Federal Reports

The OIG inspection team sought tounderstand how the U.S. GovernmentPublishing Office (GPO) maintainsindoor air quality (IAQ) at the CentralComplex Buildings in Washington, DC.

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

KPMG LLP’s (KPMG) report on its financial statement audit of the National Credit Union Administration’s (NCUA) financial statements, which includes the Share Insurance Fund, the Operating Fund, the Central Liquidity Facility, and the Community Development Revolving Loan Fund, as of and for the years ended December 31, 2023 and 2022. The NCUA prepared financial statements in accordance with the Office of Management and Budget (OMB) Circular No. A-136 Revised, Financial Reporting Requirements, and subjected them to audit.Under a contract monitored by the NCUA OIG, KPMG, an independent certified public accounting firm, performed an audit of NCUA’s financial statements as of December 31, 2023. The contract required that the audit be performed in accordance with generally accepted government auditing standards issued by the Comptroller General of the United States, OMB audit guidance, and the Government Accountability Office/President's Council on Integrity and Efficiency Financial Audit Manual. KPMG’s audit report for 2023 includes: (1) an opinion on the financial statements, (2) conclusions on internal control over financial reporting, and (3) a section addressing compliance and other matters. In its audit of the NCUA, KPMG found:• The financial statements were fairly presented, in all material respects, in conformity with U.S. generally accepted accounting principles,• There were no deficiencies in internal control identified as material weaknesses or significant deficiencies and• No instances of reportable noncompliance with laws and regulations it tested or other matters that are required to be reported under Government Auditing Standards or OMB guidance.

We audited costs claimed by the Iowa Department of Natural Resources under grants awarded by FWS through WSFR.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the Samuel S. Stratton VA Medical Center and associated outpatient clinics in New York. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued 10 recommendations for improvement in the following topic areas:• Medical Staff Privileging1. Service-specific criteria2. Equivalent specialized training and similar privileges• Environment of care1. Inspection scheduling, completion, and documentation2. Police response times to panic alarm testing3. Installation and testing of over-the-door alarms for sleeping room doors in the mental health inpatient unit4. Safe environment in the mental health inpatient unit5. Patient care areas safe and clean• Mental health1. Comprehensive Suicide Risk Evaluation completion after positive suicide risk screen2. Suicide prevention outreach activities

Eric Graham, a former Amtrak conductor based in New York, used a stolen identity to obtain employment on July 8, 1998, and continued to use that identity for over twenty-years. Our investigation determined that Graham used the stolen identity to illegally obtain a passport, credit cards, Railroad Retirement Board benefits, Amtrak employment benefits including medical coverage, and to file federal tax returns. Graham separated from Amtrak voluntarily with retirement disability on October 14, 2021. On February 13, 2024, Graham pleaded guilty in Queens Criminal Court in Kew Gardens, New York, to a misdemeanor charge of Filing a False Instrument in the Second Degree and was sentenced to probation for twelve-months.

The mission of the U.S. Postal Inspection Service is to support and protect the U.S. Postal Service and its employees, infrastructure, and customers. Postal inspectors are law enforcement agents who are assigned accountable property, such as surveillance equipment, for investigative purposes. Surveillance equipment is an electronic or mechanical device used to capture communications, visual images, and physical locations for investigative purposes. As of fiscal year 2023, the Postal Inspection Service had about 10,000 pieces of law enforcement surveillance equipment valued at over $65 million. Effective management of law enforcement equipment ensures the Postal Inspection Service can fulfill its important mission of countering mail theft and narcotics in mail and preventing identity theft to support and protect the Postal Service and its customers.

We audited the U.S. Department of Housing and Urban Development’s (HUD) oversight of multifamily housing properties with failing Real Estate Assessment Center (REAC) scores or life-threatening exigent health and safety (EHS) deficiencies. Our objective was to determine whether HUD had effective oversight of multifamily housing properties to ensure that the properties were maintained in decent, safe, and sanitary condition.The effectiveness of HUD’s oversight of physical conditions in multifamily housing properties could be improved. Of the sampled properties that we reviewed, HUD did not (1) issue 45 percent of notices of violation or default to multifamily property owners in a timely manner for failure to maintain their properties in decent, safe, and sanitary condition; and (2) receive or maintain (a) 18 percent of the required EHS certifications to support that property owners corrected life-threatening deficiencies, (b) nearly 19 percent of owners’ surveys identifying all physical deficiencies, and (c) 13 percent of owners’ certifications that all deficiencies identified in REAC inspections and the owners’ surveys had been corrected and properties complied with HUD’s physical condition standards. HUD also did not ensure that its staff complied with its policy for granting extensions to cure periods specified on the notices of violation or default for 8 of the 11 approved extension requests. Further, HUD (1) could not support that it submitted 11 of 18 required quarterly or semiannual reports to Congress on the physical condition of assisted multifamily properties assessed through REAC and (2) did not submit 7 reports to Congress by the statutory due date.These issues occurred because HUD did not have sufficient procedures and controls in place at the regional and headquarter level to ensure compliance with requirements. Further, HUD lacked sufficient oversight of its staff to ensure that adequate documentation was received and maintained to monitor multifamily housing properties’ timely compliance with physical condition standards and to report oversight results to Congress in a timely manner. As a result of HUD’s not issuing notices in a timely manner, it delayed the start of the cure period for the owners to correct identified deficiencies, which increased the risk that residents were subjected to substandard living conditions for a longer period. Further, HUD’s staff did not always have the surveys and certifications necessary to monitor whether multifamily housing property owners complied with HUD’s requirement to maintain housing in a decent, safe, and sanitary condition. Lastly, Congress did not always receive timely information concerning the physical condition of assisted multifamily housing properties, and HUD was uncertain whether required reports and schedules were issued to Congress.We recommend that the Director of Multifamily Asset Management and Portfolio Oversight develop and implement adequate procedures and controls to ensure that (1) staff issues notices of violation and default within 15 calendar days of the inspection report release date and (2) the Office of Multifamily Asset Management and Portfolio Oversight is made aware when notices are issued late and takes action as appropriate to ensure that future notices are issued in a timely manner. Additionally, we recommend that the Director (1) include more specific language regarding owner surveys in future notices of violation and default; (2) develop and implement adequate procedures and controls to ensure that owner surveys, certifications, and other relevant records are maintained and retrievable from an easily accessible location and that staff members with the appropriate level of authority approve extensions to cure periods in notices of violation and default when necessary; and (3) assess and streamline the processes for preparing, reviewing, and approving the reports as appropriate to ensure that the reports are submitted to Congress on or before the required due date.

The National Credit Union Administration (NCUA) Office of Inspector General (OIG) conducted this self-initiated audit to assess the NCUA’s use of cloud computing services. Our objectives were to determine whether the NCUA: (1) adequately addressed risk when contracting cloud computing services; and (2) effectively managed operational and security risks of implemented cloud computing services. Results of our audit determined that the NCUA needs an enterprise-wide approach to cloud computing to effectively contract and manage cloud computing services. The NCUA should align policies and procedures with this enterprise-wide approach. Our audit also determined the NCUA implemented cloud computing services as the situation or business need occurred to meet mission priorities. We believe this approach has not allowed the NCUA to clearly address federal guidance, has created inconsistent processes, and allowed for decisions and implemented services to be made unsystematically. Therefore, we are making two recommendations in our report and note that management has agreed to both recommendations. Given the current approach to the agency’s cloud computing services, the OIG plans to conduct a follow-up audit on the contracting and risk management of its use of cloud computing services once the recommendations in this report have been implemented.

Hanna Dinh, a California resident, was sentenced on February 12, 2024, in U.S. District Court, Central District of California, for conspiracy to commit wire fraud. Dinh was sentenced to 20 months in prison, followed by 3 years’ probation, of which 7 months is to be served as home confinement.Our investigation found that Dinh and others made false statements to lenders in connection with fraudulent applications for Economic Injury Disaster Loan (EIDL) and Paycheck Protection Program (PPP) loans for her company, HD Financial Firm. The applications included false representations regarding the number of employees on the company’s payroll and false certifications that the loans would be used for permissible business purposes. Dinh incorporated HD Financial Firm in June 2020 and was its sole officer and registered agent. Dinh and others submitted fraudulent EIDL and PPP loan applications seeking approximately $260,672.This investigation is part of a nationwide law enforcement action that resulted in criminal charges against 18 defendants for their alleged participation in fraud schemes that exploited the COVID-19 relief funds. A co-defendant in this case, Dr. Anthony Hao Dinh, a licensed doctor of osteopathy who was an ear, nose, and throat specialist and a facial plastic surgeon, was charged in September 2023 for allegedly defrauding the Health Resources and Services Administration Uninsured Program of approximately $230 million. Anthony Hao Dinh allegedly submitted fraudulent claims to the Uninsured Program for treatment of patients, including Amtrak employees, who were, in fact, insured. In addition, Anthony Hao Dinh allegedly billed for services not rendered and for services that were not medically necessary.

We reviewed how RMA administered and oversaw the Federal Crop Insurance Program’s requirements for prevented planting.

The Federal Election Commission (FEC) has experienced a significant decline in staffing levels over the last 20 years, losing 20% of its full-time workforce from 2002 to 2022. Based on this observed decline, the Office of Inspector General (OIG) initiated this evaluation to identify root and proximate causes of this decline and to evaluate related issues.

We audited the U.S. Department of Housing and Urban Development (HUD), Office of Community Planning and Development’s (CPD) process for collecting financial information from grantees participating in the Community Development Block Grant (CDBG) Entitlement program. Prior year HUD financial statement audits found weaknesses in CPD’s processes to estimate accrued grant liabilities and instances where it appeared CDBG grantees were holding advanced funds. Our audit objectives were to determine whether (1) the financial information collected from grantees was sufficient to monitor grantee financial reporting and performance as required by federal regulations; (2) HUD’s monitoring of grantees’ cash on hand was sufficient to ensure compliance with cash management requirements and that the monitoring was adequate to safeguard funds against the risk of fraud, waste, and abuse; and (3) HUD was properly reporting the financial information collected from its grantees in accordance with the Statements of Federal Financial Accounting Standards.We found that the financial information collected from CDBG Entitlement grantees was not sufficient to monitor grantee compliance with cash management requirements contained in federal regulations. Our review of CPD Cash on Hand Quarterly Reports (PR 29 reports) found that grantees consistently made errors in preparing the report or did not have adequate documentation to support the amounts reported. We also found PR 29 reports that were not submitted or were submitted after the required deadline for certain quarters and resubmissions that were not tracked by HUD. Without reliable and timely financial data, CPD cannot adequately monitor grantees’ excess cash or properly assess their compliance with cash management requirements, thereby increasing the funds’ susceptibility to the risk of fraud, waste, and abuse. Further, since the reports were not submitted in a timely manner and were not reliable, the information collected could not be leveraged by the Office of the Chief Financial Officer (OCFO) to properly report grantee financial information in compliance with the Statements of Federal Financial Accounting Standards. Additionally, we found opportunities for CPD to improve (1) the timing of grantee drawdowns to better align with when the actual expense was incurred and (2) its financial data collection efforts from its CDBG grantees to estimate HUD’s accrued grant liability as required by the Statements of Federal Financial Accounting Standards. CPD’s accrued grant liability estimation methodology relies on grantee drawdown data and produces an unreliable estimate due to the significant delays in grantee disbursements from when an expense is incurred. Further, CPD does not collect expense data elements from the OMB Federal Financial Report (Standard Form-425), which could potentially be used to assist HUD in producing a more precise accrual estimate, resulting in improved financial reporting. Lastly, we identified that CPD is collecting information on the PR 29 report that was not approved by the Office of Management and Budget (OMB) as required by the Paperwork Reduction Act (PRA). Consequently, CPD did not receive public input as required nor did they assess the reporting burden imposed on the grantee as required by the PRA.We recommend that CPD improve its guidance, training, and monitoring of the PR 29 report to ensure that the information collected is reliable, accurate, and timely. In addition, we recommended that CPD work with OCFO to ensure that it collects all of the information needed to properly account for all CPD activities in HUD’s financial statements in accordance with Federal financial reporting requirements and accounting standards. Lastly, we made a recommendation that CPD obtain the required approvals under the PRA for the PR 29 report.

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

The OIG performed this audit to assess VA’s compliance with executive orders, federal regulations, and VA requirements for vetting contractor employees to serve on VA contracts. If contractor employees are not vetted before working for VA, they may endanger veterans and VA employees, as well as the efficiency and integrity of VA services, government property, and VA information.The audit team found VA officials had a high rate of noncompliance. The team found that 94 percent of contract files reviewed did not include position designations establishing the investigative requirements for the contract. In addition, 90 percent did not include language to communicate vetting requirements to the contractor. Ultimately, 75 percent of employees under the contracts reviewed did not have a fingerprint check, and about 79 percent did not have a formal background investigation.Noncompliance stemmed from differences among offices concerning roles and responsibilities for the suitability program and from incorrect guidance. The Office of Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) and the Office of Information and Technology (OIT) had outdated and conflicting or inaccurate policies on the subject. Also, the Office of Acquisition, Logistics, and Construction (OALC) directed its staff to the wrong policies.Because of long-standing disagreements between HRA/OSP and OALC concerning roles and responsibilities for personnel security, the OIG recommended the VA Deputy Secretary mediate their efforts to collaborate on developing and publishing updates to the policies and procedures for vetting contractors. The OIG further recommended the assistant secretary for HRA/OSP conduct compliance inspections at the St. Cloud VA Medical Center in Minnesota, where the OIG team found 52 percent of contractor employees (none of whom were vetted) had criminal records. The OIG also recommended OALC direct acquisition professionals to the correct policies for vetting contractor employees.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (focusing on suicide prevention initiatives)The OIG issued six recommendations for improvement in two areas:1. Environment of care• Clean and safe patient areas• Well-maintained medical center• Medication access• Temperature- and humidity-controlled storage rooms2. Mental health• Comprehensive Suicide Risk Evaluations• Notification of suicidal behaviors

If the EPA does not adequately plan to increase the PSB’s capacity to respond to a 20-fold increase in employees receiving continuous vetting services, delays in processing and managing full TW 2.0 implementation may increase the risk to national security from insider threats.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the Ralph H. Johnson VA Medical Center and associated outpatient clinics in Georgia and South 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 the following topic areas:1. Quality, safety, and value• Root cause analysis for patient safety events2. Medical staff privileging• Equivalent specialized training and similar privileges3. Environment of care• Inspection deficiency tracking• Police response times to panic alarm testing4. Mental health• Reporting of suicide-related events

We found a subcontractor falsified documentation regarding clearing production platforms, causing the lessee to provide these documents to BSEE.

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 VA Office of Inspector General (OIG) conducted a healthcare inspection at the Montana VA Health Care System to assess allegations of the Chief of Staff (COS) providing pregnancy care without privileges, deficient care, and leadership failures.The OIG found that the COS practiced without privileges when providing pregnancy care for a patient during her second and third trimesters. The COS evaluated the patient for potential severe pregnancy-related conditions at the facility on two occasions instead of directing the patient to a community facility equipped to evaluate and manage obstetric care. The COS’s failure to follow evidence-based clinical standards for care placed the patient and fetus at risk.The OIG also identified opportunities for improvement in the COS’s management of another patient whose post-operative treatment included provision of an inadequate antibiotic and a delayed consultation. However, the OIG was unable to determine whether alternate management strategies would have resulted in a different clinical outcome. The OIG also found that the COS failed to perform expected preoperative testing for surgical procedures in 32 of 35 cases.The OIG found deficiencies in leaders’ oversight, resulting in a failure to detect quality of care concerns and act on known and substantiated concerns. Required ongoing professional practice evaluations were not completed for the COS, and privileging processes were not followed. The Facility Director did not initiate state licensing board reporting for the COS on two separate occasions, and failed to complete state licensing board reporting timely on a third, when reportable deficiencies were identified.The OIG made 10 recommendations related to ensuring alignment with VHA and facility policies, including those related to privileging, and maternity and pregnancy care; a review of care deficiencies to identify follow-up needs; processes for ongoing professional practice evaluations; timely completion of administrative actions; and state licensing board reporting.

The objectives of our audit were to determine whether (1) United Education Institute’s (doing business as UEI College) career pathway programs met the program eligibility requirements set forth in section 484(d)(2) of the Higher Education Act of 1965, as amended (HEA); (2) students enrolled in UEI College’s career pathway programs met the student eligibility requirements set forth in section 484(d)(1)(A) of the HEA; and (3) UEI College excluded from students’ enrollment statuses and costs of attendance the component of its career pathway programs that enables a student to attain a high school diploma or its recognized equivalent. We concluded that all eight of UEI College’s career pathway programs satisfied all seven of the program eligibility requirements in section 484(d)(2) of the HEA. While we concluded that the school’s career pathway programs satisfied the program eligibility requirements, it did not always retain sufficient documentation to show that students received counseling to support them in achieving their career goals. In addition, we concluded that all students included in our sample received passing scores on a Department-approved ATB test, as required by section 484(d)(1)(A) of the HEA. We also concluded that the ATB tests for students included in our sample from 8 of UEI College’s 11 campuses were independently administered. However, we could not conclude whether the ATB tests taken by the students included in our sample from three campuses were independently administered in compliance with 34 C.F.R. section 668.151 and the ATB test publisher’s rules. Finally, we concluded that UEI College properly excluded the high school completion component of its career pathway programs from the enrollment statuses and costs of attendance for all students included in our sample.

We contracted with the Institute for Defense Analyses (IDA), an independent firm, to evaluate the U.S. Census Bureau's EAE operation. The original objective was to determine whether the bureau prepared adequate and timely operational assessments that included the appropriate metrics to support planning for the 2030 decennial’s research and testing. The scope of the objective was later expanded to include the other major EAE components, namely evaluations and experiments. IDA found that (1) 2020 operational assessments, evaluations, and experiments were not completed in time to formally inform the development of the Census Bureau’s 2030 research and testing agenda; (2) the 2020 census EAE research program failed to prioritize the evaluation of two of the four key 2020 innovation areas and the investigation of a potentially significant 2030 innovation; (3) the Census Bureau has put management processes and tools in place but does not always use them to their potential; (4) the Census Bureau should standardize the reporting of cost data across EAE products; (5) the Census Bureau should examine delays with respect to the originally planned schedule and not just the latest re-baselined schedule; and (6) the Census Bureau should resource-load the activities in the decennial census integrated master schedule.

We conducted an extensive review of foul time logs and bridge logs for two Connecticut bridges—the Thames River Bridge and the Shaw’s Cove Bridge—and found 17 occasions in 2022 when Buildings & Bridges employees potentially fouled the tracks by passing within four feet of the near running rail without requesting the required foul time. In addition, we confirmed this information through employee interviews. Our review supported assertions that the employees did not request foul time, as required, but we were unable to determine if the required safety job briefings were given. We received a response from company officials on February 5, 2024, describing corrective actions they plan to take in response to our review.

A Digital Technology employee based in Michigan violated company policies by failing to report outside employment with at least two other companies on her Certificate of Compliance she submitted on October 10, 2023. We also identified computer misuse related to the outside employment. She was terminated on February 2, 2024, and is ineligible for rehire.

Objectives; To determine (1) whether the Social Security Administration accurately and timely paid beneficiaries subject to the earnings test and (2) the administrative costs to enforce the earnings test.

We audited costs claimed by the Nebraska Game and Parks Commission under WSFR grants awarded by the FWS.

The audit was performed under a contract with, and monitored by, the Office of Inspector General (OIG), in accordance with auditing standards generally accepted in the United States of America; the standards applicable to financial audits contained in Government Auditing Standards, issued by the Comptroller General of the United States; and applicable provisions of Office of Management and Budget (OMB) Bulletin No. 24-01, Audit Requirements for Federal Financial Statements.

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

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the Robert J. Dole VA Medical Center and multiple outpatient clinics in Kansas. 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 did not issue recommendations for improvement related to the areas reviewed for this report.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review an allegation that the Behavioral Health Service program manager denied 32 patients behavioral health community care services at the Oklahoma City VA Medical Center in Oklahoma (facility).During the review, the OIG substantiated that the program manager did not follow the consult management process and discontinued behavioral health community care consults for 29 patients. The OIG did not substantiate that the behavioral health patients were denied care but determined that the discontinued consults resulted in a delay of care for seven patients. The OIG determined that when the discontinued consults were identified, facility leaders initiated reviews and took timely action to ensure patients received the requested care.The OIG found that the program manager reviewed each community care consult and used an availability tool to identify open internal appointments, then incorrectly commented to schedule patients in specific internal openings and discontinued the consults. Despite completing required trainings, the program manager reported not recognizing that comments to schedule a patient into a specific opening could be considered a prohibited practice called blind scheduling, and incorrectly identified that the discontinue consult status allows further action to be taken. The OIG concluded that the program manager had poor knowledge of the consult management scheduling processes and failed to follow requirements for behavioral health community care consults that led to delayed care for seven patients. The Behavioral Health Service leaders and the patient safety manager reported concerns to facility leaders after identifying that the program manager was discontinuing consults. Facility leaders took actions, including investigating the reports and conducting quality reviews that showed no adverse events from the delays.The OIG made one recommendation to the Facility Director related to community care consult management and appointment scheduling processes.

Semiannual Report to Congress.

15th SIGPR Quarterly Report to Congress

FY2024 Charge Card Assessment

We audited costs claimed by the New York Department of Environment Conservation, Division of Fish and Wildlife, under WSFR grants awarded by FWS.

As of January 31, 2024, the EPA and the CSB have no outstanding OIG recommendations related to their travel and purchase card programs.

The U.S. Environmental Protection Agency prepared the Semi-Annual Report on Purchase Charge Card Violations for the period of April 1, 2023, to September 30, 2023. No additional information inconsistent with the EPA’s violation report for the reporting period came to our attention and we received no allegations of misuse of the government purchase card for the semiannual period.