Federal Reports

This informational report details control activities implemented to strengthen enforcement of the USDA organic regulations and explains how the Agricultural Marketing Service intends to measure the effectiveness of the new organic regulations.

The VA Office of Inspector General (OIG) conducted a focused review of Veterans Health Administration (VHA) guidelines for lung cancer screening (LCS) and the requirements for a VA facility LCS program. VHA has 10 mandatory elements that must be in place for a facility to establish an LCS program.Lung cancer is the third most diagnosed type of cancer in the United States and is the leading cause of cancer deaths. Lung cancer generally has a poor prognosis, but diagnosis at an early stage improves patients’ survival. The US Preventive Services Task Force first recommended LCS in 2013 and updated the recommendation in 2021. Despite the impact LCS has on improving patients’ survival, LCS rates in the United States remain low.The OIG surveyed facility staff involved in LCS. Facility staff reported that VHA LCS guideline requirements presented barriers to broader adoption of LCS and did not ensure consistent implementation. The most frequently cited barriers by facilities without an LCS program were the absence of an LCS coordinator, the lack of adequate staffing, the absence of a patient registry, and the lack of a multidisciplinary board. The OIG determined just over half of surveyed VHA facilities reported having an established LCS program consistent with VHA guidelines for LCS.In addition, the OIG found that regardless of whether facilities had established a compliant LCS program, variability remained in how facilities identify patients who met LCS criteria. Additionally, methods for interpreting low-dose computed tomography (CT) scans varied among facilities. Ten sites completing low-dose CT scans for lung cancer reported not using an established system for classification of the results.The OIG made three recommendations to the Under Secretary for Health. Recommendations addressed the operational memorandum for LCS implementation and the lack of a requirement to offer eligible patients LCS.

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 Lebanon VA Medical Center and associated outpatient clinics in Pennsylvania. 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 one recommendation in the Leadership and Organizational Risks area of review regarding conducting institutional disclosures for sentinel events.

We found that a USBR employee wrongfully obtained $28,524 in combined Unemployment Insurance and Pandemic Unemployment Assistance.

The EPA Office of Water issued a policy memorandum in September 2021 that incorrectly advised states that they do not have to review single audits of nonfederal entities that borrow money from state revolving funds.

An Amtrak senior manager based in Philadelphia, Pennsylvania, signed a civil settlement agreement with the U.S. Attorney’s Office, Middle District of Florida, on August 15, 2023, and agreed to pay $25,441 in restitution. Our investigation found that the employee submitted applications that contained false information to the Small Business Administration to qualify for a Coronavirus Aid, Relief, and Economic Security Act Economic Injury Disaster Loan Advance.

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 San Francisco VA Health Care System, which includes the San Francisco VA Medical Center and multiple 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 (focusing on emergency department and urgent care center suicide prevention initiatives)The OIG issued five recommendations for improvement in four areas:1. Leadership and Organizational Risks• Institutional disclosures for sentinel events2. Quality, Safety, and Value• Improvement actions for peer reviews• Root cause analysis for patient safety events3. Medical Staff Privileging• Ongoing Professional Practice Evaluation results and privileging decisions4. Environment of Care• Expired supplies in supply rooms

The VA Office of Inspector General (OIG) conducted an inspection to assess concerns with access to mental health care at the Charles George VA Medical Center’s (facility) outpatient Mental Health clinic in Asheville, North Carolina. Complainants alleged concerns regarding delays in Behavioral Health Interdisciplinary Program (BHIP) assessment and psychotherapy consults; prescriber turnover; prescribers’ scope of practice; community care consults; and the role of the suicide prevention team.The OIG substantiated BHIP and psychotherapy consults were not completed within the Veterans Health Administration’s required time frame. Leaders attributed delays to staff vacancies and inefficient BHIP teams. Prescribers incorrectly believed that “permission” from the BHIP team was required before placing psychotherapy consults. Leaders did not clearly communicate with each other or fully address misperceptions about the psychotherapy consult process.The facility did not have processes to ascertain why staff leave so as to inform retention strategies that are necessary to maintain staffing levels.The OIG did not substantiate prescribers were providing care outside of their scope of practice or privileges, as applicable.Facility leaders discouraged, but did not prohibit, clinic providers from entering community care consults. Nearly all the prescribers, as well as additional non-prescribing clinic providers, submitted consults during the period of review.The OIG did not substantiate that the suicide prevention team failed to support prescribers with clinical duties, including patients with a high risk for suicide patient record flag; however, there was a general misunderstanding by some prescribers about the role of the suicide prevention team. Leaders failed to communicate to staff about the suicide prevention team’s role.The OIG made seven recommendations regarding mental health consult scheduling, community care referrals, BHIP implementation, staff retention, leaders’ communication, the role of the suicide prevention team, and follow-up care for patients with high risk for suicide patient record flags.

We reviewed Agricultural Marketing Service's (AMS) controls over the Food Purchase and Distribution Program (FPDP) and determined whether AMS purchased the type and quantity of commodities necessary to mitigate the impact from retaliatory tariffs.

In our final report, we assessed the controls Agricultural Marketing Service developed and implemented to ensure awardees fulfilled the obligations of their contracts.

What We Looked AtWe queried and downloaded 93 single audit reports prepared by non-Federal auditors and submitted to the Federal Audit Clearinghouse between April 1, 2023, and June 30, 2023, to identify significant findings related to programs directly funded by the Department of Transportation (DOT).What We FoundWe found that reports contained a range of findings that impacted DOT programs. The auditors reported 26 incidents of significant noncompliance with Federal guidelines related to 18 grantees that require prompt action from DOT’s Operating Administrations (OA). Of the 26 significant findings, 13 were repeat findings related to 8 grantees. The auditors also identified questioned costs totaling $2,892,004 for five grantees. Of this amount, $2,550,676 was related to the Confederated Tribes of the Colville Reservation, Nespelem, WA. Additionally, we identified nonmonetary repeat findings that caused a qualified opinion for the Hydaburg Cooperative Association, Hydaburg, AK, the City of Fairburn, Fairburn, GA, and the Yankton Sioux Tribe, Wagner, SD.RecommendationsWe recommend that DOT coordinate with the impacted OAs to develop a corrective action plan to resolve and close the findings identified in this report. We also recommend that DOT determine the allowability of the questioned transactions and recover $2,892,004, if applicable. 

We substantiated allegations that a marina owner submitted false receipts for an FWS grant and violated the terms and conditions of the grant.

The U.S. Environmental Protection Agency Office of Inspector General conducted this evaluation to determine whether the EPA has verified that its own laboratories are complying with Resource Conservation and Recovery Act requirements for the management of hazardous waste.

Objectives: To determine whether the Social Security Administration’s (SSA) completed counts for program integrity and hearings workloads in Fiscal Years 2017 through 2021 were complete and accurate. In addition, we determined whether SSA’s spending exceeded dedicated funding amounts for program integrity and hearings backlog workloads.

The report provides information for administrative law judge trends for Fiscal Years 2018 through 2022.

This report presents a summary of the results of our self-initiated audits assessing the controls over retail transactions at three selected retail units in the Ohio 2 District. These retail units include Madeira Branch, Groesbeck Branch, and the Cincinnati Main Post Office in the Ohio 2 District of the Central Area. The U.S. Postal Service Office of Inspector General (OIG) previously issued interim reports to district management for each of these retail units regarding the conditions we identified.

During an evaluation for two Alcatraz Island contracts, we identified instances of noncompliance with Federal regulations and contract terms.

Our objective was to describe the extent to which the Federal Student Aid office (FSA) identifies individuals who belong to underserved communities and performs outreach to those identified individuals. We found that FSA provided general outreach to individuals, some of whom were part of underserved communities, and reached such individuals through several FSA offices and through its partnerships with different organizations. Although FSA performed outreach through various methods, its outreach was constrained by its limited ability to identify underserved individuals. Specifically, FSA’s direct outreach was provided to its current customers and the Free Application for Federal Student Aid collected only limited demographic information that could be used to identify applicants as individuals from underserved communities. Consequently, FSA could improve its outreach to underserved communities by evaluating its outreach practices, coordinating outreach efforts amongst its different offices, and utilizing demographic data to identify and conduct outreach to individuals in underserved communities.

Pursuant to an Office of the Inspector General subpoena, we obtained Alaska Department of Health data that contained the personally identifiable information (PII) of 217,851 individuals the State recorded as deceased from January 13, 1900 to February 14, 2023. We processed thedata through the Social Security Administration’s (SSA) Enumeration Verification System and against SSA payment records and identified 119 beneficiaries in current or suspended payment status whose PII matched that of deceased individuals in the Alaska death data.

EAC OIG, through the independent public accounting firm of Brown & Company CPAs and Management Consultants, PLLC, audited EAC’s information security program for fiscal year 2023 in support of the Federal Information Security Modernization Act of 2014 (FISMA). The objective was to determine whether EAC implemented selected security controls for certain information systems in support of FISMA.

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 VA Palo Alto Health Care System, which includes medical centers in Palo Alto, Menlo Park, and Livermore and multiple 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 (focusing on emergency department and urgent care center suicide prevention initiatives)The OIG issued four recommendations for improvement in two areas:1. Leadership and Organizational Risks• Institutional disclosures for sentinel events2. Environment of Care• Preventive maintenance on medical equipment• Access to medications only by authorized staff• Clean and safe environment

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Charlie Norwood VA Medical Center (facility) in Augusta, Georgia, to assess allegations that a spinal cord injury (SCI) patient was inappropriately admitted to an inpatient SCI unit following surgical treatment of femur and tibia bone fractures.Allegations included that the patient was not consistently monitored for blood pressure or laboratory results, had significant postoperative bleeding requiring transfer to the critical care unit (CCU), and had multiple blood transfusions. The OIG identified a concern related to a lack of communication between an orthopedic surgeon and the SCI interdisciplinary team.The OIG did not substantiate that the patient’s postoperative admission to the SCI unit was inappropriate. Postoperative SCI patients are admitted to the SCI unit unless there are complications during surgery or other concerns. The patient met post-anesthesia care unit discharge criteria, and several facility SCI staff were familiar with the patient’s care.The patient experienced significant postoperative bleeding, which resulted in the patient’s transfer to a higher level of care and multiple blood transfusions. However, the OIG determined this event was not a result of the patient’s admission to, or the postoperative care provided on, the SCI unit. SCI nurses’ close monitoring of the patient and timely initiation of a rapid response contributed to the patient’s successful recovery.The OIG identified a lack of communication between the surgeon and SCI staff related to the outpatient management of the patient’s leg fractures prior to surgery. Establishing a process to ensure improved communication and coordination between the Surgery Service and the SCI Service may benefit SCI patients with surgical needs.The OIG made one recommendation to the Facility Director related to establishing a process to optimize communication.

The Federal Election Commission (FEC) Office of the Inspector General (OIG) initiated this investigation after a media report concerning FEC Commissioner James “Trey” Trainor III’s appearance at an event in Texas where he was allegedly billed as a member of the “Trump Elections Team.” The reporting cited campaign finance experts, including a former FEC Commissioner, who expressed concerns about Commissioner Trainor’s appearance at the event. They further questioned whether Commissioner Trainor should have recused himself from adjudicating matters involving former President Donald Trump in light of his appearance at the event (as a purported member of the “Trump Elections Team”) and his prior work for the Trump 2016 campaign.

An Amtrak Assistant Lead Customer Service Representative based in New Orleans, Louisiana, resigned from his position on August 8, 2023, prior to his administrative hearing. Our investigation found that the former employee violated company policies by accepting cash kickbacks from a private transportation driver for referring passengers to his service. During his interview, the former employee admitted to receiving money for referring passengers to the transportation service. Another employee previously resigned from the company on June 1, 2023, for her involvement in the scheme.

The National Credit Union Administration (NCUA) Office of Inspector General (OIG) conducted this self-initiated audit to assess the NCUA’s Quality Assurance Program. The objective of our audit was to determine whether the NCUA conducts its quality assurance activities in accordance with requirements. The scope of our audit covered the NCUA’s actions to execute quality assurance activities from January 1, 2020, through December 31, 2022. Our audit determined the NCUA substantially conducted its Quality Assurance Program in compliance with requirements. However, we did not find full compliance with the requirements for performing or documenting quality assurance reviews and completing quality assurance reviews or issuing response memos within established timeframes. Based on our interviews, we also identified areas for potential improvements to the Quality Assurance Program. We are making three recommendations in our report to address the issues we identified.

In October 1987, the U.S. Nuclear Regulatory Commission (NRC) contracted with Southwest Research Institute (SwRI) to operate a Federally Funded Research and Development Center (FFRDC), with the principal focus to provide support for the NRC’s activities in licensing a deep geologic repository for high level waste and spent nuclear fuel. The SwRI established the Center for Nuclear Waste Regulatory Analyses to serve as an FFRDC. The current contract is the NRC’s seventh renewal of the FFRDC contract. Federal Acquisition Regulation (FAR) Section 35.017-4 requires, prior to extending a contract for an FFRDC, a sponsoring agency must conduct a comprehensive review of the use and need for the facility. The audit objectives were to determine if the NRC is (1) properly considering all FAR requirements for an FFRDC review in preparing its renewal justification; and, (2) adequately fulfilling its oversight responsibilities for the FFRDC. The Office of the Inspector General (OIG) considers all FFRDC renewal FAR requirements to be satisfied. However, opportunities for improvement were identified in how the NRC oversees the administration of the contract. Specifically, opportunities for improvement were identified in the area of final invoice billing. The OIG found that the NRC’s administration of the FFRDC contract relating to the final invoice billing is inadequate. The NRC requested SwRI to delay sending final invoices until requested to do so by the Contracting Specialist. The SwRI claims that the NRC owes $599,414 on tasks completed between fiscal years 2011 and 2021. This occurs primarily because the NRC lacks resources related to closeout of cost-reimbursement contracts. As a result, the NRC on its own initiative issued SwRI an extension of the 120-day period for submitting invoices covering that period, even though the relevant FAR section, 52.216-7(d)(5), does not provide clear authority for the agency to take such action without a request from the contractor. This increases the risk of claims that funds are subject to the Prompt Payment Act, potential billing discrepancies not being identified or corrected in a timely manner, and old contract funds being unavailable for payment. This report makes two recommendations to improve the final invoice billing and closeout process.

U.S. Customs and Border Protection’s (CBP) Office of Field Operations (OFO) does not consistently conduct outbound inspections of personal vehicles and pedestrians at land border crossings on the Southwest and northern borders to prevent the illegal exportation of currency, firearms, explosives, ammunition, and narcotics. During our audit, we visited 108 of 167 land border crossings on the Southwest and northern borders. We found the frequency of outbound inspections, inspection techniques, technology, and infrastructure in outbound inspection areas varied significantly between the two borders and among land border crossings. These inconsistencies occurred because there is no structured outbound inspection program with oversight from OFO headquarters. Field office and port of entry (POE) leadership often use professional judgment and other strategies to determine the frequency of inspections because they have wide discretion regarding when and how to conduct outbound inspections. Additionally, OFO does not have performance metrics to measure the impact of outbound inspections or a comprehensive outbound inspection policy.

Our objective was to determine whether the Postal Service complied with applicable maximum total compensation provisions of the PAEA and related Postal Service policies and guidelines for CY 2022. We reviewed significant provisions of PAEA; Postal Service policies, procedures, and guidelines regarding compensation, benefits, and bonuses; payroll, bonus, and award information from Postal Service systems; and employment agreements applicable to the compensation limits for the project scope. We also conducted interviews with Postal Service employees.

Están en riesgo más de $774 millones en Fondos rotativos estatales debido a la continua crisis financiera que azota a Puerto Rico. Es muy poco probable que puedan recuperarse estos fondos rotativos en el futuro cercano.

The Federal Emergency Management Agency (FEMA) did not ensure state and local law enforcement agencies accounted for and expended Presidential Residence Protection Assistance (PRPA) grant funds in accordance with Federal regulations and component guidelines.

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

The objective of our audit was to determine whether the Department designed and implemented processes that provided reasonable assurance that Charter Schools Program Grants to Charter Management Organizations for the Replication and Expansion of High-Quality Charter Schools (Replication and Expansion) grantees reported complete and accurate information in their annual performance reports (APR) and spent grant funds only on allowable activities and in accordance with program requirements. We found that the Department and the Charter School Program (CSP) office designed processes that should have provided reasonable assurance that recipients of Replication and Expansion grants reported complete and accurate information in their APRs. We concluded that the CSP office generally implemented these processes as designed. However, it did not always ensure that CSP program officers accurately and completely filled out APR review templates and notified grantees of issues or concerns identified during their reviews of APRs. As a result, the CSP office might not have had reliable information needed to make informed decisions about continuation funding. Additionally, the CSP office might not have provided timely assistance to grantees that needed assistance to meet their approved goals. Further, we determined that the Department and the CSP office also designed processes that should have provided reasonable assurance that Replication and Expansion grantees spent grant funds only on allowable activities and in accordance with program requirements. We concluded that the CSP office generally implemented these processes as designed. However, it did not always ensure that grantees implemented corrective actions to address significant compliance issues relevant to their uses of Replication and Expansion grant funds, fiscal control, and fund accounting. Lastly, the CSP office did not always retain records in official grant files. As a result, the CSP office could not find about 52 percent of the APR review forms that we concluded CSP program officers should have completed from October 1, 2015, through June 30, 2021. Additionally, the CSP office could not find written correspondence with the grantees associated with about 10 percent of the APR review forms that we requested for review.

This report presents the results of our audit of Management of Postal Service Smartphones.

What We Looked AtMoving international cargo across the United States-Mexico border, including via long-haul trucks, is essential to our economy. Pursuant to the United States-Mexico-Canada Agreement (USMCA) Implementation Act, in August 2021, the Federal Motor Carrier Safety Administration (FMCSA) submitted a report to Congress on all existing grants of operating authority to, and pending applications for operating authority from, all Mexico-domiciled and Mexican-owned or -controlled motor property carriers with authority to operate beyond the United States-Mexico border commercial zones. The USMCA Statement of Administrative Action directed our office to review the Department’s actions to determine whether each motor carrier with any operating authority covered by FMCSA’s reporting requirement complies with applicable Federal motor carrier safety laws and regulations. Our objectives were to determine whether FMCSA (1) met requirements in authorizing Mexico-domiciled and Mexican-owned or -controlled motor carriers to conduct long-haul trucking operations beyond border commercial zones and (2) monitored those carriers to ensure they are operating safely. What We FoundFMCSA generally followed Federal regulations and its standard operating procedures and processes when provisionally authorizing and monitoring cross-border carriers’ long-haul operations in the United States. The Agency also has an adequate tracking system to determine when carriers are due for a review to ensure they are complying with these regulations. However, FMCSA did not always conduct timely compliance reviews of carriers operating under provisional authority, which hinders FMCSA’s ability to fully assess and mitigate carrier safety risks, resulting in increased risk that unsafe carriers may be operating on the Nation’s roadways. Our RecommendationsFMCSA concurred with our three recommendations to improve its adherence to requirements in authorizing and monitoring Mexico-domiciled and Mexican-owned or -controlled motor carriers. We consider these recommendations resolved but open pending completion of planned actions.

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.

EAC OIG, through the independent public accounting firm of McBride, Lock & Associates, LLC, audited $15.2 million in funds received by the State of Alaska under the Help America Vote Act. The objectives of the audit were to determine whether the Office of the Lieutenant Governor of Alaska: 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.

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The EPA’s NCD lacks assurance that the new chemicals review process operates as intended and achieves its objective to protect human health and the environment.

An Amtrak Service Attendant based in Seattle, Washington, was terminated from employment on August 2, 2023, following her administrative hearing. Our investigation found that the former employee violated company policies by engaging in outside employment while on a medical leave of absence. During her interview, the former employee admitted to her self-employment with DoorDash.

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 Southern Arizona VA Health Care System, which includes the Tucson VA Medical Center and multiple outpatient clinics in Arizona. 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. Leadership and organizational risks• Sentinel events and institutional disclosures2. Environment of care• Inspection frequency and documentation• Inspection deficiency tracking• Infectious materials signage• Environmental safety and cleanliness3. Mental health• Patient follow-up for suicide risk

USCP had recruiting mechanisms in place for augmenting officer staffing including the use of Reemployed Annuitants (RAs). USCP plans to use RAs as a temporary measure for augmenting officer staffing and bringing in trained officers with years of experience. As a result of USCP’s increased recruiting efforts, the Department is making strides to becoming fully staffed.

CSB has one system that contains sensitive PII. Safeguarding such information in the possession of the government and preventing its breach is essential to ensuring CSB retains the trust of the American public.