Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations of delays in the receipt of patients’ colorectal cancer screening tests at the Phoenix VA Health Care System (facility) in Arizona. The OIG substantiated that 406 patient fecal immunochemical tests (FITs) were held in a non-VA warehouse due to an unpaid postage bill by the facility. The delay resulted in laboratory staff’s inability to process 403 (99 percent) FITs because they were outside the specimens’ 15-day stability period.The OIG did not substantiate a delay in further evaluation and care for the patients whose FITs were outside of the stability period and could not be tested or that patients’ personally identifiable information was not protected. The OIG found that facility staff’s plan for follow-up and efforts to ensure the patients received further evaluation and care were timely and thorough. The OIG did not identify adverse clinical outcomes for the 31 patients reviewed.After finding that patients had not recorded the specimen collection date (required to determine stability) on 86 percent of the delayed FITs, the OIG reviewed and identified concerns with the facility’s FIT processes. The OIG found the facility’s pre-printed FIT label did not include a space for the patient to record the date of collection, the laboratory manager and staff lacked knowledge and clarity about FIT stability, and primary care staff were unaware of the importance of the collection date.The OIG determined that facility and service line leaders missed opportunities to evaluate and resolve identified FIT labeling issues that were indicative of broader laboratory FIT processing failures. The OIG made two recommendations to the VISN Director related to oversight of laboratory FIT processing and three recommendations to the Facility Director related to ensuring compliance with FIT processes and ensuring specimen stability.

Audit Report for the FEC's FY 23 Annual FS Audit

The Office of the Inspector General contracted with the independent certified public accounting firm Ernst & Young LLP to audit: (1) the Social Security Administration’s (SSA) consolidated financial statements as of September 30, 2023 and the related notes to the consolidated financial statements; (2) the sustainability financial statements, including the statements of social insurance as of January 1, 2023 and the related notes to the sustainability financial statements; and (3) the statements of changes in social insurance amounts for the periods January 1, 2022 to January 1, 2023. The OIG also contracted with Ernst & Young to provide an opinion on internal control over financial reporting and report on compliance with laws, regulations, contracts, grant agreements, and other matters and to report on whether SSA’s financial management systems did not comply substantially with the requirements of the Federal Financial Management Improvement Act of 1996 (FFMIA). The contract requires that the audit be conducted in accordance with auditing standards generally accepted in the United States; Government Auditing Standards issued by the Comptroller General of the United States; and Office of Management and Budget (OMB) Bulletin No. 24-01, Audit Requirements for Federal Financial Statements. Those Standards and Bulletin require that Ernst & Young plan and perform the audits to obtain reasonable assurance about whether the financial statements are free from material misstatement and whether effective internal control over financial reporting was maintained in all material respects.

This report identifies three management challenges confronting AmeriCorps in fiscal year (FY) 2024 and beyond:· Improving financial management;· Prioritizing grant fraud prevention and detection in its programs; and· Modernizing and securing information technology.While it does not rise to the significance of a management challenge, we believe that AmeriCorps will be challenged in the future if American Rescue Plan (ARP) funding is not effectively used during FY 2024. We identified Effective Use of American Rescue Plan Funding as an emerging challenge, which is discussed later in this report.

In the audit of the Commission's financial statements for 2023 and 2022, we reported the following: - The Commission’s financial statements for fiscal years ending September 30, 2023 and 2022, were presented fairly, in all material respects, in accordance with U.S. generally accepted accounting principles; - Identified no material weaknesses in internal control over financial reporting and grant origination; and - Identified no instances of reportable noncompliance for fiscal year 2023 with provisions of applicable law, regulations, contracts, and grant agreements tested.

Each year, in compliance with Public Law 106-531, the Reports Consolidation Act of 2000, the Denali Commission Office of Inspector General issues a report summarizing what we consider the most serious management challenges facing the Commission.

Under a contract monitored by the National Credit Union Administration (NCUA) Office of Inspector General (OIG), KPMG, an independent certified public accounting firm, performed an audit of the NCUA’s schedule of investments and other taxes and receipts as of September 30, 2023. KPMG conducted the audit in accordance with auditing standards generally accepted in the United States of America, in accordance with the standards applicable to financial audits contained in Government Auditing Standards issued by the Comptroller General of the United States, and in accordance with the Office of Management and Budget (OMB) Bulletin No. 24-01, Audit Requirements for Federal Financial Statements. Those standards and OMB Bulletin No. 24-01, require that KPMG plan and perform the audit to obtain reasonable assurance about whether the schedule is free from material misstatement.KPMG prepared the audit report for the purpose of providing financial information to the U.S. Department of Treasury and the U.S. Government Accountability Office to use in preparing and auditing the Financial Report of the U.S. Government. The report includes: (1) an opinion on the schedule, (2) internal control over financial reporting specific to the schedule, and (3) compliance and other matters specific to the schedule. In its audit, KPMG found:• The schedule presents fairly, in all material respects, the investments and other taxes and receipts of the NCUA as of September 30, 2023, in accordance with U.S. generally accepted accounting principles.• There were no internal control deficiencies identified for the schedule considered to be material weaknesses; and• There were no instances of noncompliance or other matters required to be reported under Government Auditing Standards or OMB Bulletin No. 24-01.

What We Looked AtWe contracted with the independent public accounting firm KPMG, LLP to audit the Federal Aviation Administration’s (FAA) consolidated financial statements as of and for the fiscal years ended September 30, 2023, and September 30, 2022. KPMG was required to provide an opinion on those financial statements, report on internal control over financial reporting, and report on compliance with laws and other matters. The contract required the audit to be performed in accordance with U.S. generally accepted Government auditing standards; Office of Management and Budget audit guidance; and the Governmental Accountability Office’s and Council of the Inspectors General on Integrity and Efficiency’s Financial Audit Manual. We performed a quality control review (QCR) of KPMG’s report dated November 9, 2023, and related documentation, and inquired of KPMG’s representatives. What We FoundOur QCR disclosed no instances in which KPMG did not comply, in all material respects, with U.S. generally accepted Government auditing standards. RecommendationsFAA concurred with KPMG’s recommendation. We agree with KPMG’s recommendation and are not making any additional recommendations.

What We Looked AtWe contracted with the independent public accounting firm Allmond & Company, LLC (Allmond), to audit the Surface Transportation Board’s (STB) financial statements as of and for the fiscal years ended September 30, 2023, and September 30, 2022; provide an opinion on those financial statements; report on internal control over financial reporting; and report on compliance with laws and other matters. The contract required the audit to be performed in accordance with U.S. generally accepted Government auditing standards, Office of Management and Budget audit guidance, and the Government Accountability Office’s and Council of the Inspectors General on Integrity and Efficiency’s Financial Audit Manual. We performed a quality control review (QCR) of Allmond’s report, dated November 6, 2023, and related documentation, and inquired of its representatives. What We FoundOur QCR disclosed no instances in which Allmond did not comply, in all material respects, with U.S. generally accepted Government auditing standards. Our RecommendationsSTB concurred with Allmond’s ten recommendations. We agree with Allmond’s recommendations and are not making any additional recommendations.

The Office of the Inspector General (OIG) performed the procedures, which were requested and agreed to by Tennessee Valley Authority management solely to assist management in determining the validity of the Winning Performance/Executive Annual Incentive Plan (WP) Measures for fiscal year (FY) ending September 30, 2023. Tennessee Valley Authority management is responsible for the WP Measures data provided. In summary, procedures applied by the OIG found the:• FY 2023 WP goals for the enterprise measures were properly approved. • FY 2023 goals (target) for the corporate multiplier measures were properly approved. • Actual FY to-date results for the enterprise measures agreed with the underlying support, without exception.• Actual FY to-date results for the corporate multiplier measures agreed with the underlying support, without exception.• FY 2023 WP payout percentages provided by the Business Planning and Analysis organization on November 6, 2023, were mathematically accurate and agreed with the OIG’s recalculation.

EAC OIG, through the independent public accounting firm of Allmond & Company, LLC, audited EAC’s financial statements for the fiscal year ended September 30, 2023.

EAC OIG, through the independent public accounting firm of Allmond & Company, LLC, audited EAC's financial statements for fiscal year 2023. The purpose of this letter is to convey information concerning control weaknesses that did not rise to the level of a significant deficiency or material weakness.

The U.S. International Development Finance Corporation (DFC), Office of Inspector General (OIG) contracted with an independent public accounting firm to conduct a congressionally requested audit of DFC’s renewable energy and financing projects. The U.S. House of Representatives Committee on Appropriations requested DFC OIG to complete a follow-up audit similar to U.S. Agency for International Development (USAID) OIG’s audit of Overseas Private Investment Corporation’s (OPIC) Chile Energy Sector Portfolio completed in 2019. With congressional approval, this audit focused on DFC’s renewable energy and financing projects in India, which is the Corporation’s largest country investment partner at approximately $3.6 billion.

We contracted with the independent public accounting firm of CliftonLarsonAllen LLP (CLA) to audit the financial statements of FHA as of and for the fiscal years ended September 30, 2023 and 2022, and to provide reports on FHA’s (1) internal control over financial reporting and (2) compliance with laws, regulations, contracts, and grant agreements and other matters. Our contract with CLA required that the audit be performed in accordance with U.S. generally accepted government auditing standards, Office of Management and Budget audit requirements, and the Financial Audit Manual of the U.S. Government Accountability Office and the Council of the Inspectors General on Integrity and Efficiency.In its audit of FHA, CLA reportedThat FHA’s financial statements as of and for the fiscal year ended September 30, 2023 and 2022, were presented fairly, in all material respects, in accordance with U.S. generally accepted accounting principles.No material weaknesses for fiscal year 2023 in internal control over financial reporting, based on limited procedures performed. One significant deficiency for fiscal year 2023 in internal control over financial reporting, based on the limited procedures performed. The significant deficiency was related to weaknesses in internal controls over loans receivable.No reportable noncompliance issues for fiscal year 2023 with provisions of applicable laws, regulations, contracts, and grant agreements or other matters.In connection with the contract, we reviewed CLA’s reports and related documentation and questioned its representatives. Our review, as differentiated from an audit of the financial statements in accordance with U.S. generally accepted government auditing standards, was not intended to enable us to express and we do not express opinions on FHA’s financial statements or conclusions about (1) the effectiveness of FHA’s internal control over financial reporting and (2) FHA’s compliance with laws, regulations, contracts, and grant agreements or other matters. CLA is responsible for the attached Independent Auditors’ Report, dated November 13, 2023, and the conclusions expressed therein. Our review disclosed no instances in which CLA did not comply, in all material respects, with U.S. generally accepted government auditing standards.FHA’s audited financial statements are included in FHA’s Annual Management Report which can be found at- FHAFY2023ANNUALMGMNTRPT.PDF (hud.gov)

What We Looked AtWe contracted with the independent public accounting firm Allmond & Company, LLC (Allmond), to audit the National Transportation Safety Board’s (NTSB) financial statements as of and for the fiscal years ended September 30, 2023, and September 30, 2022; provide an opinion on those financial statements; report on internal control over financial reporting, and report on compliance with laws and other matters. The contract required the audit to be performed in accordance with U.S. generally accepted Government auditing standards, Office of Management and Budget audit guidance, and the Government Accountability Office’s and Council of the Inspectors General on Integrity and Efficiency’s Financial Audit Manual. We performed a quality control review (QCR) of Allmond’s report dated November 6, 2023, and related documentation, and inquired of its representatives. What We FoundOur QCR disclosed no instances in which Allmond did not comply, in all material respects, with U.S. generally accepted Government auditing standards. Our RecommendationsAllmond made no recommendations.

What We Looked AtWe contracted with the independent public accounting firm Allmond & Company LLC (Allmond) to audit the Great Lakes St. Lawrence Seaway Development Corporation’s (GLS) financial statements as of and for the fiscal year ended September 30, 2023; provide an opinion on those financial statements, report on internal control over financial reporting, and report on compliance with laws and other matters. The contract required Allmond to perform the audit in accordance with U.S. generally accepted Government auditing standards, Office of Management and Budget audit guidance, and the Government Accountability Office’s and Council of the Inspectors General on Integrity and Efficiency’s Financial Audit Manual. We performed a quality control review of Allmond’s report dated November 6, 2023, and related documentation, and inquired of its representatives. What We FoundOur quality control review disclosed no instances in which Allmond did not comply, in all material respects, with U.S. generally accepted Government auditing standards. Our RecommendationsAllmond made two recommendations in its report with which GLS concurred. We agree with Allmond’s recommendations and are making no additional recommendations.

We contracted with the independent public accounting firm of CliftonLarsonAllen LLP (CLA) to audit the financial statements of Ginnie Mae as of and for the fiscal years ended September 30, 2023 and 2022, and to provide reports on Ginnie Mae’s (1) internal control over financial reporting and (2) compliance with laws, regulations, contracts, and grant agreements and other matters.  Our contract with CLA required that the audit be performed in accordance with U.S. generally accepted government auditing standards, Office of Management and Budget audit requirements, and the Financial Audit Manual of the U.S. Government Accountability Office and the Council of the Inspectors General on Integrity and Efficiency.

In its audit of Ginnie Mae, CLA reported 

• That Ginnie Mae’s financial statements as of and for the fiscal years ended September 30, 2023 and 2022, were presented fairly, in all material respects, in accordance with U.S. generally accepted accounting principles.
• No material weaknesses or significant deficiencies for fiscal year 2023 in internal control over financial reporting, based on limited procedures performed.
• No reportable noncompliance issues for fiscal year 2023 with provisions of applicable laws, regulations, contracts, and grant agreements or other matters.

In connection with the contract, we reviewed CLA’s reports and related documentation and inquired of its representatives. Our review, as differentiated from an audit of the financial statements in accordance with U.S. generally accepted government auditing standards, was not intended to enable us to express, and we do not express, opinions on Ginnie Mae’s financial statements or conclusions about 1) the effectiveness of Ginnie Mae’s internal control over financial reporting and 2) Ginnie Mae’s compliance with laws, regulations, contracts, grant agreements, or other matters. CLA is responsible for the attached Independent Auditors’ Report, dated November 13, 2023, and the conclusions expressed therein. Our review disclosed no instances in which CLA did not comply, in all material respects, with U.S. generally accepted government auditing standards.

Ginnie Mae’s audited financial statements are included in its 2023 Annual Report which can be found at 2023 Ginnie Mae Annual Report.

Semiannual Report

This report includes EAC OIG’s independent assessment of the top management challenges facing EAC in fiscal year 2024.

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

OIG audited Rural Development’s consolidated financial statements for fiscal years 2023 and 2022.

The report contains an unmodified opinion on Commodity Credit Corporation’s (CCC) financial statements as of September 30, 2023 and 2022, as well as an assessment of CCC’s internal controls over financial reporting and compliance with laws and regulations.

OIG audited FCIC/RMA financial statements for fiscal years 2023 and 2022.

The report contains an unmodified opinion on Natural Resources Conservation Service’s (NRCS) financial statements as of September 30, 2023 and 2022, as well as an assessment of NRCS’s internal controls over financial reporting and compliance with laws and regulations.

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 Pacific Islands Health Care System, which includes the Spark M. Matsunaga VA Medical Center in Honolulu and outpatient clinics in Hawaii, Lanai, Maui, Molokai, American Samoa, Guam, and Saipan (Commonwealth of the Northern Mariana Islands).This evaluation focused on four key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of careThe OIG issued four recommendations for improvement in two areas:1. Medical Staff Privileging• Ongoing Professional Practice Evaluations o Equivalent specialized training and similar privileges o Service-specific criteria o Continuation of privileges based on results2. Environment of Care• Inpatient mental health unit environmental safety requirements

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the leadership performance and oversight by Veterans Integrated Service Network (VISN) 4: VA Healthcare in Pittsburgh, Pennsylvania.This evaluation focused on five key areas of clinical and administrative operations:• Leadership and organizational risks• Quality, safety, and value• Medical staff credentialing and privileging• Environment of care• Mental health (focusing on suicide prevention)The OIG issued two recommendations for improvement in two areas:• Medical Staff Credentialing and Privileging o Credentials files review and appointment recommendations for physicians with a history of licensure action• Environment of Care o Annual Comprehensive Environment of Care compliance report submission to the Environment of Care Committee

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

OIG identified four overarching challenges - transparency, accountability, efficiency, and sustainability - that reflect vulnerabilities affecting a broad spectrum of the Department’s programs, operations, and responsibilities. These challenges may hinder its ability to advance essential missions and protect the Nation and its citizens.

Each year, the Office of Inspector General prepares a summary of the most significant management challenges facing the United States Capitol Police (USCP or the department). These challenges reflect continuing vulnerabilities OIG identified over the last several years as well as new and emerging issues the Department will face in the coming year.

Transmittal of the Final Report Assessing the Federal Trade Commission’s Compliance with the Federal Information Security Management Act for Fiscal Year 2023 (Redacted for public release)

The Postal Accountability and Enhancement Act, enacted in 2006, limited price increases for Market Dominant products to the rate of inflation measured by the Consumer Price Index for All Urban Consumers (CPI-U). In 2020, the Postal Regulatory Commission (PRC), while establishing additional price authorities, confirmed the use of CPI-U in the price cap.The USPS OIG examined the potential impact on price authority, revenue and coverage of postal cost inflation since FY 2011 if the price cap had been based on six alternative inflation indices instead of the CPI-U. We selected the Chained Consumer Price Index for All Urban Consumers (C-CPI-U), Personal Consumption Expenditures Price Index (PCE PI), Gross Domestic Product Price Index (GDP PI), Producer Price Index for Final Demand (PPI FD), Employment Cost Index (ECI), and Consumer Price Index for Delivery Services (CPI-DS). The analysis did not address the additional rate authorities such as mail density, and it did not consider mail elasticities.

In November 2022, we conducted unannounced inspections of six U.S. Customs and Border Protection (CBP) facilities in the Miami area, specifically two Border Patrol stations and four Office of Field Operations ports of entry. Our inspections found the CBP facilities generally met the National Standards on Transport, Escort, Detention, and Search (TEDS standards) for cleanliness, food and beverages, supplies and hygiene items, bedding, and medical care. However, we found inaccurate data in detainee custody logs at two Border Patrol stations. Detainee custody logs in Border Patrol’s system of record did not accurately account for amenities provided to detainees in custody.

For our audit of the U.S. Economic Development Administration’s (EDA’s) monitoring of fiscal year (FY) 2019 disaster relief grants, our objective was to determine whether EDA monitored grants awarded under the FY 2019 EDA Disaster Supplemental Notice of Funding Opportunity (NOFO) to ensure compliance with grant terms, conditions, and performance requirements. We found that EDA generally monitored grants awarded under the NOFO. However, we found that EDA could improve project monitoring activities by following up on late submissions of Federal Financial Reports and Project Progress Reports by the grantees.

Semiannual Report to the Congress, April 1, 2023 through September 30, 2023

Our objective was to assess the Postal Service’s effectiveness at managing hazardous waste and emergency response equipment at VMFs. We conducted site observations of hazardous waste and emergency response equipment at 16 VMFs designated by state-specific regulations as large quantity generators of hazardous waste. These 16 VMFs are all located in California and Massachusetts. Also, we visited three additional judgmentally selected VMFs in these two states and interviewed Postal Service Headquarters officials, VMF management, and employees.

EAC OIG, through the independent public accounting firm of McBride, Lock & Associates, LLC, audited $1.8 million in funds received by the territory of Guam under the Help America Vote Act. The objectives of the audit were to determine whether the Guam Election Commission: 1) used funds for authorized purposes in accordance with Section 101 and Section 251 of HAVA and other applicable requirements; 2) properly accounted for and controlled property purchased with HAVA payments; and 3) used the funds in a manner consistent with the informational plans provided to EAC. The audit also determined if proper closeout procedures were followed for the CARES Act funds.

The Reports Consolidation Act of 2000 (Pub. L. No. 106-531) requires that Federal Inspectors General summarize and assess the most serious management and performance challenges facing Federal agencies and the agencies’ progress in addressing them.

Our objective was to assess the Postal Service’s effectiveness at managing hazardous waste and emergency response equipment at VMFs. We conducted site observations of hazardous waste and emergency response equipment at 16 VMFs designated by state-specific regulations as large quantity generators of hazardous waste. These 16 VMFs are all located in California and Massachusetts. Also, we visited three additional judgmentally selected VMFs in these two states and interviewed Postal Service Headquarters officials, VMF management, and employees.

We summarized what we have determined to be the most significant management and performance challenges facing the DOI for FY 2023.

During our limited-scope, unannounced inspection of Mesa Verde ICE Processing Center (Mesa Verde) in Bakersfield, California, we found that the facility complied with standards for the voluntary work program, facility conditions, and grievances. However, the facility did not accurately report or fully record an event that met the requirements of a use of force incident. Mesa Verde complied with most standards for medical care, including providing care to detainees on hunger strike, but experienced challenges finding available community optometrists, which caused delays in advanced optometry care.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the leadership performance and oversight by Veterans Integrated Service Network (VISN) 16: South Central VA Health Care Network in Ridgeland, Mississippi.This evaluation focused on five key areas of clinical and administrative operations:• Leadership and organizational risks• Quality, safety, and value• Medical staff credentialing and privileging• Environment of care• Mental health (focusing on suicide prevention)The OIG did not issue recommendations for improvement related to the areas reviewed for this report.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the Iowa City VA Health Care System, which includes the Iowa City VA Medical Center and multiple outpatient clinics in Illinois and Iowa.This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (emergency department and urgent care center suicide prevention initiatives)The OIG issued six recommendations for improvement in four areas:1. Leadership and Organizational Risks• Institutional disclosures for sentinel events2. Quality, Safety, and Value• Adverse event investigations3. Medical Staff Privileging• Service-specific criteria in Ongoing Professional Practice Evaluations• Practitioners with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations4. Environment of Care• Patient areas are clean, safe, and suitable• Panic alarm testing

The U.S. Department of Agriculture Office of Inspector General’s Annual Plan for Fiscal Year 2024 describes how OIG plans to accomplish its mission of promoting economy, efficiency, effectiveness, and integrity in the delivery of USDA programs during the fiscal year.

What We Looked At
As required by law, we report annually on the Department of Transportation’s (DOT) most significant challenges to meeting its mission. We considered several criteria to identify DOT’s top management challenges for fiscal year 2024, including impact on safety, documented vulnerabilities, large dollar implications, and the Department’s ability to effect change. Furthermore, in light of the nearly $660 billion in funding authorized by the Infrastructure Investment and Jobs Act (IIJA) to bolster the Nation’s transportation infrastructure, our report also discusses IIJA’s impact on each of the 10 management challenge areas we identified.

What We Found
We identified the following top management challenge areas for fiscal year 2024:

Aviation safety. Key challenges: enhance FAA’s oversight of aircraft certification and production, and diagnose root causes to prevent and mitigate runway incursions.

Surface transportation safety. Key challenges: identify root causes and implement safety programs to reduce fatalities and verify and enforce railroad, transit, pipeline, and hazardous materials safety compliance.

Air traffic control and airspace modernization. Key challenges: understand and address the causes of flight delays and cancellations and recover from and assess the impact of delayed and diminished NextGen programs on Agency costs and benefits for airspace users.

Surface transportation infrastructure. Key challenges: steward surface transportation investments in a changing environment, support effective funding oversight as IIJA progresses, and advance a range of surface transportation priorities and goals.

Contract and grant fund stewardship. Key challenges: award contract and grant funds to achieve the best outcomes and verify efficient and appropriate use of contract and grant funds.

Financial management. Key challenges: reduce the occurrence of improper payments, improve compliance with Federal requirements for monitoring and reporting on grantee spending, and improve the quality of financial data.

Information security. Key challenges: overcome obstacles to mitigate longstanding weaknesses in DOT’s cybersecurity program, and execute Federal priorities to move towards a Zero Trust Architecture.

Fraud prevention and detection. Key challenges: identify and assess fraud risks, and manage fraud risks through oversight, outreach, and data analysis.

Transportation transformation. Key challenges: advance safety and other DOT missions through the innovation principles, safely advance emerging and innovative vehicle technologies, and integrate new technologies into the NAS.

Organizational excellence. Key challenges: establish the workforce capabilities needed to meet the Department’s mission, manage an evolving workplace environment, and cultivate data-driven approaches to support policymakers and manage the mission.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the Mann-Grandstaff VA Medical Center in Spokane, Washington. 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 three areas:1. Quality, safety, and value• Peer Review Committee summary analysis data• Executive-level medical committee review2. Environment of care• Safe work practices• Clean and sterile storeroom access3. Mental health• Suicide-related event reporting• Completion of Comprehensive Suicide Risk Evaluations