Federal Reports

Our objective was to evaluate the effectiveness of internal controls over the Postal Service’s annual capital property review at network distribution centers and processing and distribution centers. We judgmentally selected four network distribution centers and processing and distribution centers to conduct site visits.

Our objective was to determine whether DIA's Emergency and Extraordinary Expenses (EEE) were properly authorized and that reimbursements were properly supported. We issued our results in a classified report on September 29, 2023.

From February 28 to March 2, 2023, we conducted unannounced inspections of four U.S. Customs and Border Protection (CBP) facilities in the Laredo area, specifically three Border Patrol stations and one Office of Field Operations port of entry. Our inspection revealed instances of high time in custody in some Border Patrol holding facilities. We also found CBP faced challenges properly documenting and securing personal property. Three of the four facilities we inspected did not accurately track or record property on inventory logs or in the respective data systems. In addition, we found inaccurate data in detainee custody logs at all inspected CBP facilities.

U.S. Customs and Border Protection (CBP), U.S. Immigration and Customs Enforcement (ICE), and the United States Secret Service (Secret Service) did not adhere to Department privacy policies or develop sufficient policies before procuring and using commercial telemetry data (CTD). Specifically, the components did not adhere to DHS’ privacy policies and the E-Government Act of 2002, which require certain privacy sensitive technology or data obtained from that technology, such as CTD, to have an approved Privacy Impact Assessment (PIA) before such technology is developed or procured.

For this year’s review, IGs were required to assess 20 Core IG FISMA Reporting Metrics and 20 Supplemental IG FISMA Reporting Metrics across five security function areas — Identify, Protect, Detect, Respond, and Recover — to determine the effectiveness of their agencies’ information security program and the maturity level of each function area.1 The maturity levels are: Level 1 - Ad Hoc, Level 2 - Defined, Level 3 - Consistently Implemented, Level 4 - Managed and Measurable, and Level 5 - Optimized. To be considered effective, the NRC’s information security program must be rated Level 4 – Managed and Measurable.The audit included an assessment of the NRC’s information security programs and practices consistent with the FISMA and reporting instructions issued by the Office of Management and Budget (OMB). The scope also included assessing selected security controls outlined in the National Institute of Standards and Technology (NIST) Special Publication (SP) 800-53, Revision 5, Security and Privacy Controls for Information Systems and Organizations, for a sample of systems in the NRC’s FISMA inventory of information systems. Audit fieldwork covered the NRC’s headquarters located in Rockville, MD from January 2023 to June 2023. The audit covered the period from October 1, 2022, through June 30, 2023.We concluded that the NRC implemented effective information security policies, procedures, and practices, since it achieved an overall Level 4 – Managed and Measurable maturity level; therefore, the NRC has an effective information security program. Although we concluded that the NRC implemented an effective information security program overall, its implementation of a subset of selected controls was not fully effective. We noted new and repeat weaknesses in its security program related to the risk management, supply chain risk management, configuration management, identity and access management, security training, incident response, and contingency planning domains of the FY 2023 IG FISMA Reporting Metrics. As a result, we made three new recommendations to assist the NRC in strengthening its information security program. Additionally, we noted 21 prior year recommendations remain open from the FY 2022 FISMA audit and FY 2021 FISMA evaluation based on inspection of evidence received during fieldwork.

The OIG contracted with CliftonLarsonAllen, LLP (CLA) to conduct a vulnerability assessment and an external penetration test of the U.S. Nuclear Regulatory Commission’s (NRC) information system environment in support of the NRC’s fiscal year (FY) 2023 Federal Information Security Modernization Act of 2014 (FISMA) audit. During the vulnerability assessment and external penetration test, CLA identified weaknesses that, if remediated, would help strengthen the NRC’s security posture.

Annual summary perspective on the most serious management and performance challenges facing the FTC, as well as a brief assessment of the agency’s progress in addressing those challenges.

Our objective was to reassess the company’s management and oversight of New Acela, including the trainset acquisition and other program elements necessary to launch revenue service, since we last reported on the program in 2020.We found that, despite recent improvements to the New Acela Program’s management, the program is more than three years behind schedule and additional delays are likely. Current delays have resulted in significant cost increases, operational impacts, and delayed revenue, and further schedule slippage would exacerbate these impacts. We identify two reasons for the current—and likely future—delays to New Acela. First, the vendor has not produced a validated computer model that demonstrates the New Acela is safe to proceed with additional trainset testing. While federal regulations require the company to submit to FRA trainset performance predictions from the computer model showing that it is valid, the vendor is responsible for developing and validating the model. This is the first step in a multi-step regulatory process for FRA to approve the trainsets to operate in passenger revenue service. Second, of the 12 serial trainsets and 22 café cars the vendor has produced, all have defects. Although some defects are expected when producing a new trainset, the vendor’s schedule for addressing them is incomplete, and without more complete information, the company cannot verify whether remediating the defects will impact the overall program schedule and the revenue service launch. More broadly, the issues we identified on New Acela are similar to challenges that have occurred on other rolling stock acquisitions. Since Amtrak is planning a multi-billion dollar program to replace its fleet of long-distance trains while it is also engaged in the ongoing process of replacing its intercity trains, we recommend that the company 1) enhance its process to formally capture and incorporate lessons learned from New Acela and other rolling stock purchases, 2) direct the vendor to provide complete and accurate schedules to address defects, and 3) work with the vendor to identify the risk of future defects.

The VA Office of Inspector General conducted a healthcare inspection at the Hampton VA Medical Center (facility) in Virginia to assess allegations related to the delay in diagnosis and treatment of a patient with a newly found lung mass.The OIG substantiated that there was a delay in diagnosis and treatment for a patient with a new lung mass, highly suspicious for cancer. The OIG found multiple care coordination deficiencies in scheduling and communication that led to the delay. As the patient likely had metastatic disease at initial presentation, the OIG could not determine if the delay in care coordination contributed to the patient’s death.The OIG determined the facility did not have an operational cancer committee, tumor board, or a certified cancer registrar at the time of the inspection. The lack of administrative oversight, and programmatic development, directly impacts the quality of patient cancer care. The lack of the programs did not contribute to the patient’s death, but may have impacted the quality of oncology services provided by the facility.The OIG determined that the facility submitted a Joint Patient Safety Report after being notified of the OIG inspection. Although a root cause analysis was conducted, the facility failed to identify care coordination deficiencies, such as scheduling delays, as contributing factors to the patient’s death. An institutional disclosure was conducted but lacked documented evidence that facility leaders provided the patient’s family member the required information about potential compensation.The OIG made seven recommendations to the Facility Director related to care coordination agreements, compliance with Veterans Health Administration (VHA) Patient Aligned Care Team policies and VHA cancer registry requirements, and a review of both the root cause analysis and institutional disclosure to ensure alignment with VHA policies.

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 Gulf Coast Veterans Health Care System in Biloxi, Mississippi. 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 three areas:1. Quality, Safety, and Value• Defined governance structure2. Medical Staff Privileging• Ongoing Professional Practice Evaluationso Service-specific criteriao Data maintained in privileging folders• Evaluations by practitioners with equivalent specialized training and similar privileges• Executive Committee of the Medical Staff review3. Environment of Care• Clean and safe environment

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 Central Arkansas Veterans Healthcare System, which includes the John L. McClellan Memorial Veterans’ Hospital (Little Rock), Eugene J. Towbin Healthcare Center (North Little Rock), and multiple outpatient clinics in Arkansas. 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 five recommendations for improvement in three areas:1. Quality, Safety, and Value• Root cause analysis2. Medical Staff Privileging• Defined time frames for Focused Professional Practice Evaluations3. Mental Health• Comprehensive Suicide Risk Evaluations• Suicide safety plans• Follow-up for patients at risk for suicide

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 Alexandria VA Health Care System, which includes the Alexandria VA Medical Center and associated outpatient clinics in Louisiana. 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 emergency department and urgent care center suicide prevention initiatives)The OIG issued four recommendations for improvement in two areas:1. Medical Staff Privileging• Completing Focused Professional Practice Evaluations• Reviewing Ongoing Professional Practice Evaluation data• Providers with equivalent specialized training and similar privileges completing Ongoing Professional Practice Evaluations2. Mental Health• Completing Comprehensive Suicide Risk Evaluations

The Office of the Inspector General (OIG) initiated this Special Inquiry following a radioactive release to the environment from the National Institute of Standards and Technology (NIST) test reactor located in Gaithersburg, Maryland on February 3, 2021. After the release, the NIST test reactor was shut down for more than two years before receiving authorization to restart from the U.S. Nuclear Regulatory Commission (NRC). This NIST event was one of eight unscheduled incidents or events in fiscal year 2021 that the NRC determined to be significant to public health or safety.This Special Inquiry’s focus broadened from the 2021 NIST event to include consideration of the NRC’s oversight of other Research and Test Reactor (RTR) facilities to assess potential systemic issues. However, this report primarily discusses the NRC’s oversight of the NIST test reactor prior to the February 2021 event because the event highlights areas in which the agency’s oversight could be improved as it relates to other smaller nuclear facilities.

We reviewed the U.S. Small Business Administration’s (SBA) oversight of Restaurant Revitalization Fund (RRF) recipients. The American Rescue Plan Act of 2021 authorized SBA to administer the RRF and provided $28.6 billion to assist eligible small businesses adversely affected by the Coronavirus Disease 2019 (COVID-19) pandemic.We determined program officials developed a plan for monitoring RRF award recipients use of funds and recovering unused or improperly awarded funds. However, program implementation was not executed in accordance with the plan.We made six recommendations for SBA to develop processes and procedures to improve oversight of RRF program recipients and recover unused or improperly awarded funds.

The U.S. Environmental Protection Agency Office of Inspector General conducted this evaluation to determine whether the EPA adhered to its tribal consultation policies during the development of:- The 2014 EPA Plan for the Federal Certification of Applicators of Restricted Use Pesticides within Indian Country.- The 2017 Certification of Pesticide Applicators rule revision.- The 2020 proposed revisions to the 2014 EPA Plan for the Federal Certification of Applicators of Restricted Use Pesticides within Indian Country.

To assist the Office of Personnel Management in assessing the reasonableness of retirement, health benefits, and life insurance withholdings and contributions, as well as enrollment information, we reviewed information submitted from multiple government agencies.

The Peace Corps employs more than 3,400 staff who help execute the agency mission and serve on the front lines of the Volunteer experience. Approximately 92 percent of staff at overseas posts are personal services contractors (PSCs), who also make up 70 percent of all Peace Corps staff. A significant part of the agency’s success depends on how well it manages its human resources operations to hire, train, and retain quality PSC staff. Our evaluation assesses the agency’s human resources management for overseas PSCs, focusing on the posts’ operations and the support they receive from agency offices and staff. We did not measure PSC satisfaction with human resources services or address the human resources management of the agency’s direct hire staff.

The Small Business Administration's (SBA) Office of Inspector General (OIG) is issuing this management advisory to bring attention to concerns regarding SBA’s decision to end active collections on delinquent COVID-19 Economic Injury Disaster Loans (EIDL) with an outstanding balance of $100,000 or less.First, SBA’s decision to cease collections risks violating the Debt Collection Improvement Act of 1996, which prohibits ending collections on fraudulent, false, or misrepresented claims, because SBA OIG and other oversight agencies are continuing to work on identifying COVID-19 EIDL fraud that may not have been identified by the agency. It is also unclear whether SBA plans to end active collections on loans for borrowers who received multiple COVID-19 EIDLs of $100,000 or less that, when combined, exceed $100,000.Second, SBA based its decision to end active collections on a cost-benefit analysis that used a dissimilar loan program and a private-sector loan servicing model to estimate proceeds from collections and collection costs. The cost-benefit analysis did not include periodic comparisons of costs incurred and amounts collected as federal regulations require.Finally, SBA does not appear to have fully evaluated its consultant’s recommendation to sell a portion of the COVID-19 EIDL portfolio to maximize the return to taxpayers.SBA management agreed with recommendations 3, contingently agreed to recommendation 2 based on the outcome of recommendation 1, partially agreed with recommendations 1 and 4, and disagreed with recommendation 5.

Our objective was to determine whether the CISO is adequately staffed by assessing recruitment, retention, and performance measurements. For this audit, we reviewed the CISO workforce and strategic staffing activities for fiscal year (FY) 2021 through FY 2023 and interviewed headquarters personnel.

Management and performance challenges facing the Commission and briefly assesses management’s progress

We found the e-Manifest Fund’s financial statements to be fairly presented and free of material misstatement.

Objective: To determine whether the Social Security Administration took appropriate and timely action in response to representative payees’ alleged misuse of benefits.

Our objective was to evaluate the Postal Service’s efforts to respond to mail theft. For this audit, we reviewed processes and procedures for addressing mail theft, management of arrow keys, and mail theft complaints, investigations, and carrier robberies from October 1, 2020, through September 30, 2022, for five Postal Inspection Service divisions: Chicago, Houston, Los Angeles, New York, and Washington, DC.

Objective: To determine whether the Social Security Administration appropriately applied the Windfall Elimination Provision and Government Pension Offset. We also gathered information about the Agency’s efforts to obtain non-covered pension data for beneficiaries.

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) conducts information security inspections to assess whether VA facilities are meeting federal security requirements. They are typically conducted at selected facilities that have not been assessed in the sample for the annual audit required by the Federal Information Security Modernization Act of 2014 (FISMA) or at facilities that previously performed poorly. The OIG selected the VA Dublin Healthcare System in Georgia because it had not been previously visited as part of the annual FISMA audit.The OIG’s information security inspections focus on three security control areas that apply to local facilities and have been selected based on their levels of risk: configuration management, security management, and access controls. During this inspection, the OIG found deficiencies in all three areas.Deficiencies in configuration management included critical-risk vulnerabilities that VA’s Office of Information and Technology did not identify. These security vulnerabilities were not being remediated within VA’s established time frames, which could risk unauthorized access to, or the alteration or destruction of, critical systems.The team identified three security management control weaknesses at the healthcare system: several special-purpose systems did not have authorization to operate, two of these systems did not have appropriate security categorizations, and the healthcare system identified but did not remediate unapproved software.The healthcare system also had deficiencies in physical access security, emergency power, and monitoring of physical and environmental controls.The OIG made four recommendations to the assistant secretary for information and technology and chief information officer to improve controls at the facility because they are related to enterprise-wide information security issues similar to those identified on previous FISMA audits and information security inspections. The OIG also made three recommendations to the Carl Vinson VA Medical Center director.

The VA Office of Inspector General (OIG) conducted national surveys of Veterans Integrated Service Network (VISN) patient safety officers (PSO) and facility patient safety managers (PSM). Both surveys focused on patient safety topics, including oversight, culture, staffing, and training. The OIG also conducted interviews with Veterans Health Administration (VHA) Quality and Patient Safety leaders and PSOs.The OIG identified opportunities for VHA to strengthen patient safety programs at VISNs and facilities. Variability in PSO oversight related to site visit frequency and volume, and unclear expectations for PSO follow-up of facility patient safety program deficiencies, exist. PSOs reported barriers to meeting with community care third-party administrators to discuss quality and safety concerns. A majority of PSOs reported responsibilities for areas outside of the patient safety program while a high percentage of PSMs reported feelings of burnout. Facilities that have a PSM and additional staff achieved a higher level of compliance with completing patient safety requirements.Inclusion of an analysis of patient safety data within National Center for Patient Safety (NCPS) published quarterly reports would help staff drive improvement. Both PSOs and PSMs identified that patient safety is not always considered in decision making. Lastly, although PSO and PSM training is recommended, no formalized training requirements are available.The OIG made one recommendation to the VHA Under Secretary for Health related to evaluating PSO and PSM communication with community care third-party administrators and two recommendations to the VHA Assistant Under Secretary for Quality and Patient Safety related to establishing facility patient safety program oversight requirements and evaluating barriers that limit VISN and facility leaders’ engagement with PSOs and PSMs. The OIG made six recommendations to the VHA NCPS Executive Director related to evaluating quarterly reports, PSO and PSM burnout, patient safety program staffing, and implementing formalized training.

We have identified a concern regarding the inability of both OIG and Agency personnel to extract EPA SBIR contract data—such as information about proposals, bids, awards, contractors, and subcontractors—from the EPA Acquisition System in meaningful ways to allow for oversight through data analytics, queries, and other proactive initiatives.

The EPA should review unliquidated obligations for programs that received a substantial increase through the IIJA to ensure that the funds are used for the intended programs or deobligated timely to fund other environmental projects, as appropriate.

To see our report, click on the link below

For this audit, our objective was to determine if the U.S. Department of Commerce and its bureaus identify and remediate vulnerabilities on their high value IT assets (HVAs) in accordance with federal requirements. We found that while the Department conducts HVA assessments in accordance with federal requirements, it did not always effectively identify and remediate vulnerabilities. It also did not follow best practice security guidance for HVAs. As a result, I. HVAs are operating with significant risk due to unresolved vulnerabilities; and II. OIG successfully exploited security weaknesses on multiple HVAs. All seven of the HVAs in our review had at least one exploitable vulnerability type, and the Department’s vulnerability scanners do not always identify vulnerabilities in HVAs. We also learned during our audit that the U.S. Patent and Trademark Office (USPTO) had asked the Department to downgrade all of its HVAs to non-HVAs. In September 2023, the Department’s Chief Information Officer agreed to downgrade the majority of USPTO’s HVAs.

Audit of the USITC's Vehicle Fleet Program

The objective was to determine whether the Social Security Administration’s mobile phone security conformed with Federal standards and guidelines. Our audit report (A-14-19-50811) contain information that, if not protected, could result in adverse effects to the Agency’s information systems. In accordance with government auditing standards, we have separately transmitted to SSA management our detailed findings and recommendations and excluded from this report certain sensitive information because of the potential damage if the information is misused. We have determined the omitted information neither distorts the audit results described in this summary report nor conceals improper or illegal practices.

Based on our review of Preventive Maintenance (PM) metric data provided by the Tennessee Valley Authority (TVA), we determined PMs were generally being performed within established schedules at TVA’s nuclear plants; however, some metrics indicated performance could be improved. In addition, we found other areas where improvements are needed, including: (1) some discrepancies between TVA’s PM metrics data in Cognos (the business analytics reporting tool used across TVA to access and analyze company data) reports and the data submitted to an industry peer organization; (2) PMs needed that were not established, causing declines of equipment condition and a regulatory finding; and (3) recurring issues that prevented or delayed PMs being performed. Additionally, we identified obsolescence-related equipment issues at TVA’s nuclear plants. Specifically, obsolescence-related equipment issues were identified in many program, system, and component health reports as having a negative impact.

During the pandemic, the contracts and grants workforce played a critical role in providing support to taxpayers, local governments, and other recipients through pandemic relief programs. The CARES Act directed the PRAC to review the sufficiency of contract and grant staffing and other resources from agencies across the federal government to determine if they had the resources necessary to adequately perform their duties. The PRAC conducted a survey of 29 agencies, and each provided their experiences on the impact the pandemic had on their agency’s ability to effectively perform their work. Leveraging these responses, lawmakers and agencies can plan and prepare for future national emergencies.

EAC OIG assessed the EAC’s grant closeout process. The objectives of the risk assessment were to (1) gain an understanding of EAC’s grant closeout process (both administrative and final), (2) determine the volume of grants that have not been closed out, (3) identify challenges leading to delays in grant closeouts, if any, and (4) determine any areas of risk that warrant an audit or further consideration.

The GPO OIG Inspection team examined the GPO’s Top 10 Safety Hazards program. They assessed how the GPO develops the Top 10 Safety Hazards list; plans, schedules, and supports Top 10 Safety Hazards repairs; and analyzed the status of each item on the Fiscal Year (FY) 2022 Top 10 Safety Hazards list.

U.S. Customs and Border Protection (CBP) accounted for its firearms but did not always maintain accurate records for firearm locations or quantities of ammunition, as required. During our physical inventory of firearms in storage at 12 sites, we identified 126 firearms not located at the address indicated in CBP’s system of record. CBP also did not ensure ammunition control, accountability, and loss reporting complied with policy requirements for sensitive assets.

FCC OIG announces the voluntary repayment of $49.4 million of improperly claimed Affordable Connectivity Program (ACP) subsidies after OIG sent the provider a warning letter and issues an advisory notifying other ACP providers of its concern that dozens of other providers are likely not complying with FCC usage and related de-enrollment rules.

FCC OIG announces the voluntary repayment of $49.4 million of improperly claimed Affordable Connectivity Program (ACP) subsidies after OIG sent the provider a warning letter and issues an advisory notifying other ACP providers of its concern that dozens of other providers are likely not complying with FCC usage and related de-enrollment rules.

The Veterans Affairs Enterprise Cloud (VAEC) hosts more than 200 systems that employees, veterans, and contractors use to support the delivery of health care, compensation benefits, and home loan guarantees for veterans. The OIG conducted this audit to determine if VA is effectively assessing and monitoring security and privacy controls for cloud computing in accordance with federal guidance to include the National Institute of Standards and Technology (NIST) risk management framework. Based on the audit team’s findings, the team also assessed VA’s process for monitoring cloud service performance levels (including outages).In September 2020, NIST updated its guidance regarding security and privacy controls. Although VA has been working on updates, systems were not yet compliant as of June 2023. This occurred because of failures in oversight to ensure that policies and procedures reflected governing federal security and privacy controls. For the 13 VAEC systems reviewed, the team found deficiencies in the areas of securing personally identifiable information and supply chain management, though no incursions or other impacts were detected.The audit team only identified weaknesses in the last of seven steps in NIST’s risk management framework related to controls. Specifically, the audit team estimated that 123 of the 148 systems hosted on the VAEC did not have proof of continuous monitoring.The OIG also found VA may be missing opportunities to recoup service credits when vendors do not perform as required, such as when service provider actions result in outages that exceed agreed-upon acceptable durations. This occurred, in part, because VA lacked a consistent process to identify, document, and submit cloud service recoupment claims. Further, VA did not identify who was responsible for submitting the requests to the cloud service providers and making the claims. VA concurred with the OIG’s five recommendations for corrective action.

Objective: To determine whether the Social Security Administration accurately processed manual actions related to the termination of benefits for Old-Age, Survivors and Disability Insurance beneficiaries.

Objective: To determine whether the Social Security Administration included the required whistleblower rights and protection language in contracts that exceed the simplified acquisition threshold, in accordance with the Federal Acquisition Regulation.

Objective: To determine whether the Social Security Administration properly processed windfall offset determinations.

The VA Office of Inspector General (OIG) conducts information security inspections to assess whether VA facilities are meeting federal security requirements. They are typically conducted at selected facilities that have not been assessed in the sample for the annual audit required by the Federal Information Security Modernization Act of 2014 (FISMA) or at facilities that previously performed poorly. The OIG selected the El Paso VA Healthcare System because it had not previously been visited as part of the OIG’s annual FISMA audit.The OIG focused on three control areas it determined to be at highest risk—configuration management, security management, and access controls. The OIG identified two deficiencies in configuration management controls, none in security management controls, and six in access controls. The configuration management deficiencies were in vulnerability management and flaw remediation. The healthcare system’s vulnerability management controls did not identify all network weaknesses, such as unsupported versions of applications, and flaw remediation controls did not ensure comprehensive patch management. Further, some vulnerabilities were not remediated within established time frames. Additionally, the software system used to report vulnerabilities to facilities was not complete and accurate. For example, it did not have host names for 16 percent of the entries.The OIG identified multiple access deficiencies: inventories of keys used by employees to gain access to buildings and rooms were not completed, reviews of physical access logs were not done quarterly as required, temperature and humidity controls were lacking in communications rooms, surveillance cameras were inoperable, water detection controls were not working, and the emergency power shutoff was not tested annually.The OIG made eight recommendations to address the noted deficiencies.

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 Northern California Health Care System, which includes the Sacramento VA Medical Center, Martinez VA Medical Center, an outpatient clinic at Travis Air Force Base, and other outpatient clinics in California. 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 seven recommendations for improvement in three areas:1. Medical Staff Privileging• Evaluation result documentation and reporting• Reprivileging recommendations based on service-specific Ongoing Professional Practice Evaluation data2. Environment of Care• Panic and over-the-door alarm testing in the inpatient mental health unit• Cleanliness, furnishings, and equipment• Properly stored and secured medications3. Mental Health• Timely follow-up for patients at risk for suicide discharged from the Emergency Department

This informational report provides general information and highlights CARES Act funding as of June 30, 2023. This informational report does not contain any findings or recommendations, and it was prepared using information obtained during the audit work and from public sources.

The USDA OIG Office of Analytics and Innovation developed a public data stroll on the broadband program in partnership with the U.S. Department of Commerce OIG called Broadband: A Data Stroll.

The Office of Inspector General completed a final action verification of all 10 recommendations in our Feb. 7, 2020, report on the Multi-Family Housing Tenant Eligibility.

To see our report, click on the link below