Federal Reports

The OIG has concerns that immediate public notifications are not being made for drinking-water lead-action-level exceedances that may pose a significant risk to public health.

The Veterans Health Administration (VHA) uses staffing data to assess whether medical facilities have the necessary resources to manage community care needs. Accurate staffing data are critical for decision-making and funding allocation to support veterans’ access to community care. The VA Office of Inspector General (OIG) assessed whether medical facility leaders identified, authorized, recruited, and retained nurses and medical support assistants (MSAs) to meet increased demand for community care. The OIG found that VHA does not have reliable data or sufficient tools to assess community care staffing levels and needs at the network or national level. Facility leaders do not use consistent organizational codes to identify community care staff across VA medical facilities. Additionally, VA’s staffing assessment tool relies on self-reported data that are not effectively verified. Due to data entry errors and a lack of consistent validation or quality review, VHA included inaccurate information in congressionally mandated reports. Despite these limitations, facility community care leaders generally identified local staffing needs, and their resource management committees authorized the requested staff. Although most facilities could adequately recruit and retain community care nurses, many could not recruit and retain MSAs. To compensate for the lack of MSAs, some facilities used innovative strategies such as hiring incentives or consolidated community care units to help process community care referrals. The under secretary for health concurred or concurred in principle with the OIG’s five recommendations to improve the reliability of community care staffing data and recruitment and retention of MSAs.

This report provides information on 610,219 Disability Insurance (DI) beneficiaries whose claims were approved at the initial claim level by various state disability determination services (DDS) during Calendar Years (CY) 2020 and 2021. In each case, disability examiners (1) determined the beneficiaries had disabling conditions that were permanent and that medical improvement was not expected, and (2) established a 7-year medical review diary. As of December 22, 2022, SSA had terminated the DI benefit payment status of only 319 (.05 percent) beneficiaries after determining they were no longer disabled. However, SSA had terminated the payment status of 75,857 beneficiaries who died after SSA approved their claims, including 4,444 beneficiaries who died during the 5-month DI waiting period.

In response to a congressional request, the VA Office of Inspector General (OIG) inspected the John D. Dingell VA Medical Center in Detroit, Michigan (facility) to assess leaders’ progress toward implementation of recommendations from the VHA Office of the Medical Inspector (OMI). The OIG evaluated facility leaders’ actions related to High Reliability Organization (HRO) goals and Veterans Integrated Service Network (VISN) 10 leaders’ oversight of, and support provided to, the facility leaders.The OIG found concerns related to VISN and facility leaders’ corrective actions in response to 6 of the 10 OMI recommendations. (1) Facility leaders did not meet VHA requirements related to the supervision of post-graduate year -1 residents. (2) Facility leaders delayed taking a privileging action and missed opportunities for state licensing board (SLB) reporting. (3) The interim chief of surgery’s facilitation of morbidity and mortality (M&M) conferences was inconsistent. (4) The facility corrective action plan was deficient for the OMI recommendation regarding the reassessment of a Peer Review Committee member. (5) The VISN academic affiliations officer was not made aware of the OMI recommendation related to resident supervision, did not provide oversight to the facility’s surgical residency program, and did not ensure compliance with VHA policy. (6) The VISN surgical workgroup did not document vital information from the facility, which could have ramifications across other VISN facilities.The OIG identified additional concerns regarding stable and continuous leadership in the facility, the impact of leaders’ actions on HRO principles, and VISN oversight of, and support to, facility leaders. The OIG made four recommendations to VISN leaders and five recommendations to facility leaders. Recommendations addressed resident supervision, National Surgery Office review, National Practitioner Data Bank and SLB reporting, M&M conferences, VISN academic affiliations officer roles and responsibilities, VISN surgical workgroup, VISN oversight and support to the facility, and continued efforts towards HRO.

We summarized (1) direct payments SSA made to claimant representatives during Calendar Years 2018 through 2022, and (2) user fees SSA charged claimant representatives to process the direct payments during Fiscal Years 2018 through 2022

An Amtrak Assistant Passenger Conductor based in Denver, Colorado, was terminated from employment on May 25, 2023, following his administrative hearing. The Denver Police Department requested our assistance in identifying an individual who was suspected of shoplifting items valued at $244 from a Whole Foods Market while wearing an Amtrak uniform. Our investigation resulted in the identification of the former employee and he, subsequently, pleaded guilty to and was convicted for shoplifting.

The EPA needs to shift its focus from point sources to nonpoint sources to achieve the necessary Chesapeake Bay TMDL pollutant reduction goals.

Our objective was to identify any challenges with company systems and processes that could impede the Capital Delivery department’s ability to effectively track and manage costs for capital projects.Amtrak’s Capital Delivery department is strengthening its ability to track and manage costs. For example, the company is developing a single project management system that it anticipates will replace or integrate at least 12 systems to address the challenge project teams currently have tracking costs across multiple systems. We identified additional challenges, however, with the systems and processes that the department uses for project cost management. Specifically, detailed and standardized cost data are not readily available to project teams, and project cost management guidance is outdated. These challenges hinder project teams and company executives from obtaining consistent, detailed cost data to manage the company’s portfolio of capital work—foundational capabilities that are critical to effectively managing costs on billions of dollars in taxpayer-funded projects.We recommended Amtrak study how it can develop and use more detailed and standardized costs for effective project cost management and then create a plan specifying the people, processes, and systems it needs to do so. While that study is ongoing, we recommended Amtrak develop and implement rules in the short term that define how project teams should categorize costs using existing systems and processes. Finally, we recommended that Amtrak update and implement project cost management procedures to reflect current processes and requirements.

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

The OIG inspection team examined how the U.S. Government Publishing Office (GPO) addressed violations identified during the 2016 U.S. Environmental Protection Agency (EPA) and the 2014 DC Department of Energy & Environment (DOEE) inspections.

This required external peer review was conducted in accordance with the Council of the Inspectors General on Integrity and Efficiency (CIGIE) Inspection and Evaluation Committee guidance as contained in the CIGIE Guide for Conducting External Peer Reviews of Inspection and Evaluation Organizations of Federal Offices of Inspector General (December 2021). The peer review was conducted from April 5, 2023, through July 14, 2023.The Reviewing OIG assessed the extent to which the Office of the Special Inspector General for the Troubled Asset Relief Program (SIGTARP) complied with the CIGIE Quality Standards for Inspection and Evaluation, December 2020 (Blue Book). This assessment included a review of SIGTARP’s internal policies and procedures, Evaluations Policies and Procedures Manual, January 1, 2022, implementing the Blue Book standards. It also included a review of selected inspection and evaluation reports issued between April 1, 2020, and March 31, 2023, to determine whether the reports complied with the Blue Book standards and the SIGTARP’s internal policies and procedures.

We conducted this work as part of our ongoing inspection of the funding provided to the Forest Service's Restoration Projects on Federal and Non-Federal Land from the Infrastructure Investment and Jobs Act (IIJA).

Chemawa Indian School did not accurately account for or use financial resources in accordance with laws and regulations during FYs 2019 through 2021.

We selected the State of California’s 2018 disaster owner-occupied rehabilitation and reconstruction program to audit after an internal risk assessment of disaster grantees showed the grant was newer and had not yet disbursed the majority of its funding. The State received more than $1 billion for the 2018 disasters. Our audit objective was to determine what the State is considering and to what extent resilience-based mitigation efforts help homeowners to withstand potential future disasters, along with how the State is prioritizing its efforts in the program to assist qualified low-to-moderate-income beneficiaries. The State’s owner-occupied rehabilitation and reconstruction program generally planned for resilience-based mitigation efforts and prioritized its efforts to assist qualified low-to-moderate-income beneficiaries. The State faced some challenges, such as verifying structure type and size and assessing ownership and primary residency, in implementing this program due to it being one of the first housing rehabilitation and reconstruction programs addressing a wildfire disaster. The State’s efforts to adjust its program and requirements as it encountered challenges indicate its willingness to address exceptions when known. We recommended that the State should ensure that it has proper documentation for compliance with building standards and ownership and primary residence determinations.

Our objective was to evaluate the efficiency and effectiveness of the Surface Transfer Centers in the Western Pacific Region. To accomplish our objective, we reviewed key performance indicators associated with the transfer centers and conducted site visits at the transfer centers in Southern California, Northern California, and Salt Lake City.

Our objective was to evaluate the Postal Service’s performance during the FY 2023 peak mailing season and the implementation of its peak season preparedness plan. We also conducted fieldwork at the Athens S&DC and the Brooklyn PDC to determine if the new facilities had an impact on peak season operations.

We investigated allegations that a retired USPP Sergeant violated ethics regulations by seeking employment with a company while overseeing its work.

Keith Kovaleski, a former Amtrak Assistant Foreman, based in New York, was sentenced to 10 months’ home confinement in U.S District Court, District of New Jersey, on July 12, 2023, for marketing and distributing over $3 million worth of misbranded and unapproved new drugs. On July 11, 2023, his spouse, Sylvia Kovaleski, was also sentenced for her involvement in the scheme to 3 years’ probation. The couple was ordered to forfeit over $3 million as restitution. They pleaded guilty to the charges in March 2022.

What We Looked AtWe performed a quality control review (QCR) on the single audit that Eide Bailly LLP performed for the Riverside County Transportation Commission’s (RCTC) fiscal year that ended June 30, 2021. During this period, RCTC expended approximately $626.8 million from U.S. Department of Transportation (DOT) programs. Eide Bailly determined that DOT’s major programs were the Federal Transit Administration’s Federal Transit Cluster and the Federal Highway Administration’s Transportation Infrastructure Finance and Innovation Act Program. Our QCR objectives were to determine whether (1) the audit work complied with the Single Audit Act of 1984, as amended, the Office of Management and Budget’s Uniform Guidance, and the extent to which we could rely on the auditor’s work on DOT’s major programs and (2) RCTC’s reporting package complied with the reporting requirements of the Uniform Guidance. What We FoundEide Bailly complied with the requirements of the Single Audit Act, the Uniform Guidance, and DOT’s major programs. We found nothing to indicate that Eide Bailly’s opinion on DOT’s major programs was inappropriate or unreliable. In addition, we did not identify deficiencies in RCTC’s reporting package that required correction and resubmission.

NASA’s Deep Space Network transmits scientific and communications data between dozens of spacecraft and Earth. However, the network is oversubscribed with demand exceeding supply by 40 percent at times. While NASA is upgrading this critical infrastructure, the effort is costing more and taking longer than planned—challenges that could intensify as more “big data” missions like Artemis come online.

What We Looked AtOn March 24, 2015, Germanwings Flight 9525 crashed in the Alps, killing all 150 people on board. The crash was due to deliberate actions by the copilot. According to the final accident report, the copilot started to suffer from severe depression in 2008. In July 2009, and each year thereafter, the aeromedical center continued to renew the copilot's medical certificate. On March 10, 2015, a private physician recommended the copilot receive psychiatric hospital treatment due to a possible psychosis, but no aviation authority was informed. Concerned with issues regarding the impact of pilot mental health on passenger safety, Senator Dianne Feinstein requested that we review procedures and methods the Federal Aviation Administration (FAA) employs to evaluate the psychological health of airline pilots. Our objectives were to assess FAA's procedures for (1) evaluating the psychological health of airline pilots and (2) mitigating potential threats to aviation safety from pilots with psychological health issues.What We FoundFAA has comprehensive procedures to evaluate pilots' psychological health, which include a framework of policies, guidelines, and collaboration with airlines. FAA's adherence to the procedures resulted in an extensive and structured process to evaluate pilots' psychological health--a key component to help mitigate potential safety risks. However, FAA's ability to mitigate safety risks is limited by pilots' reluctance to disclose mental health conditions. According to FAA and aviation industry organization officials, primary factors that discourage pilots from reporting their mental health conditions are the stigma associated with mental health, potential impact on their careers, and fear of financial hardship. Addressing these barriers is critical for FAA to mitigate potential aviation safety risks.Our RecommendationsFAA concurred with our two recommendations to address FAA's need to encourage pilots with mental health issues to disclose and seek treatment for their conditions. We consider the recommendations resolved but open pending completion of planned actions.

Transformation: Semiannual Report to Congress for October 1, 2022 – March 31, 2023.

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 Northern Arizona VA Healthcare System because it had not been previously visited as part of the annual FISMA audit.The OIG’s information security inspections focus on three 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 previously unidentified critical vulnerabilities, uninstalled patches, and network operating systems no longer supported by the vendor—all of which could deprive users of reliable access to information and could risk unauthorized access to, or the alteration or destruction of, critical systems. The OIG identified almost twice as many devices on the network than the inventory listed, which constitutes a security management weakness. Weak access controls included missing video surveillance at a data center, inadequate fire-detection and suppression equipment, insufficient water sensors and climate controls, unmounted or stacked network equipment, and communications rooms without backup power supplies.The OIG made six recommendations to the assistant secretary for information and technology and chief information officer to improve controls at the healthcare system 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 five recommendations to the Northern Arizona VA Healthcare System director.

The U.S. International Development Finance Corporation Office of Inspector General (DFC OIG) contracted with RMA Associates, LLC (RMA) to conduct a review of DFC’s compliance with Payment Integrity Information Act of 2019 (PIIA) for fiscal year (FY) ending September 30, 2022. The review was conducted in accordance with 1) the Office of Management and Budget (OMB) Memorandum M-21-19, Transmittal of Appendix C to OMB Circular A-123, Requirements for Payment Integrity Improvement and 2) OMB Circular A-136, Financial Reporting Requirements, June 3, 2022.

Our objective was to review cash and inventory, daily reporting activities, clock ring adjustments, and employee separations at the Madeira Branch Office. The scope period was October 1, 2022 through March 31, 2023.

Our objective was to review cash and stamp inventory, daily reporting activities, clock ring adjustments, and employee separations at Groesbeck Branch. Our audit scope was October 1, 2022, through March 31, 2023.

Our objective was to review cash and stamp inventory, daily reporting activities, clock ring adjustments, and employee separations at the Cincinnati Main Office. Our audit review scope period was October 1, 2022, through March 31, 2023.

Five Ticket Accounting Clerks based in Massachusetts violated company policies by using their Smart ID badges to fraudulently swipe one another in and/or out of Amtrak’s time and attendance machines. Four employees admitted to the violations during their interviews with our agents, and we found a fifth employee also violated company policies by helping these employees engage in this misconduct. The five employees resigned in lieu of their disciplinary hearings and are ineligible for rehire.

ln accordance with our Annual Performance Plan Fiscal Year 2022, the Office of Inspector General (OIG) conducted a review of United States Capitol Police (USCP or Department) field office operations in order to better plan future work. USCP is in the initial stages of developing field office operations. OIG identified opportunities for future reviews that include areas such as property inspections, interviews with partner agencies, reviews of agreements with partner agencies, and compliance with policies and procedures.

The Federal Emergency Management Agency (FEMA) did not always secure information stored on mobile devices. Specifically, FEMA did not document whether it removed all data from mobile devices that were disposed of, lost or stolen, or taken on international travel. This occurred because FEMA did not ensure employees followed Department of Homeland Security policy and because FEMA did not have supplemental guidance with specific requirements for sanitizing lost or stolen mobile devices.

Our objective was to assess the security controls of the MDD‑TRs deployed at Postal Service facilities. Specifically, we performed testing on the devices using automated tools and manual review techniques to evaluate the devices’ security controls and functionality.

Our objective was to review cash and stamp inventories, daily reporting activities, clock ring adjustments, and employee separations at the Hillcrest Station, Rancho Santa Fe Post Office, and Chula Vista Post Office. Our audit review scope period was July 1, 2022, through December 31, 2022. We reviewed the Hillcrest Station, Rancho Santa Fe Post Office, and Chula Vista Post Office during the week of February 27, 2023. We are issuing this capping report to provide the U.S. Postal Service with overall findings and recommendations for all three post offices.

The U.S. Department of Agriculture (USDA) Infrastructure Investment & Jobs Act (IIJA) Funding Dashboard allows stakeholders to explore USDA programs that received IIJA funding, as well as IIJA monies awarded through USDA.

The PRAC along with 10 of our member Offices of Inspectors General began a case study-based review, in part, to learn more about how much pandemic relief funding went to recipients within six randomly selected communities. Using a combination of federal, state, and local data sources, we identified that 10 federal agencies provided approximately $2.65 billion in pandemic relief funds to the six communities through approximately 89 pandemic relief programs and subprograms during the first 18 months of the pandemic (March 2020 through September 2021). We also found that tracking pandemic funds to the community level required the use of multiple non-public federal, state, and local data systems. In addition, we found that data collection and system limitations at the federal, state, and local levels impacted our efforts to obtain consistent data or data reports. This is the first in a series of reports to be issued under this review.

We determined the Tennessee Valley Authority’s (TVA) coal plants have taken steps to reduce combustible coal dust since dedicated Combustible Dust Program funding was provided by TVA in 2018. Specifically, coal plants have dedicated combustible dust housekeeping crews to help mitigate combustible dust accumulations, and projects were completed to improve conditions at the plants. However, we identified areas of noncompliance with TVA Technical Safety Procedure 18.1205, Combustible Dust (Combustible Dust TSP), related to (1) coal dust accumulation, (2) documentation of combustible dust daily inspections, and (3) training. In addition, we identified an area for improvement related to inconsistent language in the Combustible Dust TSP and site combustible dust programs.

EAC OIG issued this advisory to advise EAC’s Executive Director on recent Federal Advisory Committee Act (FACA) board costs, which were incurred without appropriate policies and procedures to ensure that federal regulations were followed and costs were minimized.

We inspected the U.S. Small Business Administration’s (SBA) administrative process used to review potentially fraudulent Restaurant Revitalization Fund (RRF) applications and recover funds.Program officials designed the RRF application validation and approval processes using the Government Accountability Office’s A Framework for Managing Fraud Risks in Federal Programs. However, 3,790 applications submitted through a point-of-sale partner were processed without verifying gross sales, a key control designed to prevent ineligible entities from receiving awards.As a result, SBA’s RRF application processing system approved almost all 3,790 applications for awards, totaling $557 million, despite not having gross sales verified. Once notified, SBA took quick action and prevented $278.4 million from being disbursed to 1,618 of the 3,790 applicants, including 946 of the 1,056 potentially fraudulent awards which had been reported to the OIG Hotline. However, SBA has not reviewed the remaining 2,172 awards, totaling $278.6 million, which included the remaining 110 potentially fraudulent awards reported to OIG, totaling $20.7 million.We made one recommendation to prioritize and complete the review of 2,172 RRF awards, which includes 110 RRF awards that were suspected of fraud and referred to the OIG Hotline. These awards were flagged for having unsupported gross sales. SBA should take appropriate administrative actions to recover improper payments.SBA agreed with the recommendation. SBA managers planned to review all 2,172 RRF awards during the post-award process and resolve the recommendation.

We conducted this work as part of our ongoing, integrated oversight of the funding provided to Forest Service's Collaborative Aquatic Landscape Restoration (CALR) program by the Infrastructure Investment and Jobs Act (IIJA).

We determined whether the Foreign Agricultural Service (FAS) has implemented effective policies and procedures in the Market Access Program to evaluate participant eligibility, select applications, and allocate funding.

This report responds to a congressional inquiry. Our objective was to assess the effectiveness of procedures for the acceptance, handling, and delivery of Cremated Remains. We interviewed Postal Service Headquarters officials, local management and employees, a third-party company, and outside stakeholders. We conducted site observations at four mail processing facilities and 16 delivery units.

Without timely tracking and remediation of known vulnerabilities, the Agency risks compromising the confidentiality, integrity, and availability of environmental and radiation data used for determining responses to national incidents and safeguarding first responder personnel.

In July 2022, we conducted unannounced inspections of U.S. Customs and Border Protection (CBP) facilities in the Yuma and Tucson areas of Arizona, specifically five U.S. Border Patrol facilities and two Office of Field Operations (OFO) ports of entry (POE).

As part of our annual audit planning, we completed a threat assessment to identify high risk cybersecurity threats that could potentially impact Tennessee Valley Authority (TVA). We determined the potential impact for system intrusion through misconfigurations or unpatched systems to be high. Therefore, we included an audit of TVA Transmission Operations and Power Supply (TOPS) organization’s management of Mac® desktops and laptops as part of our 2022 audit plan. In summary, we determined MacBooks® managed by TOPS followed TVA’s configuration management policy. However, we determined 3 of 15 MacBooks® did not follow TVA policy for patch management. Specifically, one MacBook® was obsolete, and two had inconsistent patching history. In addition, we identified a gap between TVA policy and a TOPS patch management work instruction. TVA management agreed with our findings and took action to (1) surplus one MacBook® we identified as obsolete and (2) update the TOPS work instruction to align with TVA policy.

Our objective was to determine if the Postal Service has effective controls for maintaining accurate and complete data in CAMS; if there are manual controls within CAMS that can be automated; and if there are data options within CAMS that are not being utilized effectively.