply Chain contracts and purchase orders with greater than $1 million in spend in any one fiscal year from October 1, 2020, through September 30, 2023.We found TVA’s management of early payment discounts could be improved as 18 percent of all available discounts, totaling $826,252, were not taken during the audit period. Based on our analysis and interviews with relevant personnel, we determined some personnel were often unaware of important aspects of how to manage (1) early payment discount terms, (2) invoices sent by vendors after the discount period expired, and (3) invoices sent by vendors before materials are received. Additionally, we noted TVA Supply Chain maintains dashboards that could be used to help management identify training needs.

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.

An Amtrak secretary based in Pennsylvania violated company policies by regularly logging into work remotely, then not showing up to her worksite or arriving late, leaving early, or both. Our investigation found that the employee logged in remotely 30 times on 18 days during a one-month period, when her supervisor only approved her to work remotely on only four of the 18 days. Therefore, the employee was absent from her worksite without her supervisor’s knowledge or approval on 22 of 30 instances. She was terminated on March 12, 2024, after her corporate hearing. The former employee is not eligible for rehire.

In January 2017, HUD awarded the City $141.2 million in Community Development Block Grant National Disaster Resilience grant funding for disaster resilience. HUD designed the grant to give states flexibility in planning program activities and help state and local communities recover from past disasters, while also improving their infrastructure to withstand future extreme events through strategic community investments. The City initially reported to HUD that it would complete its National Disaster Resilience program activities by September 2022.Using the flexibility provided by the block grant, the City opted to focus its National Disaster Resilience program activities on improving its ability to withstand future extreme events. All 11 of the City’s major infrastructure projects that were planned in 2017 and designed to combat flooding, had been significantly delayed. Only 1 project made progress but had been underway for 5 years, 2 projects were slated for cancellation and the remaining 8 still in the design or planning phase. Thus, after more than 6 years, the City had made little progress toward achieving its goals for the National Disaster Resilience program. In addition, the City had disproportionately spent more of its National Disaster Resilience funds on planning and administration than on the design and construction of its planned projects and program activities. Further, the City’s Retrofit program did not reduce the flood risk in many cases and left some homeowners with more flooding and physical and financial burdens. These problems occurred because the City (1) did not properly plan the implementation of its projects, (2) lacked adequate staff and a staffing plan, (3) did not properly charge costs, and (4) failed to adequately monitor its projects and programs. As a result, (1) the City has been left vulnerable to damage from future rain and flood events, (2) homeowners are more exposed to property damage, and (3) the City may run out of funds needed for program oversight. If the City runs out of funds, it will need to allocate non-Federal funds, which may be limited, to complete monitoring and oversight of the National Disaster Resilience program.We recommend that HUD require the City to (1) reassess the eight infrastructure projects still in the design or planning phase to determine whether the City can complete the projects or how the remaining funds could be best used within the 6 years remaining for the grant period, (2) support or repay $104,425 for inadequate supporting documentation, (3) work with HUD to amend its action plan to ensure that $14,683,335 in project funds are put to better use, (4) ensure appropriate staff levels, (5) ensure adequate and timely monitoring of its projects and programs, (6) implement a HUD-approved planning and administration budget and staffing plan, (7) identify and correct misallocated costs, (8) develop a plan on how it will fulfill its required program oversight if it runs out of planning and administration funds, (9) determine how the Retrofit program can better serve homeowners, and (10) develop a plan to review the condition of the property updates and determine where repairs are needed. We believe that implementation of the recommendations in this report will improve the effectiveness of the City of New Orleans’ (the City) National Disaster Resilience grant activities in recovering from past disaster events as well as improved the City’s its ability to withstand future extreme events.

On March 9, 2024, an Amtrak Foreman II 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 $20,000, including $16,100.93 in restitution. Our investigation found that the employee applied for and received a fraudulent Paycheck Protection Program (PPP) Loan for an alleged catering company business in the amount of $13,540. During his interview, the employee admitted that the PPP loan application was false, and his business did not generate the income which appeared on his loan application.

An annual update on the OIG’s oversight of the U.S. Environmental Protection Agency’s implementation of the IIJA, which appropriates over $60 billion to the EPA for fiscal years 2022 through 2026, representing the largest appropriation that the Agency has ever received.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the Charles George VA Medical Center, which includes multiple outpatient clinics in North Carolina. 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. Quality, safety, and value• Sentinel event investigation start dates• Root cause analyses2. Medical staff privileging• Consolidation of credentialing and privileging activities• Credentialing and Privileging Manager reports directly to Chief of Staff3. Mental health• Comprehensive Suicide Risk Evaluation completion

This report summarizes the results of our fiscal year 2023 Federal Information Security Modernization Act (FISMA) of 2014 evaluation and assessment of the U.S. Small Business Administration’s (SBA) information security systems policies, procedures, and practices.Our objectives were to determine whether SBA complied with FISMA and assess the maturity of controls used to address risks in each of the nine security domains.There are five open recommendations from two previous evaluations. In this report, we made 11 recommendations for improvements in 6 domains: risk management, supply chain risk management, identity and access management, data protection and privacy, security training, and contingency planning. We did not repeat recommendations from previous years being implemented in the areas of risk management, supply chain risk management, and contingency planning. The agency agreed with all 11 recommendations.

Peer Review: External Peer Review Report for the SEC OIG Inspection and Evaluation Function

An Amtrak employee based in Seattle, Washington, was terminated from employment on March 7, 2024, following our investigation. Our investigation found that the employee violated company policies by using his company email to conduct business for an outlaw motorcycle gang and by maintaining sexually explicit images on his company devices. The former employee also acknowledged that he was denied entry into Canada due to his association with the outlaw motorcycle gang, thus interfering with his ability to perform his duties.

An Amtrak car inspector based in New York, New York, violated company policies by engaging in outside employment as a bus operator; providing security services at night clubs, lounges, and bars; and working as a bouncer while on a medical leave of absence. The employee was on a medical leave of absence from the company since November 8, 2015, and had not returned to work. On March 6, 2024, after his corporate trial and in accordance with his union agreement, the employee forfeited his seniority and is considered out of service.

The objective of the audit is to express an opinion on whether the Commission’s financial statements are presented fairly, in all material respects, in accordance with U.S. generally accepted accounting principles.

This report was revised on October 17, 2024, to correct a sentence on page 12, which provided information that contained a minor, factual error. The error was not significant to the findings and audit conclusion.

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 outpatient settings of the Manchester VA Medical Center, which includes multiple outpatient clinics in New Hampshire. 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• Medical Executive Council reviews of professional practice evaluations• Equivalent specialized training and similar privileges• Veterans Integrated Service Network oversight2. Environment of care• Inspections• Clean and safe patient areas3. Mental health• Comprehensive Suicide Risk Evaluation completion

The VA Office of Inspector General (OIG) substantiated allegations from January 2022 that employees did not properly reprocess reusable medical equipment (RME) within the facility’s Sterile Processing Service (SPS). Facility leaders halted all endoscope usage, as well as stopped surgeries and procedures requiring RME, until an investigation was completed.The OIG identified multiple issues that contributed to SPS deficiencies, including unaddressed, previously-identified issues within SPS, such as the failure to implement CensiTrac Instrument Tracking System, SPS standard operating procedures (SOPs) being out of date and not accessible to staff, competency training being inadequate and ineffective, failure to control traffic in the sterile area that potentially impacted the integrity of RME, and the negative impact of interim and acting leaders within SPS.In April 2022, the facility had potentially harmful, abnormal critical water test results, which led to another halting of all RME reprocessing. The OIG found that leaders delayed addressing consistently abnormal testing results within SPS.The OIG made two recommendations to the VISN Director related to reviewing the facility’s SPS water management program and ensuring the VISN SPS Management Board reviews critical water testing results.The OIG made seven recommendations to the Facility Director related to ensuring that the SPS chief conducts comprehensive staff competency assessments for reprocessing RME; the CensiTrac Instrument Tracking System is fully implemented and staff are trained in its use; SPS maintains a safe and clean environment in all areas where RME processing is performed; a plan is developed for remediation of the location of the training room adjacent to SPS’s clean storage area; all clinic areas have or share a designated soiled utility storage room; SOPs for all RME are developed and disseminated; and the facility Water Working Group submits critical water test results to the VISN.

ln accordance with our Annual Performance Plan Fiscal Year 2022, the Office of Inspector General (OIG) conducted a review of United States Capitol Police (USCP or Department) Past Major Events and Protests. Our objective was to determine if (1) the Department's organizational structure and processes for major events and protests were the most efficient and effective and (2) the Department complied with selected policies, procedures, applicable laws, regulations, guidance, and best practices. Our scope included operations, existing policies, and procedures related to major events and protests after January 6, 2021.

Postal markets around the world are transforming. Letter mail volume is declining while the parcel sector becomes increasingly competitive. These trends are placing significant financial pressure on national posts and their ability to sustain the provision of universal postal services. These trends have inspired discussions in many countries about how postal regulatory frameworks might adapt to a new market reality. In this paper, the U.S. Postal Service Office of Inspector General (OIG) examines the main oversight activities of the Postal Regulatory Commission (PRC) in the U.S. and other postal regulators in selected countries with developed postal markets. The paper also explores challenges and trends affecting postal regulation and regulatory oversight.

Significant unresolved vulnerabilities in the CDX system increase the risk of threat actors gaining unauthorized access to CDX and other connected program services.

Interim Report: Audit of the Effectsthe Main Street Lending Program’sLoan Losses Have on Treasury’sInvestment in the Program

Significant unresolved vulnerabilities in the CDX system increase the risk of threat actors gaining unauthorized access to CDX and other connected program services.

If the EPA does not mitigate its Central Data Exchange data integrity issues, it cannot provide assurance that its environmental data are accurate and reliable.

OIG reviewed the Rural Business-Cooperative Service’s administration of the pre-award process for the Meat and Poultry Processing Expansion Program.

Recognizing the importance of an agile process, the PRAC, in coordination with CIGIE, hosted an Agile Oversight Forum in January 2023. This report captures the lessons learned and best practices shared by oversight experts from around the country at the Forum. The product is intended to be a starting point for offices and is not a standard for conducting oversight work.

The purpose of this memorandum is to notify stakeholders of the decision to cancel the EAC OIG audit of the administration of HAVA funds by the State of Minnesota.

We issued this management alert to notify the National Telecommunications and Information Administration (NTIA) of potential risks identified during an ongoing evaluation that could affect NTIA’s broadband programs, primarily the Broadband Equity, Access, and Deployment (BEAD) program. Specifically, we asked industry stakeholders to identify challenges they are facing with broadband programmatic deployment to unserved and underserved locations. Stakeholders indicated that their top challenges include requirements and exclusions in applicable program provisions that prefer fiber over non-fiber technologies, lengthy permitting processes, and workforce shortages. These challenges could delay broadband deployment, decrease competition for grants, encourage overbuilding and wasteful spending in locations with existing broadband access, and increase deployment costs. We provided three proposed actions for NTIA to consider to address the potential impacts of the identified challenges.

MEMORANDUM FOR DEPARTMENT OF DEFENSE LEAD INSPECTOR GENERAL

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 outpatient settings of the Aleda E. Lutz VA Medical Center, which includes multiple outpatient clinics in Michigan. 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. Quality, safety, and value• Root cause analyses2. Medical staff privileging• Ongoing Professional Practice Evaluation data• Equivalent specialized training and similar privileges3. Mental health• Comprehensive Suicide Risk Evaluation completion

The U.S. Government Publishing Office (GPO), Office of the Inspector General (OIG), completed an investigation into a fraudulent Facebook account bearing the name and image of GPO Director Hugh Halpern.

Pet collars containing pesticides continue to be used without assurance that there are no unreasonable adverse effects on the environment, including pets.

The objective of the audit is to determine the effectiveness of the Commission’s information security program and practices.

The Mars Sample Return Program is one of the most complex, demanding, and ambitious robotic science missions ever undertaken. Before authorizing whether to advance the program to its next phase, we recommend that NASA stabilize design for key program elements, ensure cost and schedule estimates fully account for the program’s complexity, and consider all launch scenarios.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the White River Junction VA Medical Center and associated outpatient clinics in New Hampshire and Vermont. 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. Quality, safety, and value• Patient safety analyses2. Medical staff privileging• Focused Professional Practice Evaluations• Ongoing Professional Practice Evaluations3. Mental health• Suicide-related event reporting• Comprehensive Suicide Risk Evaluation completion

This audit report found that Mt. Rogers CS complied with the RHC Program rules.

This audit report found that New River Valley CS complied with the RHC Program rules

The U.S. Postal Service and its contracted trucking companies and drivers play a key role in transporting and maintaining the safety and security of the mail. The Postal Service has approximately 4,600 trucking contracts (highway contract routes and freight auction services) with associated costs of $5.2 billion. The Postal Service’s ability to effectively manage and oversee these operations, while promoting safety controls and compliance, will support contract performance and protect the safety of motorists nationwide.

The state DWSRF agencies’ capacity to effectively manage federal DWSRF grants is crucial to the success of the DWSRF Program. Obstacles that affect state DWSRF agency capacity may result in decreased investment in critical water infrastructure projects.

We audited the U.S. Department of Housing and Urban Development’s (HUD) Office of Fair Housing and Equal Opportunity, Fair Housing Initiatives Program (FHIP), Education and Outreach Initiative (EOI). We conducted this audit to help HUD determine whether the education and outreach provided was going to the people who have been systematically denied full housing opportunity. Our audit objective was to assess how FHIP organizations promoted equity within the EOI to reach underserved populations. FHIP organizations promoted equity within the EOI to reach underserved populations. We reviewed a selection of 10 FHIP organizations and found that they (1) researched and identified need in their area that included underserved populations, (2) developed a statement of work to address the need identified, and (3) developed a strategy to evaluate their performance. FHIP organizations performed research to complete needs assessments, using census data; local studies; their own past performance; and research on emerging issues, such as new laws focused on underserved populations. They evaluated their performance to ensure that their outreach provided impact, using client feedback, social media impressions, and intake referrals. As a result, the FHIP organizations provided fair housing outreach and education to underserved populations to increase awareness of fair housing rights and responsibilities.This report contains no recommendations.

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 217 processing facilities and about 33,500 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 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.

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.

The AmeriCorps Office of Inspector General (AmeriCorps OIG) investigated allegations that City Year, Inc.’s Chicago office (CYC) made unallowable charges on its procurement cards. AmeriCorps OIG reviewed CYC’s procurement card expenses and identified nearly $114,000 in questionable and unsupported expenses charged to AmeriCorps funds between 2014 and 2019.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the Minneapolis VA Health Care System, which includes the Minneapolis VA Medical Center and associated outpatient clinics in Minnesota 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 one recommendation for improvement in the mental health topic area:• Comprehensive Suicide Risk Evaluation completion