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Brought to you by the Council of the Inspectors General on Integrity and Efficiency
Federal Reports
Report Date
Agency Reviewed / Investigated
Report Title
Type
Location
U.S. Agency for International Development
Financial Audit of USAID Resources Managed by RA International FZCO in South Sudan Under Contract 72066821C00004, January 1 to December 31, 2022
Financial Audit of USAID Resources Managed by THINK Tuberculosis and HIV Investigative Network (RF.) NPC in South Africa Under Multiple Awards, March 1, 2022, to February 28, 2023
Closeout Financial Audit of the Disabilities Integration of Services and Therapies Network for Capacity and Treatment Project in Vietnam Managed by Sustainable Health Development Center, Cooperative Agreement AID-440-A-15-00002, January 1, 2022, to March
Audit of Schedule of Expenditures of Ministry of Education, Partnership for Education II Project in Jordan, Implementation Letter 278-IL-DO3-EDY-MOE-005, January 1 to December 31, 2022
Financial Audit of USAID Resources Managed by Stichting International NGO Safety Organisation Under Multiple USAID Awards for the Fiscal Year Ended December 31, 2022
Financial Audit of USAID Resources Managed by Jaramogi Oginga Odinga University of Science and Technology in Kenya Under Cooperative Agreement 72061521CA00004, May 11, 2021, to March 31, 2023
Financial Audit of USAID Resources Managed by Associao ComuSanas in Mozambique Under Cooperative Agreement 72065620CA00006, January 1 to December 31, 2022
The CFPB Can Enhance Certain Practices to Mitigate the Risk of Conflicts of Interest for Division of Supervision, Enforcement and Fair Lending Employees
Our objective was to evaluate the effectiveness of the company’s processes and controls for managing and safeguarding its inventory. We found that the Procurement and Supply Chain and the Mechanical departments recently began improving inventory management, but they continue to face challenges strategically managing Maintenance-of-Equipment inventory in ways that have operational, customer service, and financial impacts. For example, the company faces challenges in achieving an appropriate inventory balance, providing an effective ordering system, and safeguarding inventory from risk of loss or theft. We also identified $14.4 million in inventory items that the company will likely never use again—funds that Amtrak could have put to better use. We recommended that the company implement processes to improve inventory data, develop strategic inventory goals, assess the costs and benefits of carrying surplus and obsolete inventory to determine which materials to sell or scrap, and implement processes to safeguard inventory.
Actions Need to Be Taken to Address Inaccurate Internet Search Engine Taxpayer Assistance Center Location Information Which Poses a Threat to Employee Safety
What We Looked At Each year, the Federal Aviation Administration (FAA) procures billions of dollars in information technologies (IT) and telecommunications (telecom) products and services in support of its mission to provide the safest and most efficient aerospace system in the world. For fiscal year 2024, the Agency requested approximately $3.9 billion for its IT and telecom needs. Our prior audit of the Department of Transportation’s (DOT) IT shared services contract vehicles identified issues with DOT’s award and modification practices. Given our previous findings, and the high dollar amounts FAA expends for IT and telecom services, we initiated this audit. Our objective was to evaluate FAA’s practices for awarding and modifying its IT and telecom contracts. We focused our review on the award and modification practices associated with (1) determining sound pricing and (2) promoting competition. What We FoundFAA’s noncompliant IT and telecom contracting practices inhibit establishment of sound pricing. Per the Agency’s Acquisition Management System (AMS), procurement teams are required to conduct price and, at times, cost analyses, and program offices must develop sound independent Government cost estimates (IGCEs) prior to contract awards. However, FAA officials could not provide the required price and cost analyses for 3 of 26 sample contracts or the required IGCE for 1 of these 3 contracts. Additionally, FAA developed inadequate IGCEs for 16 sample contracts. Without adequate IGCEs, FAA lacks a critical pricing tool to help conduct price analysis, detect unreasonable offerors, and establish sound pricing. FAA’s IT and telecom contract award and modification actions also restrict competition. Specifically, FAA extended contracts noncompetitively, expanded the scope of a contract noncompetitively, and made questionable noncompetitive award decisions. These actions were largely due to the Agency’s lack of sufficient procurement planning and unclear guidance in AMS. As a result, FAA denies other firms the opportunity to deliver IT and telecom products and services. Our RecommendationsWe made seven recommendations to strengthen FAA’s IT and telecom contract award and modification practices. FAA concurred with all seven recommendations. We consider all recommendations resolved but open pending completion of planned actions.
We audited the Boston Housing Authority’s public housing program to determine whether the physical condition of the Authority’s program units complied with the U.S. Department of Housing and Urban Development’s (HUD) and the Authority’s requirements. The audit was initiated based on our assessment of risks associated with public housing agencies’ program units and recent media attention and public concern about the condition of subsidized housing properties.
The Authority’s public housing program units were not consistently maintained in a decent, safe, and sanitary condition and in good repair. Specifically, we reviewed a sample of 36 units and determined that 31 units had 113 deficiencies. Of the 31 units, 61 percent had 37 deficiencies that existed at the time of the Authority’s last inspection, and 35 percent had 18 life-threatening deficiencies that needed to be corrected within 24 hours. Further, we reviewed the site, exterior, systems, and common areas of 29 of the Authority’s public housing buildings and determined that 24 buildings had 105 deficiencies, which included 31 life-threatening deficiencies that needed to be corrected within 24 hours. Of the 24 buildings, 6 buildings had 18 deficiencies that existed at the time of the Authority’s last inspection.
Additionally, the Authority did not consistently perform annual self-inspections for all public housing units and correct deficiencies in a timely manner. Specifically, for 55 units reviewed, the Authority did not perform 37 of the 103 required inspections, collectively, for the Authority’s 2022 and 2023 fiscal years. Additionally, we reviewed 71 deficiencies that the Authority identified during its annual inspections, consisting of 31 life-threatening and 40 non-life-threatening deficiencies. We determined that the Authority did not correct (1) more than 22 percent of the life-threatening deficiencies within 24 hours, including six deficiencies that were miscategorized as non-life threatening and (2) more than 87 percent of the non-life-threating deficiencies within the Authority’s 20-day requirement. See table 1 below.
Table 1. The Authority’s annual inspection deficiencies were not corrected in a timely manner
Category
Correction timeframe
Deficiencies reviewed
Deficiencies reported as corrected by the Authority after required timeframes
Lacked support of corrective actions
Life threatening
24 hours
31
7
-
Non-life threatening
20 days
40
35
6
Totals
71
42
6
The Authority also did not consistently correct life-threatening, non-life-threatening health and safety, and non-health and safety deficiencies identified during HUD’s Real Estate Assessment Center’s (REAC) inspections in a timely manner. We reviewed a sample of 41 life-threatening, 35 non-life-threatening health and safety, and 86 non-health and safety deficiencies and determined that the Authority did not consistently correct the deficiencies within HUD’s or the Authority’s established timeframes. It also did not consistently support that deficiencies had been corrected. Further, of the 162 deficiencies, we determined that 66 still existed at the time of our observations, or we could not confirm whether the Authority had corrected the deficiencies. See table 2 below.
Table 2. The Authority did not correct REAC inspection deficiencies in a timely manner
Category
Correction timeframe
Deficiencies reviewed
Deficiencies reported as corrected by the Authority after required timeframes
Lacked support of corrective actions
Uncorrected or unverified at the time of our observation
Life threatening
24 hours
41
23
8
4
Non-life threatening
20 days
35
29
23
14
Non-health and safety
25 days
86
73
50
48
Totals
162
125
81
66
Further, the Authority did not certify to HUD, within 3 business days, that the 41 life-threatening deficiencies had been corrected, remedied, or acted upon to abate within 24 hours.
These conditions occurred because the Authority did not ensure that its (1) inspectors thoroughly inspected units in a consistent manner and (2) policy requiring quality control inspections of units and buildings was fully and consistently implemented. Additionally, after HUD’s COVID-19 waiver of the requirement for annual inspections expired and the Authority resumed performing inspections, the Authority lacked staffing resources to inspect all units, create work orders, correct the deficiencies identified in the Authority’s properties during its own inspections and REAC’s inspections in a timely manner, and report and certify in HUD’s Physical Assessment Subsystem that life-threatening deficiencies identified through a HUD REAC inspection had been corrected in a timely manner.
As a result, families resided in units that were not decent, safe, sanitary, and in good repair for longer periods, and HUD did not have timely information to monitor whether the Authority corrected life-threatening deficiencies in accordance with HUD’s 24-hour requirement. If the Authority does not improve the quality of its inspections and address its increasing backlog of work orders, there is a risk of additional families’ residing in units that are not decent, safe, sanitary, and in good repair. We recommend that the Director of HUD’s Boston Office of Public Housing require the Authority to (1) develop and implement a plan to correct the deficiencies identified for its public housing program units and buildings, including the remaining outstanding deficiencies noted during HUD’s REAC inspections, and (2) implement quality control procedures for its inspection and work order processes and mitigation of noted deficiencies to enhance the effectiveness of its unit inspections and ensure that all units meet HUD’s and its own requirements.
This informational report provides general information related to the Infrastructure Investment and Jobs Act (IIJA) funding for the Federal Wildland Firefighter Salaries and Expenses.
Financial Audit of the Productive Enterprises for Peace Program in Colombia, Managed by Banco de las Microfinanzas - Bancama S.A. Cooperative Agreement 72051419CA00001, January 1 to December 31, 2022
Federal Financial Institutions Examination Council Financial Statements as of and for the Years Ended December 31, 2023 and 2022, and Independent Auditors’ Report
We audited the Department’s progress in managing and implementing the Business Applications Solution (BAS) program. BAS is an enterprise financial system that will modernize the Department’s aging and disparate systems. We found that although the program prepared for the National Oceanic and Atmospheric Administration's (NOAA's) operational transition to BAS, (1) the Department has not established the program’s baselines and does not adequately oversee the program’s cost and schedule performance; (2) the program does not have adequate cost and schedule management controls; and (3) the Department should capture the lessons it learned from implementing BAS at NOAA and apply them to upcoming implementations at the National Institute of Standards and Technology and the U.S. Census Bureau.
This report is a follow up to SBA OIG Report Number 21-06, Paycheck Protection Program (PPP) Loan Recipients on the Department of Treasury’s (Treasury) Do Not Pay (DNP) List, which reported SBA did not use Department of Treasury (Treasury) DNP data to screen borrowers for eligibility prior to approving loans originated before August 8, 2020 (PPP round one). In this report, we assess SBA actions to address potentially ineligible loans identified in report 21-06 and its implementation of controls to review DNP data for PPP loans originated after August 8, 2020 (PPP round two).SBA implemented a review plan to address 25,634 potentially ineligible PPP loans originated prior to August 8, 2020, and review DNP data sources pre-award for loans originated after August 8, 2020; however, inadequate policies and procedures exposed the program to avoidable risks. OIG found SBA’s review plan only included reviewing loans with submitted forgiveness applications where all funds had been disbursed and used. As a result, during PPP round one, lenders approved and disbursed 1,799 loans totaling over $89 million with known DNP matches that were not subject to manual review.OIG also found SBA’s manual loan reviews did not always sufficiently ensure borrowers’ eligibility. We statistically sampled 176 of 25,634 loans with DNP matches and concluded that SBA appropriately resolved 84 and inappropriately cleared the remaining 92 by either using pre-decisional memos that did not address the DNP hold codes, or the loan files did not contain sufficient documentation to support SBA’s review decisions. By projection, we estimate that lenders disbursed, and SBA forgave, 12,234 of 25,634 loans (or 48 percent) totaling over $1.4 billion without verifying the borrowers’ eligibility, which further exposed the program to financial losses and improper payments. In addition, SBA did not use all Treasury’s DNP restricted data sources for reviewing applicants during the first 2 months of pre-award reviews of DNP data for second round PPP loans. SBA identified 2,777 potentially ineligible applicants, totaling approximately $22.4 million. By comparison, our reassessment of applications using all Treasury’s minimally required DNP data sources identified 59,893 additional potentially ineligible loans, totaling about $1.9 billion. OIG recommends SBA implement or enhance policies and procedures to ensure compliance with program requirements and federal standards for identifying/preventing improper payments and seek remedy or repayment of ineligible loans.
Audit of a Court Services and Offender Supervision Agency’s System Pursuant to the Federal Information Security Modernization Act of 2014, Fiscal Year 2023
Audit of the United States Marshals Service’s Misconduct Investigation and Discipline Case Management System Pursuant to the Federal Information Security Modernization Act of 2014, Fiscal Year 2023
EAC OIG audited funds received by the State of North Carolina under the Help America Vote Act, totaling $33 million. This included Election Security and Coronavirus Aid, Relief, and Economic Security (CARES) Act grants.
This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the Alaska VA Healthcare System, which includes the Colonel Mary Louise Rasmuson Campus in Anchorage and other outpatient clinics in Alaska. 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. Environment of care• Temperature and humidity monitoring2. Mental health• Suicide-related event reporting• Comprehensive Suicide Risk Evaluation completion
This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the James A. Haley Veterans’ Hospital in Tampa and associated outpatient clinics in Florida. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued four recommendations for improvement in the following topic areas:• Environment of care1. Patient care areas clean and orderly2. Separate storage of clean and dirty equipment and supplies3. Placement of examination tables• Mental health1. Monthly reporting of suicide-related events
Audit of the Court Services and Offender Supervision Agency’s Information Security Management Program Pursuant to the Federal Information Security Modernization Act of 2014, Fiscal Year 2023
Audit of the United States Marshals Service’s Information Security Management Program Pursuant to the Federal Information Security Modernization Act of 2014, Fiscal Year 2023
Audit of the Schedule of Expenditures of Centers for Civic Initiatives Tuzla, Under Multiple Awards in Bosnia and Herzegovina, January 1 to December 31, 2022
Independent Audit Report John Snow, Inc. and John Snow Research & Training Institute, Inc. Home Office Compliance with Cost Accounting Standards and Federal Acquisition Regulations
Independent Review of the U.S. Department of State Accounting and Authentication of FY 2023 Budget Formulation Compliance Report and Detailed Accounting Report
Audit of the U.S. Nuclear Regulatory Commission's Implementation of the Federal Information Security Modernization Act of 2014 for Fiscal Year 2023 Region II: Atlanta, Georgia
Implementation Review of Corrective Action Plan: Audit of the Public Buildings Service’s Effectiveness in Managing Deferred Maintenance, Report Number A190066/P/2/R21009, September 30, 2021
The Veterans Benefits Administration (VBA) uses the VA Schedule for Rating Disabilities (rating schedule) to determine monthly compensation to eligible veterans for service connected disabilities based on documented medical severity. In 2021, VA updated the rating schedule for the musculoskeletal body system. The VA Office of Inspector General (OIG) reviewed the effectiveness of VBA’s implementation of the changes to the rating schedule specifically for hip and knee replacements or resurfacing.The OIG estimated that in approximately 33 percent of reviewed claims, VBA rating specialists did not assign the correct number of months when granting periods of convalescence. Ratings specialists lack effective tools to determine convalescence benefits and help calculate the proper period. The specialists rely on manually entered dates, increasing the risk of error. Approximately 18 percent of claims did not accurately consider veterans’ additional entitlement to special monthly compensation, and an estimated 38 percent resulted in improper payments of about $3.3 million dollars in total benefits overpayments and underpayments. Further, VBA did not sufficiently monitor claims decision accuracy following the rating schedule update. The OIG team also determined that although VBA provided training on the rating schedule update, nearly 75 percent of staff did not achieve a passing score of 80 percent and required retraining.The under secretary for benefits concurred with the OIG’s four recommendations: (1) review hip and knee replacements and resurfacing claims completed from February 7, 2021, through August 31, 2022, to ensure benefits to veterans were correct; (2) implement a plan to assist rating specialists in determining accurate benefits; (3) develop procedures to monitor claims and ensure processing is compliant with rating schedule revisions; and (4) supplement training on rating schedule updates to improve comprehension on applying changes.
What We Looked At The Coronavirus Aid, Relief, and Economic Security (CARES) Act provided the Federal Aviation Administration (FAA) with $10 billion in funding, including about $525 million for airport development expenses. FAA distributed these funds through its Airport Improvement Program (AIP), which requires grant recipients to comply with various Federal procurement requirements, including Buy American Preferences. Previous Office of Inspector General (OIG) audits identified weaknesses in FAA’s processes for awarding and administering AIP grants and its oversight of CARES Act funds. Given the size of the funding allocation, its expeditious distribution, and related findings in prior reports, we initiated this audit. Our objectives were to evaluate FAA’s processes for (1) awarding and administering CARES Act-funded airport development grants and (2) overseeing associated recipient contracts to ensure compliance with Federal and Agency grant and procurement requirements. What We Found FAA did not always follow its processes for awarding and administering its CARES Act airport development grants. Specifically, FAA did not carefully review development grant applications before it distributed CARES Act funds over 20 percent of the time and did not always require sponsors to submit annual financial reports on time. Although the Agency strengthened its oversight of CARES Act-funded invoices, it did not effectively communicate and adhere to these changes. These oversight gaps prevent FAA from assuring that the program operates as intended and in a fiscally responsible manner. FAA’s CARES Act-funded airport development contracts also did not meet several key Federal requirements. The Agency did not ensure that sponsors met the requirements for completing cost or price analyses in more than 55 percent of contracts we reviewed. FAA also did not always ensure that Buy American waivers met all requirements prior to approval. Thus, FAA cannot be certain that project costs were reasonable or that sponsors complied with Made in America Laws. These issues result in a total of $106 million in funds at risk for better use. Our Recommendations We made eight recommendations to strengthen FAA’s oversight of CARES Act funds for airport development projects. FAA concurred with all eight recommendations and provided appropriate completion dates. We consider all recommendations resolved but open pending completion of the planned actions.
Notification of Concerns Regarding Federal Bureau of Prisons' Policies Pertaining to Special Housing Unit Logs Used to Record Mandatory Rounds and the Retention Period for the Original Logs
Financial Audit of the Community of Special Coffees Project, Managed by Central de Organizaciones Productoras de Caf y Cacao del Per, Cooperative Agreement 72052721CA00006, September 15, 2021, to December 31, 2022
Financial Audit of Sindh Municipal Services Delivery Program in Pakistan Managed by the Government of Sindh Planning and Development Department, Grant 391-PEPA-DG-S-MSP-2011-01, July 1, 2021, to June 30, 2022.
Financial Audit of the Khyber Pakhtunkhwa Reconstruction Program in Pakistan Managed by the Provincial Reconstruction Rehabilitation and Settlement Authority, Provincial Disaster Management Authority, Agreement 391-011, for the year ended June 30, 2022
Financial Audit of USAID Resources Managed by Ajuda de Desenvolvimento de Povo para Povo in Angola Under Multiple Awards, January 1 to December 31, 2022
OIG reviewed the U.S. Small Business Administration’s (SBA’s) Controls Over Cash Contributions and Gifts, Fiscal Year 2023. SBA’s authority to receive and use cash contributions and gifts is in Section 132(a) of Division K in Public Law 108-447.SBA complied with the Consolidated Appropriations Act and SBA regulations and policies regarding soliciting and accepting cash contributions from six new entities that cosponsored the 2023 event. SBA’s Office of Communications and Public Liaison obtained proper approval from the Office of General Counsel for the National Small Business Week cosponsored activity. However, we noted SBA did not ensure the timely and accurate closeout of the 2023 event in accordance with standard operating procedures.We made one recommendation for SBA to fully implement a 90-day closeout process for National Small Business Week as outlined in Standard Operating Procedure 90 75 5. SBA management agreed with the recommendation, stating the Office of Strategic Alliances plans to closeout National Small Business Week 2024 no later than August 1, 2024.
Audit of Federal Awards Performed in Accordance with Title 2 U.S. Code of Federal Regulations Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards
This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the Battle Creek VA Medical Center in Michigan and associated 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 one recommendation for improvement in the mental health area of review:• Comprehensive Suicide Risk Evaluation completion after positive suicide risk screen
Due to the risk of employee exposure to airborne radioactive materials and industrial/chemical airborne hazardous materials at the Tennessee Valley Authority’s (TVA) nuclear plants, we performed this evaluation of the radiological respiratory program. We found the selected respiratory requirements we reviewed for TVA’s Nuclear Power Group Standard Programs and Processes 05.10, Radiological Respiratory Protection Program, were being performed as required at TVA’s nuclear plants. Specifically, we found (1) training and medical evaluations were completed as required, and (2) all plants were meeting requirements for appraising the effectiveness of their Radiological Respiratory Protection Programs.
Audit of Community Service and Other Grants Awarded to KTTZ-TV and KTTZ-FM, Licensed to Texas Tech University, Lubbock, Texas for the Period September 1, 2019 through August 31, 2021, Report No. ASJ2213-2403
The AmeriCorps Office of Inspector General (AmeriCorps OIG) investigated an allegation that thePerry County School District (PCSD) in New Augusta, Mississippi enrolled PCSD employees in itsGrow Your Own Teacher AmeriCorps program as full-time AmeriCorps members (members) andhad them perform the same duties as members that they performed as PCSD employees.
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.
Financial Audit of the Support for Water and Sanitation in India Managed by KPMG Advisory Services Private Limited, Contract 72038621C00001, the April 1, 2022, to March 31, 2023
Financial Audit of USAID Resources Managed by Rural Agency for Community Development and Assistance in Kenya Under USAID Award No.720BHA21GR00380 for the Fiscal Year Ended December 31, 2022
Audit of the Criminal Division’s Money Laundering and Asset Recovery Section Special Analytics System Pursuant to the Federal Information Security Modernization Act of 2014, Fiscal Year 2023
Audit of the United States Trustees Program’s Credit Counseling & Debtor Education System Pursuant to the Federal Information Security Modernization Act of 2014, Fiscal Year 2023
This report communicates the results of the Fiscal Year 2023 Federal Trade Commission Office of Inspector General review of the FTC’s compliance with the Payment Integrity Information Act of 2019 (PIIA) (Public Law 116-117).
The Office of Criminal Enforcement, Forensics and Training Incorporated Essential Discovery Elements into Its Policies and Procedures, but Additional Training Could Improve Awareness
Audit of Claims Processing and Payment Operations at all Blue Cross and Blue Shield Plans as Related to Provider Network Status for Contract Year 2019 through 2021
The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA Southern Nevada Healthcare System (facility) to assess allegations that facility staff delayed ordering medications following a patient’s discharge from a community hospital. The OIG substantiated that inadequate care coordination led to a delay in ordering discharge medications and found deficiencies in facility staff's response to the patient’s death by suicide.The OIG found a community care nurse provided inadequate care coordination, including delayed and omitted clinical documentation. The OIG determined this limited primary care staff's ability to provide care in advance of and after discharge from the community hospital.Primary care staff care coordination process deficiencies contributed to a delay in the patient’s discharge medications. Primary care staff failed to provide health education to the patient about how to obtain the prescribed medications and did not provide same day access to address a lapse in cardiac medication. Additionally, the primary care provider failed to order the patient’s discharge medications.The OIG determined that a VISN physician lacked critical clinical information, did not conduct a complete medication reconciliation, and lacked knowledge of the process to order the patient’s anticoagulant medication, contributing to the delay in ordering medication.The OIG found primary care staff failed to notify suicide prevention staff of the patient’s death by suicide and failed to complete a suicide behavior overdose report immediately upon notification. Further a former suicide prevention program manager failed to timely complete the behavioral health autopsy and a family interview tool contact form.The OIG made one recommendation to the VISN Director to review the patient’s care and take actions as warranted and four recommendations to the Facility Director related to community care coordination, primary care, actions required following a patient death by suicide, and to take actions as warranted.
RMA Associates, LLC (RMA), under contract with the Department of Homeland Security Office of Inspector General, concluded that DHS complied with applicable statutes, regulations, and policies governing grants and contracts awarded by means other than full and open competition in fiscal year 2023. During that year, DHS awarded 28 noncompetitive grants worth approximately $17 million and 410 noncompetitive contracts worth approximately $589 million through means other than full and open competition.
In our final report, we reviewed key aspects of the Food and Nutrition Service funding and administration of Pandemic Electronic Benefits Transfer assistance.
We audited the Kentucky Commission on Human Rights’ fair housing complaint intake process. We initiated this audit based on an internal risk assessment of Fair Housing Assistance Program agencies’ challenges. Our audit objectives were to (1) determine the extent to which the Commission processed fair housing inquiries within 30 days and (2) evaluate its reasons for closing fair housing inquiries.We were unable to determine the extent to which the Commission processed fair housing inquiries within 30 days due to a lack of supporting documentation. Also, the Commission could not provide evidence that would have allowed us to determine whether fair housing inquiries were properly closed. In addition, the Commission did not have clarity on what inquiries should be recorded in the U.S. Department of Housing and Urban Development’s (HUD) Enforcement Management System (HEMS) or what type of documents should be recorded in that system to support closure decisions. These conditions occurred because the Commission lacked staffing for its housing intake process, lacked an effective system to track the processing of inquiries, and was not always able to retrieve documents because some emails were lost. Also, the Commission did not have a record retention policy for its intake, and its staff was inadequately trained for recording intake data in HEMS. As a result, the Commission could not consistently provide assurance to its customers that it properly processed and closed inquiries from complainants in a timely manner. If complainants’ alleged discrimination is not addressed properly and in a timely manner, the Commission may not help to stop ongoing discrimination, hold those responsible for their actions, and deter future discrimination.We recommend that HUD’s Deputy Assistant Secretary for Enforcement require the Commission to (1) update its intake policy and procedure to clarify which inquiries are to be recorded in HEMS; (2) develop an internal agency intake training guide, distribute it to all agency housing staff members, and ensure that all intake staff members participate in HUD-approved training related to intake; (3) implement a record retention policy to ensure that decisions on inquiries are sufficiently supported; (4) implement a plan to ensure that it has sufficient staff to meet its obligations under the Fair Housing Assistance Program cooperative agreement; and (5) implement a system to better track the intake and processing of potential fair housing inquiries.
Audit of the Criminal Division’s Information Security Management Program Pursuant to the Federal Information Security Modernization Act of 2014, Fiscal Year 2023
Audit of the United States Trustees Program’s Information Security Management Program Pursuant to the Federal Information Security Modernization Act of 2014, Fiscal Year 2023
Audit of the Bureau of Alcohol, Tobacco, Firearms and Explosives’ Firearms Integrated Technology Portfolio – Federal Licensing System Pursuant to the Federal Information Security Modernization Act of 2014, Fiscal Year 2023
What We LookedWe performed a quality control review (QCR) on the single audit that MSL CPAs and Advisors performed for the Greater Orlando Aviation Authority’s (GOAA) fiscal year that ended September 30, 2022. During this period, GOAA expended approximately $178 million from U.S. Department of Transportation (DOT) programs. MSL determined that DOT’s major program was the Federal Aviation Administration’s Airport Improvement Program. Our QCR objectives were to determine whether (1) MSL’s 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 auditor’s work on DOT’s major program and (2) GOAA’s reporting package complied with the reporting requirements of the Uniform Guidance. What We FoundMSL complied with the requirements of the Single Audit Act, the Uniform Guidance, and DOT’s major program. We found nothing to indicate that MSL’s opinion on DOT’s major program was inappropriate or unreliable. However, we identified deficiencies in MSL’s audit work that require correction in future audits. Accordingly, we assigned MSL a rating of pass with deficiencies.
Open configuration options Recruitment of Individuals Who Identify as Hispanic or Latino for Employment With the U.S. Department of Housing and Urban Development
The U.S. Department of Housing and Urban Development’s (HUD) Office of the Chief Human Capital Officer (OCHCO) and the Office of Departmental Equal Employment Opportunity (ODEEO) both have responsibilities related to increasing the percentage of employees who identify as Hispanic or Latino. HUD provides an Annual Equal Employment Opportunity Program Status Report, also known as the Annual Management Directive 715 Report (MD-715), to the U.S. Equal Employment Opportunity Commission. In HUD’s fiscal year (FY) 2022 MD-715 and FY 2021 and FY 2022 Annual Reports on Hispanic Employment, HUD described 14 primary initiatives related to the recruitment of individuals who identify as Hispanic or Latino. The initiatives fall into four categories: barrier analysis, collaboration and partnerships with stakeholders, marketing and outreach, and applicant flow data. In addition to these initiatives, HUD described several other efforts that OCHCO and ODEEO had completed or planned related to increasing the percentage of individuals who identify as Hispanic or Latino. OCHCO and ODEEO collaborated quarterly, and ODEEO presented participation rates at quarterly briefings with general deputy assistant secretaries. OCHCO and ODEEO also hired new staff and filled vacant positions. Additionally, OCHCO established a recruitment event calendar and initiated the procurement process for technology-based recruitment tools, while ODEEO leveraged minority-serving and Hispanic-serving institution databases.We found that OCHCO and ODEEO faced challenges with determining the impact of recruitment efforts related to individuals who identify as Hispanic or Latino. No HUD-wide standard existed for how to measure the success of recruitment efforts. During interviews, both OCHCO and ODEEO officials stated that they considered success to be an increase in participation rates, which is the number of employees who identified as Hispanic or Latino in HUD’s total workforce, and spreading the word about HUD as an employer. Additionally, OCHCO was unable to tie a specific hire to a specific recruitment effort.OCHCO began tracking recruitment events it attended or planned to attend in February 2022 but did not track all recruitment efforts from other HUD program offices or their respective field offices. Collecting and maintaining complete information about all recruitment efforts, as well as being able to measure the impact of those efforts, are crucial to measuring the success of the recruitment process.HUD’s applicant flow data, which is information collected about applicants' demographics, such as race and ethnicity, have only been available since FY 2022 due to HUD’s transition to a new system. This means that OCHCO has not yet determined whether analyzing applicant flow data could help measure the impact of recruitment efforts. OCHCO plans to organize and analyze applicant flow data as more data become available. OCHCO also faced data limitations related to its race and national origin (RNO) data. We identified a risk that the RNO data might not give OCHCO an accurate account of HUD’s workforce because the data do not include a category for those employees who chose not to identify their RNO, as providing RNO data is voluntary.We offer three recommendations to improve OCHCO’s ability to determine the impact of recruitment efforts and to collect information about recruitment efforts across all HUD program offices and their respective field offices.
The U.S. Postal Service offers reduced postage rates (i.e., worksharing rates) to mailers for handling, pre-applying barcodes, pre-sorting, and transporting mail. Worksharing rates are also referred to as workshare discounts because postage rates are reduced based on costs the Postal Service is estimated to avoid from worksharing activities the mailing industry performs, which enables the Postal Service to increase its operational efficiency. In fiscal year (FY) 2022, 87 percent of domestic market dominant mail was workshared. Ninety-seven percent of domestic market dominant workshared mail consisted of either First-Class Mail or Marketing Mail. Domestic market dominant workshared First-Class Mail and Marketing Mail consisted primarily of letters. The Postal Service increased the percentage of workshare discounts that align with avoided costs from 41 percent in FY 2018 to 91 percent in FY 2022. Worksharing is dependent on the Postal Service, Postal Regulatory Commission, and mailing industry performing several key activities; and the procedures for the workshare discount calculation process being current and sufficiently detailed for effective implementation by responsible personnel.
For our evaluation of the United States Patent and Trademark Office’s (USPTO’s) and the U.S. Department of Commerce’s (the Department’s) ethics oversight of USPTO patent examiners, our evaluation objective was to determine whether USPTO and the Department effectively administered ethics rules to prevent financial conflicts of interest by USPTO patent examiners. Overall, we found that USPTO and the Department did not effectively administer the Department’s ethics program to protect against potential conflicts of interest by patent examiners. Specifically, we found that I. USPTO and the Department did not ensure examiners filed confidential financial disclosure reports (CFDRs) as required; II. The Department did not identify or resolve potential financial conflicts in CFDRs; and III. USPTO and the Department did not provide specialized training or guidance to examiners on potential ethics conflicts.
The OIG conducted this inspection to assess the stewardship and oversight of funds by the VA Memphis Healthcare System in Tennessee. This inspection assessed financial activities and administrative processes to determine whether appropriate controls and oversight were in place. These included open obligations, purchase card use, inventory and supply management, and pharmacy operations.After analyzing a judgmental sample of 20 open obligations, the team found that 10 obligations totaling approximately $11.5 million were more than 90 days past the end of the performance period, and the team could not verify whether healthcare system staff reviewed these obligations, as required. In another sample, the team found that four obligations had residual funds of $7,200 that should have been deobligated.Using a sample of 40 purchase card transactions, the team estimated that staff may have made noncompliance errors in over 18,500 transactions resulting in approximately $19.8 million in questioned costs.For inventory and supply management, the team found that training issues, inadequate staffing levels, poor oversight, and data validity issues affected the healthcare system’s stock levels. Healthcare system staff also could not provide documentation to show that required physical inventories were completed or that the chief supply chain officer reviewed the list of personnel with access to the inventory system.The team also found that the healthcare system can further improve pharmacy efficiency by adhering to inventory management best practices, such as adding scannable barcodes to shelving, increasing inventory turnover rates for “A” and “C” items in accordance with Pharmacy Benefit Management target rates, and ensuring compliance with the B09 reconciliation process.The OIG made nine recommendations to the healthcare system director to address the issues identified.
Audit of the Justice Management Division’s Information Security Management Program Pursuant to the Federal Information Security Modernization Act of 2014, Fiscal Year 2023