Federal Reports

In July 1973, a fire damaged or destroyed up to 18 million Army and Air Force official military personnel files at the National Archives and Records Administration’s (NARA) National Personnel Records Center (NPRC) in St. Louis, Missouri. This disaster makes it difficult for affected veterans—those who served in the Army or Air Force prior to 1960 or 1964, respectively—to obtain required records when filing claims for benefits. If a veteran’s records cannot be located because they were destroyed in the fire, a veterans service representative requests reconstruction of medical treatment records, military service records, or both, depending on the veteran’s needs. The National Defense Authorization Act (NDAA) of 2023 requires the VA Office of Inspector General (OIG) to report on the extent to which Veterans Benefits Administration (VBA) personnel follow the Adjudication Procedures Manual when assisting veterans with obtaining or reconstructing service records and medical information that were damaged or destroyed during the fire. The OIG therefore conducted this audit to assess VBA’s assistance to these veterans with obtaining damaged or destroyed records. The OIG found that VBA staff did not always follow procedures in a timely manner or in the order outlined in the Adjudication Procedures Manual and did not always complete required follow up procedures. The OIG made three recommendations: to establish a process to identify and track veterans’ records that have been determined to be fire damaged or destroyed, to train VBA staff on the process for requesting service treatment and military service records for fire related records and provide more specific guidance on information required for the NPRC to locate veterans’ records, and to ensure VBA staff follow steps as outlined in the manual for when to send required forms and conduct follow-up.

We investigated allegations that a coal operator failed to pay mineral royalties on coal produced from Federal leases in Wyoming and Kentucky.

We reviewed how the Risk Management Agency (RMA) implemented and administered hemp crop insurance provisions.

This report represents our current assessment of the U.S. Small Business Administration's programs and activities that pose significant risks, including those that are particularly vulnerable to fraud, waste, error, mismanagement, or inefficiencies. The Challenges are not presented in order of priority, except for the COVID 19 challenge, which we address first in this report. We also view the other challenges as critically important to SBA operations.

OIG determined that two of the three challenges that impact the Agency ability to advance equal opportunity for all in the workplace. The challenges are customer service, data and technology transformation and modernization, and digital records management.

Edel Perez Acanda, a resident of Miami, Florida, was sentenced on October 16, 2023, in U.S. District Court, Southern District of Florida, for Theft of Government Funds. Perez Acanda was sentenced to 2 months in prison, 3 years’ probation, and was ordered to pay $81,114 in restitution to Amtrak. Perez Acanda was employed by a company contracted by Amtrak to provide food services. Our investigation found that co-defendant Bryan DeCastro fraudulently altered the timecards of Perez Acanda and another individual to make it appear they worked more hours than they did, resulting in payment for hours they did not work. Perez Acanda then paid DeCastro kickbacks for falsely inflating the timecards.

Objective: To determine whether the Social Security Administration decreased the number of auxiliary beneficiaries with missing or incorrect Social Security numbers on the Master Beneficiary Record.

We found that a company in Colorado failed to report production and pay royalties for oil and gas produced from Federal leases.

We found the fund’s financial statements, except for expenses and income from other appropriations, to be fairly presented.

The objectives of the audit were to determine whether the Kentucky Department of Education (Kentucky) had an adequate oversight process in place to ensure that (1) local educational agencies’ (LEA) American Rescue Plan (ARP) Elementary and Secondary School Emergency Relief (ESSER) plans met applicable requirements and (2) LEAs use ARP ESSER funds in accordance with applicable requirements and their approved LEA ARP ESSER plans. Overall, we found that Kentucky had adequate processes to ensure that LEA ARP ESSER plans met applicable requirements. We also determined that the ARP ESSER plans for Warren County and Jefferson County met applicable requirements and that Kentucky was consistent in how it reviewed and approved the two plans. We did, however, find that Kentucky’s process for reviewing LEA ARP ESSER reimbursement requests should be documented and could be strengthened to provide additional assurance that LEAs use ARP ESSER funds for allowable purposes. Although Kentucky had been consistent in how it oversees LEAs’ use of ARP ESSER funds, it did not request a listing of expenditures or review any supporting documentation from LEAs as part of its review of LEA reimbursement requests. Without supporting documentation to verify that the expenditures are allowable and properly accounted for, there is an increased risk that Kentucky will not identify or become aware of significant compliance issues involving the ARP ESSER program. Additionally, Kentucky did not have written policies and procedures to guide personnel through the reimbursement process. Without documented processes for reviewing LEA reimbursement requests, Kentucky officials might not fully understand what is expected of them or what they should be reviewing. This could result in inconsistencies in how Kentucky personnel perform these reviews and missed opportunities to identify unallowable or questionable expenditures that should be analyzed more closely. Also, at the end of our fieldwork, Kentucky had designed but not yet started additional monitoring of selected LEAs based on their overall risk. After the exit conference, Kentucky provided us with written policies and procedures for its ARP ESSER monitoring process. We reviewed those policies and procedures and concluded that they were designed in a way that should enable Kentucky to identify and select high-risk LEAs for review and detect instances of noncompliance during monitoring reviews.

This report summarizes the following top management and performance challenges facing the Department of Commerce in FY 2024: (1) continuing the transition to zero trust to overcome IT security shortcomings and strengthen cybersecurity; (2) awarding and overseeing grants to expand broadband access to all Americans; (3) promoting growth in domestic semiconductor manufacturing and research; (4) enhancing weather, water, and climate services; (5) leveraging trustworthy artificial intelligence and modernizing IT systems; (6) effectively enforcing export controls and supporting U.S. supply chain resilience; (7) ensuring public safety entities have the network services they need to respond effectively to emergencies; (8) managing and overseeing contracts and grants while ensuring equitable procurement; (9) safeguarding intellectual property to promote innovation and economic prosperity; (10) ensuring the Census Bureau provides quality data to stakeholders; (11) protecting funds awarded under the Public Wireless Supply Chain Innovation Fund grant program; and (12) ensuring strong oversight and effective use of funding for National Institute of Standards and Technology construction and maintenance.

This report, one in a series of audits examining NASA’s development of space flight systems for Artemis IV and future missions, examines the Agency’s plans to move its individual SLS contracts to a commercial services contract to lower the cost of the launch system.

The Office of the Inspector General conducted a review of TVA’s Technology Portfolio Management (TPfM) organization to identify factors that could impact TPfM’s organizational effectiveness. Interviews with TPfM personnel revealed positive interactions within TPfM. However, we identified issues that included engagement risk in one group that affected morale. We also identified opportunities to improve (1) performance of the Technology and Innovation mission pertaining to role clarity and execution and (2) communication and collaboration with business partners.

The U.S. Postal Service needs effective and productive operations to fulfill its mission of providing prompt, reliable, and affordable mail service to the American public. It has a vast transportation network that moves mail and equipment among about 280 processing facilities and 35,000 post offices, stations, and branches. The Postal Service is transforming its processing and logistics networks to become scalable, reliable, visible, efficient, automated, and digitally integrated. This includes modernizing operating plans and aligning the workforce; leveraging emerging technologies to provide world-class visibility and tracking of mail packages in near real time; and optimizing the surface and air transportation network. The U.S. Postal Service Office of Inspector General reviews the efficiency of mail processing operations at facilities across the country and provides management with timely feedback to further the Postal Service’s mission.

The Postal Service’s mission is to provide timely, reliable, secure, and affordable mail and package delivery to more than 160 million residential and business addresses across the country. The U.S. Postal Service Office of Inspector General reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission.

The U.S. Postal Service’s mission is to provide timely, reliable, secure, and affordable mail and package delivery to more than 160 million residential and business addresses across the country. The U.S. Postal Service Office of Inspector General reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission.

The U.S. Postal Service’s mission is to provide timely, reliable, secure, and affordable mail and package delivery to more than 160 million residential and business addresses across the country. The U.S. Postal Service Office of Inspector General reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission.

The Postal Service’s mission is to provide timely, reliable, secure, and affordable mail and package delivery to more than 160 million residential and business addresses across the country. The U. S. Postal Service Office of Inspector General reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission.

Our objective was to evaluate the effectiveness of the Postal Service’s BRM operations. We reviewed BRM policies and procedures, analyzed data, observed operations at 11 judgmentally selected sites, and met with Postal Service staff and BRM mailers.

A Lead Service Attendant based at New York Penn Station violated company policies by engaging in outside employment at two temporary employment agencies and an assisted living facility in Delaware while on medical leave and receiving Railroad Retirement Board benefits. The employee resigned prior to her disciplinary hearing and is ineligible for rehire.

An Amtrak engineer based in Miami, Florida, signed a waiver of administrative hearing on October 9, 2023, following a year-long investigation into time and attendance abuses by a Miami-based yard crew. By signing the waiver, the employee waived his rights to an administrative hearing and accepted responsibility for the administrative charges against him and understood that future misconduct may result in termination.Our investigation found that yard crew employees violated company policies by routinely leaving work several hours before the end of their shifts while continuing to falsely claim regular or overtime pay for time they did not work. From June 2, 2022, to April 10, 2023, 10 additional employees were disciplined as a result of our investigation. Five of these employees signed a waiver to an administrative hearing, accepting responsibility of the administrative charges against them, and the other five either resigned while under investigation or were terminated from employment for their roles in the scheme.Finally, we provided the company with observations for their consideration that we learned during our investigation.

An Amtrak Coach Cleaner based in Miami, Florida, was terminated from employment on October 5, 2023, following her administrative hearing. Our investigation found that the employee violated company policies by engaging in outside employment while on a medical leave of absence.

Top Management and Performance Challenges Facing the Federal Labor Relations Authority for Fiscal Year 2024

Poor contractor performance and technology development issues threaten to push NASA’s On-Orbit Servicing, Assembly, and Manufacturing 1 project (OSAM-1) beyond its $2.05 billion budget and projected December 2026 launch date.

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Michael E. DeBakey VA Medical Center (facility) in Houston, Texas, to evaluate Veterans Integrated Service Network (VISN) and facility leaders’ response to critical surgical events from 2018 through 2021 and assess actions to prevent reoccurrence.The facility reported eight critical surgical events during this time frame—five wrong-site surgeries and three instances of retained surgical items. The OIG found that facility leaders took progressive actions including peer reviews, counseling, a focused professional practice evaluation (FPPE) for cause, and termination to address a provider responsible for three wrong-site surgeries. However, the OIG identified deficiencies with the implementation and quality of the FPPE for cause, and in reporting the provider to state licensing boards (SLBs) and the national practitioner data bank (NPDB).Facility leaders ensured a root cause analysis (RCA) was generated for each critical surgical event and that Surgery Service leaders implemented additional actions to improve processes. However, the OIG identified deficiencies with some RCAs related to timeliness and subsequent action plans. The OIG determined that three critical surgical events may have been prevented in the absence of the RCA deficiencies. Facility leaders and staff could not explain the reasons for the deficiencies in the RCAs.The OIG determined VISN leaders provided oversight and consultation to facility leaders regarding critical surgical events. VISN leaders provided consultation and recommendations to facility leaders for managing the provider, and conducted annual reviews of the facility’s RCA process, identified deficiencies, and alerted facility leaders to areas in need of improvement.The OIG made three recommendations to the Facility Director related to conducting and documenting FPPEs for cause, reporting providers to SLBs and the NPDB, and completing RCAs and subsequent action plans.

The SBIR and STTR Extension Act of 2022 reauthorized the Small Business Innovation Research (SBIR) and the Small Business Technology Transfer (STTR) programs. The Inspector General of a Federal agency that participates in the SBIR or STTR programs must submit an annual report to Congress describing its investigations involving those programs (15 U.S.C. Section 638b(c). Information in this report presents the OIG investigative information related to SBIR for FY 2023.

Legionnaires’ disease is caused by Legionella bacteria, found naturally in freshwater environments. The bacteria can become a health concern when spread through showerheads, faucets, ice machines, and hot water tanks in the water systems of large buildings. A 2017 CDC report concluded that one in every four people with healthcare associated Legionnaires’ disease dies.Veterans Health Administration (VHA) Directive 1061 establishes standards to prevent and control healthcare associated Legionnaires’ disease at VHA owned buildings where patients, residents, visitors, or staff stay overnight. The VA Office of Inspector General (OIG) audited whether VHA is complying with the directive and effectively addressing the prevention and control of Legionella for potable water distribution systems.The OIG determined that the four VA medical facilities reviewed—in Salem, Virginia; Brooklyn, New York; Pittsburgh, Pennsylvania, and Dublin, Georgia—did not fully comply with VHA requirements on components of their healthcare-associated Legionella disease prevention plans, water safety testing validation collection, remediation actions, and reporting practices. VHA leaders also did not receive complete water safety test results needed for effective oversight. Additionally, VA medical facility leaders responsible for notifying clinical staff of Legionella conditions did not communicate positive test results to staff to ensure awareness of elevated diagnostic levels. Specifically, the OIG found incomplete healthcare associated Legionella disease prevention plans; inconsistent water sampling; noncompliance with remediation actions; and inconsistent test result reporting.The OIG made eight recommendations to improve oversight of Legionella water sampling, fix identified problems, and ensure Directive 1061 is followed.

This report presents the results of our audit of mail delivery, customer service, and property conditions review at the Louisiana District.

The U.S. International Development Finance Corporation Office of Inspector General (OIG) contracted with the independent public accounting firm RMA Associates, LLC (RMA) to conduct the Federal Information Security Modernization Act of 2014 (FISMA) audit of the United States International Development Finance Corporation (DFC) for Fiscal Year (FY) 2023 to evaluate the effectiveness of the DFC's information security program and practices, and determine what maturity level DFC achieved for each of the core metrics outlined in the FY 2023 - 2024 Inspectors General (IG) FISMA Reporting Metrics. Our objectives were to evaluate the effectiveness of the DFC's information security program and practices, and determine what maturity level DFC achieved for each of the core metrics outlined in the FY 2023 - 2024 IG FISMA Reporting Metrics.

Hanna Dinh, a California resident, pleaded guilty to Conspiracy to Commit Wire Fraud on October 2, 2023, in U.S. District Court, Central District of California. 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), including 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 pandemic. A co-defendant in this case, Dr. Anthony Hao Dinh, was also charged for allegedly orchestrating an approximately $230 million fraud on the Health Resources and Services Administration Uninsured Program. Dr. Dinh allegedly submitted fraudulent claims for treatment of patients, including Amtrak employees, that were insured but billed them to the uninsured progra

As required by the Inspector General Act of 1978 (as amended), this Semiannual Report summarizes the activities of the Department of Transportation Office of Inspector General for the preceding 6-month period.

In this Semiannual Report to Congress (SAR), we discuss OIG’s accomplishments and activities from April 1, 2023, through September 30, 2023, as well as our goals and plans.

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