Federal Reports

VA’s Denver Logistics Center (DLC) manages millions of dollars of supplies intended for Veterans Health Administration (VHA) facilities and patients. According to VA policy, VA staff who use, supervise, or control VA-owned goods are accountable for those goods from acquisition to disposition.The VA Office of Inspector General (OIG) audited to determine whether the DLC maintained accurate inventories of VA-owned goods and identified significant deficiencies in inventory management operations and systems. Specifically, the DLC’s inventory records did not align with on-hand supplies or include all goods, and the DLC lacked an effective internal control system. Inaccurate inventories, weak internal controls, and lack of reporting outside of the DLC created the risk of misleading financial reporting and increased costs to VHA. Further, supplies and veteran information kept at DLC warehouses were not physically secured.The audit also revealed the DLC did not have appropriate system controls to protect inventory data. The DLC’s inventory management system software has access and security vulnerabilities and lacked transparency. Like the VA-owned supplies on hand, the DLC system hardware was also vulnerable to physical access and security risks. Overall, the DLC’s inventory ordering system is becoming unsustainable.The DLC has largely operated under minimal oversight of its inventory operations, and the OIG found that oversight to be ineffective at ensuring VA policies were followed and VA-owned goods protected. The independent nature of DLC operations, along with the deficiencies identified in this audit, impedes the DLC from effectively fulfilling its mission and creates a heightened risk of fraud, waste, and abuse.VA concurred with the OIG’s 11 recommendations to improve the inventory management operations and oversight of the DLC and with another eight recommendations that address information system deficiencies.

VHA relies heavily on community providers for dialysis services for veterans, having spent about $1.2 billion on these services from October 2020 through September 2022. The Office of Integrated Veteran Care (IVC) is responsible for managing the delivery of community dialysis services through community care network (CCN) contracts and nationwide dialysis services contracts (NDSCs). CCN providers receive up to the Medicare rate plus some administrative fees, while NDSC providers received more than the Medicare rate.According to the MISSION Act, community provider reimbursement cannot exceed Medicare rates except in highly rural areas, in states with an all payer model, or when VA makes an exception. Although the MISSION Act was not in effect when the current NDSCs were awarded, VA must consider these requirements in future acquisitions. In fiscal year 2021, VHA announced its intent to transition dialysis services from NDSCs to the CCN. The OIG conducted this audit to determine if VHA effectively provides veterans access to dialysis services by evaluating whether it followed its prescribed referral process that prioritizes the use of available CCN over NDSC providers.VHA experienced several barriers to ensuring compliance with its community dialysis referral requirements and increasing use of CCN providers over NDSC providers. Specifically, IVC did not effectively oversee dialysis care in the community, clearly assign oversight responsibilities for community dialysis services, ensure medical facility dialysis coordinators followed required referral steps, or use available data to inform decisions. The team also found some inaccurate or incomplete data in the information system used by dialysis coordinators to identify available providers.The OIG recommended VHA clarify guidance, establish roles and responsibilities, improve data accuracy, and ensure future dialysis service contracts meet MISSION Act payment rate requirements.

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We found that a former BIA employee defrauded the Government through misuse of Government credit cards and other misconduct.

What We Looked AtSince 2014, the Federal Aviation Administration’s (FAA) Airport Improvement Program has obligated more than $3.18 billion to eligible airports each fiscal year for airport development and planning. At the direction of Congress, FAA published its Policy and Procedures Concerning the Use of Airport Revenue (Revenue Use Policy) to define airport revenue and identify permitted and prohibited uses of that revenue. FAA amended this policy in 2014 to address revenue use for aviation fuel taxes. Given the importance of promoting effective stewardship of taxpayer dollars used to support the Nation’s airports, we initiated this audit. Our objective was to assess whether FAA’s oversight policies and procedures are sufficient to prevent or detect airport revenue diversion. For this audit, we focused on FAA’s efforts to ensure compliance with FAA’s rules for collecting and using aviation fuel taxes. What We FoundSince amending its Revenue Use Policy, FAA has made progress confirming whether State and local Government laws comply with the amendments. However, the Agency has not yet tested or validated if the compliant jurisdictions use the proceeds from aviation fuel taxes according to the jurisdictions’ approved action plan. Without testing the jurisdictions’ approved action plan for using aviation fuel taxes, FAA cannot ensure that revenue is used for aviation‑related purposes as required by Federal regulations. In addition, the Agency has not taken enforcement actions against the five jurisdictions that are not yet in compliance with the amendments. According to Agency officials, the lack of testing, validation, and enforcement action is due to congressional guidance that encouraged the Agency to postpone enforcement. By potentially diverting aviation fuel tax revenue from airports for non‑aviation-related purposes, these jurisdictions increase the risk of hindering the airports’ ability to remain self‑sufficient and improve their infrastructure. Our RecommendationsWe made three recommendations to improve FAA’s oversight policies and procedures for preventing and detecting airport revenue diversion. FAA concurred with our recommendations and provided appropriate actions and completion dates. We consider all recommendations resolved but open pending completion of the planned actions.

What We Looked AtExtreme weather events, including those potentially caused by effects of climate change, are a source of major disruptions to the National Airspace System (NAS). In November 2021, Congress passed the Infrastructure Investment and Jobs Act (IIJA) authorizing $25 billion to the Federal Aviation Administration (FAA) to fund programs to address aging aviation infrastructure. Specifically, it funded the Airport Infrastructure Grant program, Airport Terminal Program, and the Facilities and Equipment program. Also, in November 2021, President Biden issued Executive Order (EO) 14052, which directed agencies tasked with implementing IIJA to take steps, such as prioritizing as appropriate and to the extent consistent with law, building resilient infrastructure projects that help combat climate change. As part of our IIJA funding oversight and given the policy emphasis on climate change and resiliency, we initiated this audit. Our objective was to assess FAA’s plans for prioritizing resiliency into IIJA aviation programs. What We FoundFAA has taken steps to address resiliency in discretionary IIJA aviation programs. For example, FAA incorporates resiliency and climate change in its project selection criteria for these programs. However, FAA has not established a mechanism for collecting and reporting data on the extent to which IIJA-funded projects address FAA’s and the Department of Transportation’s (DOT) strategic goals on climate and sustainability. Also, FAA does not have a framework to prioritize projects that address climate change in its standards. As a result, FAA and airports are not required to consider climate change impacts when proposing infrastructure projects. However, in September 2021, FAA entered into an interagency agreement with DOT’s John A. Volpe National Transportation Systems Center (Volpe) for a 5-year study to identify the climate change risk to airport systems. Yet, the results of this study, which is currently scheduled to conclude in 2026, will not be available for many projects that receive funding before the study’s end. Our RecommendationsWe made two recommendations to improve FAA’s prioritization of resiliency and climate change in IIJA aviation programs.

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

The VA Office of Inspector General (OIG) conducted a national review to determine compliance with Veterans Health Administration (VHA) policy on the management of emergent care needs of acute sexual assault victim-survivors. Sexual assault is an invasive form of interpersonal violence that can have medical, psychological, and legal consequences, requiring a coordinated and compassionate response from medical providers and law enforcement officers when victim-survivors seek care.The OIG found deficiencies in adherence to VHA policy, including requirements to ensure the provision of sexually transmitted infection prophylaxis and pregnancy prophylaxis when clinically indicated, to offer psychological counseling, and in the documentation of signature informed consent for forensic examinations. The majority of VHA facilities utilized community sexual assault forensic examiner (SAFE) resources to provide forensic examinations, which was identified as a best practice for most VHA sites.Care related to acute sexual assault is a low frequency but crucial occurrence in VHA, presenting challenges maintaining staff knowledge and training. Additionally, facility and community resources as well as jurisdictional requirements on reporting and evidence collection for acute sexual assault vary across facilities. VHA policy establishes requirements to ensure that veterans have access to safe, high-quality care. However, supplemental facility policy or guidance is needed to ensure facility procedures align with local community resources and jurisdictional requirements to ensure frontline staff have easy access to current clinical practices when responding to acute sexual assault. The OIG determined that opportunities exist for many facilities to improve guidance addressing management of acute sexual assault patients. Improved facility guidance would help ensure implementation of VHA policy by providing frontline staff and VA police with relevant, accessible local procedures and resources when responding to patients presenting with acute sexual assault.The OIG made eight recommendations to the Under Secretary for Health related to practice deficiencies and improving guidance.

An Amtrak Coach Cleaner based in Beech Grove, Indiana, was terminated from employment on December 12, 2023, following his administrative hearing. Our investigation found that the employee violated company policies by falsely claiming employment with the U.S. Army from 2004-2015 on a resume he submitted to the company, when he was actually serving time in prison for arson.

An Amtrak electrician based in Wilmington, Delaware, violated company policies by engaging in outside employment by operating his general contracting business while on a medical leave of absence. The employee was on a medical leave of absence since February 2020 and had not returned to work as of the issuance of our investigative report. The employee resigned on December 12, 2023, prior to his scheduled administrative hearing.

The Pandemic Response Accountability Committee’s (PRAC) Semiannual Report to Congress, covering the period from April 1, 2023 through September 30, 2023.

Like other organizations, Amtrak (the company) faces the inherent cybersecurity risk that employees or contractors are “insider threats”—that is, that they could maliciously or unintentionally use information systems or data in a manner that harms the company. Insider threats may cause more harm and are more difficult to detect than external cyber‐attackers because individuals within an organization already have access to systems and data. Amtrak Office of Inspector General’s (OIG) recent investigations identified company employees and contractors who misused or took advantage of their system access and exposed sensitive company information. Accordingly, our objective was to assess the effectiveness of company controls to protect its information systems and data from insider threats. Our recommendations included conducting an insider threat risk assessment, establishing a policy for insider threat activities, and developing a process to track and enforce company access requirements. In commenting on a draft of this report, company executives agreed with our recommendations and identified actions that the company plans to take to address them.THE TRANSPORTATION SECURITY ADMINISTRATION AND THE DEPARTMENT OF TRANSPORTATION HAVE DETERMINED THAT THIS REPORT CONTAINS SENSITIVE SECURITY INFORMATION (SSI) that is controlled under 49 CFR parts 15 and 1520 to protect Sensitive Security Information exempt from public disclosure. For Amtrak OIG, public disclosure is governed by 5 U.S.C. § 552 and 49 CFR parts 15 and 1520. This public version of the report has been redacted.

Our objective was to evaluate whether the Postal Service had security controls in place to protect the application from cyberattacks, prevent unauthorized access to restricted data, and determine compliance with secure coding practices. We conducted a security assessment of the application including penetration tests to evaluate the application and internal security posture. We also performed a source code review to verify if appropriate security controls were present.

KPMG audited DOI’s financial statements and found three material weaknesses and one significant deficiency in financial reporting internal controls.

The DOI took actions to address the six recommendations we reviewed; we determined all six recommendations have been implemented.

This report has an accessibility notice.

Continuity of operations (COOP) is an effort within the executive office of the President of the United States and individual federal executive departments and agencies to ensure that mission essential functions continue to be performed during disruption of normal operations. Mission essential functions are a limited set of agency-level functions that are directly related to accomplishing the mission of the organization and must be continued throughout, or resumed rapidly after, a disruption of normal activities.We included an audit of the Tennessee Valley Authority’s (TVA) COOP plan on our annual audit plan due to the operational risks that could result from noncompliance with federal continuity guidance and/or inadequate COOP plan implementation. Our audit objective was to determine if TVA's COOP plan complies with applicable laws, regulations, and executive orders and has been adequately implemented. Our audit scope included the TVA COOP plans and applicable laws, regulations, and executive orders implemented as of December 31, 2022.We determined TVA’s COOP plan generally complies with applicable laws, regulations, and executive orders and has been adequately implemented. However, we identified three instances in which TVA’s COOP plan is not currently in compliance with federal continuity directive guidance, including:• Annual COOP training for TVA employees is not currently required.• COOP program essential records are not adequately maintained.• One organization’s COOP plan does not include a defined review cadence to ensure timely updates.Additionally, we determined COOP program guidance does not address TVA’s information management policy.

Our annual plan identifies the audits, inspections, and other activities that the OIG intends to undertake to assist the U.S. Department of Education in fulfilling its responsibilities to America’s citizens and students.

This audit focused on determining the root causes of poor service performance and customer service issues in Colorado mountain towns. The audit team visited 13 delivery units and one processing and distribution center throughout the mountain towns; conducted observations of processing, delivery, and retail operations; interviewed personnel on challenges faced; and conducted data analysis on service performance.

This Office of Inspector General Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the VA Providence Healthcare System, which includes the Providence VA Medical Center and multiple outpatient clinics in Massachusetts and Rhode Island. 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 two areas:1. Medical staff privileging• Equivalent specialized training and similar privileges for Focused Professional Practice Evaluations2. Mental health• Timely completion of Comprehensive Suicide Risk Evaluations

This Semiannual Report summarizes the Office of Inspector General's activities and accomplishments for April 1, 2023, to September 30, 2023. The Office of Inspector General issued one audit report, one evaluation report, and two other special project report. The Office of Inspector General received 178 hotline contacts during the reporting period.

We found that the NPS did not adequately monitor States’ administration of LWCF funds.

Our audit objectives were to determine whether the Postal Service:Fairly stated accounting transactions in the general ledger and whether selected controls surrounding those transactions were designed and operating effectively.Properly tested, documented, and reported its examination of selected key financial reporting controls at Headquarters (HQ) and Accounting Service Centers (ASCs).

NGA OIG Fall Semiannual Report to Congress, 1 April - 30 September 2023

This report highlights and summarizes significant audit, inspection, and investigative results during this period that have strengthened Department of Energy programs and operations for the period ending September 30, 2023.

The Denali Commission Office of Inspector General issues its Semiannual Report to Congress summarizing the OIG's activities and accomplishments from April 1, 2023, to September 30, 2023.

FEC OIG's Semiannual Report to Congress.

This report summarizes the oversight work performed by EAC OIG during the 6-month period ended September 30, 2023.

Semiannual Reports to Congress, Volume 90 (April 1, 2023 - September 30, 2023)

Next Stage: Semiannual Report to Congress for October April 1, 2023 – September 30, 2023. Office of Inspector General, U.S. AbilityOne Commission.

NSA OIG Semiannual Report to Congress 1 April 2023 to 30 September 2023

The Inspector General Act of 1978 requires the Inspector General to prepare semiannual reports summarizing the activities of the Office of Inspector General for the preceding six-month period. The semiannual reports are intended to keep the Secretary and Congress fully informed of significant findings, progress the Agency has made, and recommendations for improvement.

Our Semiannual Report to Congress covering the period April 1 to September 30, 2023, features highlights of the OIG’s audit and investigations accomplishments during the past 6 months.

The Office of Inspector General is tasked with ensuring efficiency, accountability, and integrity in the U.S. Postal Service. We also have the distinct mission of helping to maintain confidence in the mail and postal system, as well as to improve the Postal Service's bottom line. We use audits and investigations to help protect the integrity of the Postal Service. Our Semiannual Report to Congress presents a snapshot of the work we did to fulfill our mission for the six-month period ending September 30, 2023. Our dynamic report format provides readers with easy access to facts and information, as well as succinct summaries of the work by area. Links are provided to the full reports featured in this report, as well as to the appendices.

I am pleased to submit the Amtrak Office of Inspector General (OIG) Semiannual Report to the United States Congress for the six months ending September 30, 2023, which summarizes our independent and objective reviews and investigations related to Amtrak’s programs and operations.The following report provides a complete review of our oversight work during the reporting period. Over the next six months, we are committed to providing oversight on high-impact areas such as major programs like the Frederick Douglass Tunnel, Portal North Bridge, Amtrak’s acquisition of next generation long-distance trains, and other areas important to the company, the Board of Directors, Congress, and the public. We trust that you will find this report informative.

Our objective was to evaluate the U.S. Postal Service’s effectiveness in planning air capacity on specific lanes (pair of originating and destinating air stops). We analyzed Postal Service air weight data for the specific lanes planned to one aviation supplier for ten operating periods starting January 1, 2022, and ending May 26, 2023.