Federal Reports

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We investigated allegations that a Bureau Director did not comply with ethics obligations. We did not substantiate these allegations.

The VA Office of Inspector General (OIG) conducted an inspection to evaluate the care provided to a patient who died by suicide in the Emergency Department and assessed leadership failures related to the event at the John Cochran Division of the VA St. Louis Health Care System (facility) in Missouri.The OIG determined that deficiencies in the quality of Emergency Department care provided to the patient resulted in a delay of care and may have contributed to the patient’s death. The OIG found that an Emergency Department nurse may not have properly administered a suicide risk screen and did not monitor the patient after triage. The OIG determined that an Emergency Department physician did not evaluate the patient due to the nurse’s failure to communicate that the patient was awaiting evaluation. Over two hours and twenty minutes elapsed from the time the patient arrived in the Emergency Department to the time the patient was found unresponsive. The OIG found deficiencies related to the root cause analysis process and determined that facility leaders did not complete a timely institutional disclosure or comply with Veterans Health Administration requirements in reporting to state licensing boards. The OIG also identified a concern related to the chief of the Emergency Department’s conduct, specifically their attempt to direct staff responses during the OIG inspection. The OIG made six recommendations to the Facility Director related to the chief of the Emergency Department’s conduct; standardized administration of the suicide risk screen; monitoring Emergency Department patients; completion of root cause analyses and administrative investigations on the same event; completion of institutional disclosures within required time frames; and state licensing board reporting.

U.S. Customs and Border Protection (CBP) apprehended and subsequently released a migrant without providing information requested by the Federal Bureau of Investigation’s Terrorist Screening Center (TSC) that would have confirmed the migrant was a positive match with the Terrorist Screening Data Set (Terrorist Watchlist). This occurred because CBP’s ineffective practices and processes for resolving inconclusive matches with the Terrorist Watchlist led to multiple mistakes. For example, CBP sent a request to interview the migrant to the wrong email address, obtained information requested by the TSC but never shared it, and released the migrant before fully coordinating with the TSC.

The VA Office of Inspector General (OIG) conducted this review to assess the VA Philadelphia Healthcare System’s oversight and stewardship of funds and to identify potential cost efficiencies. The review assessed the following financial activities and administrative processes to determine whether the healthcare system had appropriate oversight and controls in place: open obligations oversight, purchase card use and oversight, inventory and supply management, and pharmacy operations.The OIG found that the healthcare system could improve the following:• Deobligation of residual funds. Six of 10 sampled open obligations had residual funds totaling about $44,500 that should have been promptly deobligated.• Management of purchase card transactions. Potential noncompliance errors in about 18,500 purchase card transactions led to about $16 million in questioned costs. The healthcare system also may have missed cost savings on frequently used goods.• Inventory management. Inventory management could be made more efficient by ensuring stock levels and inventory values are recorded correctly, establishing local processes and procedures for monitoring inventory reports, implementing a plan for staff training to increase awareness of internal controls and data reliability in the inventory system, and ensuring all supply chain performance measures are maintained in compliance with VA policy.• Pharmacy efficiency. The healthcare system could narrow the gap between observed and expected drug costs, avoid end-of-year purchases, and meet requirements for monthly reconciliation reporting.VA concurred with the OIG’s 12 recommendations made to the healthcare system director to use as a road map to improve financial operations. The recommendations address issues that, if left unattended, may eventually interfere with effective financial efficiency practices and the strong stewardship of VA resources.

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 Phoenix VA Health Care System, which includes the Carl T. Hayden 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 four areas:1. Leadership and organizational risks• Institutional disclosures2. Quality, safety, and value• Peer review committee recommendations for improvement actions• Review of peer review committee’s summary analysis3. Medical staff privileging• Professional practice evaluations4. Environment of care• Inspections• Video recording

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.

Our objective was to assess Postal Service initiatives to increase cost coverage of Flats products.

EPA issuance of informative BEACH Act reports would allow Congress to make informed program decisions, improve program oversight, and enhance transparency.

We audited costs claimed by the New Hampshire Fish and Game Department under grants awarded by the FWS through WSFR.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess an allegation that staff delayed providing intervention and care for a patient who died following a medical emergency at a VA outpatient clinic. The OIG identified issues related to quality of care and the facility response.The OIG substantiated that a nurse delayed initiating cardiopulmonary resuscitation (CPR) after establishing the patient did not have a pulse and was not breathing, but was unable to determine if the delay led to the patient’s death. The OIG determined that failures in response to the medical emergency included ineffective emergency notification speakers to activate the emergency response, and incomplete incident documentation and review.During the inspection, the OIG identified concerns related to the quality of care provided to the patient in the days prior to and at the time of the incident that presented potential opportunities for additional assessment of the patient’s symptoms. Additional concerns included leaders’ response to the incident and staffs’ knowledge of the processes in place for advance healthcare planning with patients. The OIG found that in response to the incident, facility leaders conducted an emergency management debrief and completed an after-action review. However, facility leaders’ reviews of the incident were limited by a lack of information documented in the EHR, and decisions made based upon an unconfirmed determination of the patient’s cause of death.The OIG made five recommendations to the Facility Director related to ensuring proper outpatient clinic emergency processes including staff training, emergency notification, and documentation; ensuring compliance with CPR documentation; monitoring after-action plans for completion and compliance; consulting with the Office of General Counsel’s Regional Counsel to determine if an institutional disclosure is warranted; and evaluating and addressing staff’s understanding of advance care planning.

On August 24, 2021, the Peace Corps notified the United States Congress that Peace Corps/Dominican Republic (hereafter referred to as “the post”) intended to resume operations in December 2021. The first intake arrived in March 2022 with 13 Volunteers, including 2 reinstated Volunteers. On September 29, 2022, the Office of Inspector General announced this review to assess the post’s compliance with specific agency policies and procedures related to Volunteer and trainee health and safety, and the re-entry process.

On May 11, 2021, the U.S. Environmental Protection Agency Office of Inspector General,Administrative Investigations Directorate initiated an investigation into potentially improperexpenditures made by Dr. Katherine A. Lemos. The purpose of theinvestigation was to determine whether Dr. Lemos (1) improperly used Board funds for travelfrom her residence in San Diego to her official duty station in Washington, D.C.; (2) exceededthe statutory cap on expenses for her office refurbishment; and (3) hired two senior aides on anoncompetitive basis.

The Washington NDC is a highly mechanized U.S. Postal Service mail processing plant that distributes standard mail and packages in piece and bulk form. To carry out its mission, the Washington NDC owns the following types of assets:Capital assets have a unit cost of $10,000 or more, are acquired through purchase, transfer, or donation, and depreciate. In calendar year 2014, the threshold for capital assets was increased from $3,000 to $10,000.Expendable assets cost less than $10,000 and include items such as repair parts, replacement components, mail transport equipment, and workroom furniture. Sensitive assets are a subcategory of expendable assets and consist of assets vulnerable to theft or loss, and include items such as computers, laptops, cell phones, digital cameras, and other valuable portable equipment. Assets can be stored onsite in internal stockrooms or outside in storage facilities. Washington NDC management utilizes a 6,375 square feet external portable structure – built in 1995 – to store equipment and repair parts that exceed the storage capacity of its internal stockroom.

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 Southern Nevada Healthcare System, which includes the North Las Vegas VA Medical Center and multiple outpatient clinics in Nevada. 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 three recommendations for improvement in three areas:1. Leadership and organizational risks• Institutional disclosures2. Medical staff privileging• Ongoing Professional Practice Evaluations3. Environment of care• Electrical receptacles and switches in compliance with applicable requirements

The U.S. Environmental Protection Agency Office of Inspector General, Administrative Investigations Directorate initiated an investigation into potentially improper expenditures made by Dr. Katherine A. Lemos.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the leadership performance and oversight by Veterans Integrated Service Network 17: VA Heart of Texas Health Care Network in Arlington. This evaluation focused on five key areas of clinical and administrative operations:• Leadership and organizational risks• Quality, safety, and value• Medical staff credentialing and privileging• Environment of care• Mental health (focusing on suicide prevention)The OIG issued one recommendation for improvement in the Medical Staff Credentialing and Privileging review area regarding physicians with a potentially disqualifying licensure action.

This report presents the results of our self-initiated audit of the efficiency of operations at the Memphis Processing and Distribution Center (P&DC) and Mail Processing Annex (MPA) in Memphis, TN (Project Number 23-099). We judgmentally selected the Memphis P&DC and MPA based on a review of first and last mile failures; work hours; mail volume and productivity; overall scanning performance; and late, canceled, and extra trips. The Memphis P&DC and MPA are in the Southeast Processing Division. The P&DC processes letters and flats. The MPA processes parcels. The Memphis P&DC and MPA services multiple 3-digit ZIP Codes in urban and rural communities.

The U.S. Small Business Administration (SBA) Office of Inspector General (OIG) conducted this review to provide a comprehensive estimate of the potential fraud in the U.S. Small Business Administration’s (SBA) pandemic assistance loan programs. Over the course of the Coronavirus Disease 2019 (COVID-19) pandemic, SBA disbursed approximately $1.2 trillion of COVID-19 Economic Injury Disaster Loan (EIDL) and Paycheck Protection Program (PPP) funds.In the rush to swiftly disburse COVID-19 EIDL and PPP funds, SBA calibrated its internal controls. The agency weakened or removed the controls necessary to prevent fraudsters from easily gaining access to these programs and provide assurance that only eligible entities received funds. However, the allure of “easy money” in this pay and chase environment attracted an overwhelming number of fraudsters to the programs.We estimate that SBA disbursed over $200 billion in potentially fraudulent COVID-19 EIDLs, EIDL Targeted Advances, Supplemental Targeted Advances, and PPP loans. This means at least 17 percent of all COVID-19 EIDL and PPP funds were disbursed to potentially fraudulent actors.OIG collaboration with SBA, the U.S. Secret Service, other federal agencies, and financial institutions has resulted in nearly $30 billion in COVID-19 EIDL and PPP funds being seized or returned to SBA.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Collierville Main Post Office (MPO) in Collierville,. The Collierville MPO is in the Tennessee District of the Southern Area and services ZIP Code 38017. This ZIP Code serves about 47,868 people in a predominantly urban area. This delivery unit has 19 rural routes and 15 city routes. We judgmentally selected the Collierville MPO based on the number of Customer 360 inquiries, Informed Delivery contacts, undelivered route information, and stop-the-clock scans performed at the unit.Our objective was to evaluate mail delivery, customer service, and property conditions at the Collierville MPO in Collierville, TN.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Cordova Main Post Office in Cordova, TN. The Cordova Main Post Office is in the Tennessee District of the Southern Area and services ZIP Codes 38016 and 38018. These ZIP Codes serve about 78,549 people in a predominantly urban area. This delivery unit has 48 rural routes. We judgmentally selected the Cordova Main Post Office based on the number of Customer 360 inquiries and Informed Delivery contacts associated with the unit, undelivered route information, and stop-the-clock scans performed at the unit.Our objective was to evaluate mail delivery, customer service, and property conditions at the Cordova Main Post Office in Cordova, TN.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Desoto Carrier Annex in Memphis, TN. The Desoto Carrier Annex is in the Tennessee District of the Southern Area and services ZIP Codes 38103, 38106 and 38126. These ZIP Codes serve about 46,690 people in a predominantly urban area. This delivery unit has 37 city routes. We judgmentally selected the Desoto Carrier Annex based on the number of Customer 360 inquiries and Informed Delivery contacts associated with the unit, undelivered route information, and stop-the-clock scans performed at the unit.Our objective was to evaluate mail delivery, customer service, and property conditions at the Desoto Carrier Annex in Memphis, TN.

Our objective was to evaluate the efficiency of operations at the Memphis P&DC and MPA. To accomplish our objective, we focused on four audit areas: mail clearance times; delayed mail; late, canceled, and extra outbound trips; and load scans. Specifically, we analyzed Enterprise Data Warehouse data for workhours, overtime, and penalty overtime from April 2022 to March 2023. We reviewed Surface Visibility Web data for late, canceled, and extra trips, as well as load scans between April 2022 and March 2023. Further, we identified mail clearance times in Web End of Run data for the Memphis P&DC and MPA and compared them with operations shown in the Run Plan Generator report. During our site visit the week of May 1, 2023, we interviewed P&DC and MPA management and observed mail processing and dock operations.

This interim report presents the results of our self‑initiated audit of mail delivery, customer service, and property conditions at the Germantown Main Post Office (MPO) in Germantown, TN. The Germantown MPO is in the Tennessee District of the Southern Area and services ZIP Codes 38138 and 38139. These ZIP Codes serve about 39,970 people in an urban area. This delivery unit has 10 rural routes and 20 city routes. We judgmentally selected the Germantown MPO based on the number of Customer 360 inquiries, Informed Delivery contacts, undelivered route information, and stop-the-clock scans performed at the unit.Our objective was to evaluate mail delivery, customer service, and property conditions at the Germantown MPO in Germantown, TN.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Hickory Hill Station in Memphis, TN. The Hickory Hill Station is in the Tennessee District of the Southern Area and services ZIP Codes 38115, 38125, and 38141. These ZIP Codes serve about 98,465 people in a predominantly urban area. This delivery unit has 26 city routes and 22 rural routes. We judgmentally selected the Hickory Hill Station based on the number of Customer 360 inquiries and Informed Delivery contacts associated with the unit, undelivered route information, and stop-the-clock scans performed at the unit.Our objective was to evaluate mail delivery, customer service, and property conditions at the Hickory Hill Station in Memphis, TN.

Our objective was to assess the management of the inventory, security, and utilization of the Commission’s smartphones. We used a combination of data analytics, interviews, and control tests to determine if appropriate controls were in place and functioning as intended.

Compliance review of recommendations in AUD-2018-013

We audited costs claimed by the Guam Department of Agriculture, Division of Aquatic and Wildlife Resources, under WSFR grants awarded by the FWS.

USDA OIG determined whether National Institute of Food and Agriculture (NIFA) designed and implemented adequate internal controls to properly select Agriculture and Food Research Initiative (AFRI) grant recipients and monitor AFRI projects’ compliance.

Our initial objective was to assess the effectiveness of the company’s oversight and coordination of its private security contractors, but we reported our observations now to inform the company’s efforts to consolidate private security contractors under a nationwide contract.In June 2020 we reported that the Amtrak Police Department (APD) did not have full visibility over private security contractors because various end-user departments can independently seek agreements for their services. During our most recent audit work, we observed that the company continues to face impediments identifying the totality of its private security workforce. For example, we identified an additional 17 private security contractors (companies or individuals) that APD and the Procurement department were unaware of. Two factors impact the company’s efforts: 1) it has neither a companywide contract repository nor an alternative process to identify these contractors, and 2) it has not determined which department or individual, if any, should be responsible for evaluating and approving the requests of end‐user departments for private security services.We provided these observations for the company’s consideration. The company agreed with our observations and is taking corrective action.

Objectives: To determine whether the Social Security Administration (SSA) has established internal controls to (1) initiate enrollment, upon request, in the Direct Express® Debit Card program (Program) and (2) resolve benefits returned to the Agency because of an unfinished enrollment.

Objective: To determine how the COVID-19 pandemic affected the disability determination services’ (DDS) processing of disability claims.

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

An Engineering Supervisor based in New York City violated company policies by working in violation of the 16-hour rule, receiving unnecessary “Time Paid Not Worked,” and receiving pay for more than 24 hours in a day. Specifically, we found 41 occasions when the supervisor claimed compensatory time for minimal or no work and 35 occasions when the employee did not swipe in or out on a time-and-attendance machine, as required by company policy. The employee resigned in lieu of his disciplinary hearing and is ineligible for rehire.

The comments are in response to The Social Security Administration’s Oversight of Beneficiaries Who Receive Benefits Under the Direct Express® Debit Card Program, A-04-20-50977, that was submitted by Comerica Bank on July 25, 2023 pursuant to Pub. L. No. 117- 263, § 5274.

Colby Frazier, a resident of Long Beach, California, was sentenced to 30-months in prison on charges of Wire Fraud and Aggravated Identity Theft in U.S. District Court, Eastern District of Pennsylvania, on June 21, 2023, for his participation in a "phishing" scheme in which he fraudulently obtained credit card and personal identifying information (PII) from his victims, including names and banking information. Frazier used the victims' credit card information and PII to purchase online travel tickets on common carriers, including Amtrak, and then resold the tickets to other individuals and kept the proceeds. Frazier was previously indicted on July 11, 2019, and he pleaded guilty to the charges on May 19, 2021. He was also ordered to pay $67,056 in restitution to Amtrak.

We performed audits at the Southern Maine Processing and Distribution Center (P&DC) and five delivery units serviced by the P&DC in the Portland Maine region during the week of March 13, 2023. These audits responded to a request from Senator Susan Collins and interest from Representative Chellie Pingree in mail operations in the Portland, ME region. The delivery units included the Industrial Park Annex, Saco, ME; Lewiston Main Post Office (MPO), Lewiston, ME; Main Office Carrier Section, Portland, ME; Southern Maine Carrier Unit, Scarborough, ME; and Sanford MPO, Sanford, ME.

The VA Office of Inspector General (OIG) conducted a national review evaluating the transition of clinical care for service members with opioid use disorder (OUD) from the Department of Defense (DoD) to the Veterans Health Administration (VHA). OUD is an established risk factor for opioid overdose death and suicide. Failure to identify and document a patient’s OUD history may decrease the likelihood of future providers using medically relevant information in clinical decision-making and may put patients at risk for adverse outcomes, such as overdose.The OIG conducted electronic health record reviews for two groups identified from a sample of discharged service members with an OUD diagnosis documented in the DoD treatment record, who had a VHA primary care or mental health encounter between the date of DoD discharge and July 4, 2021. Group 1 consisted of patient records without an OUD diagnosis in VHA data and group 2 consisted of patients with an opioid-related death.Deficiencies were found in VHA primary care and mental health providers’ documentation identifying OUD in encounters, progress notes, and problem lists for both study groups reviewed, despite having a diagnosis of OUD in DoD treatment records.The OIG evaluated provider perceptions of barriers documenting OUD and use of risk mitigation strategies. More than half of VHA providers who responded to a questionnaire reported no expectation of reviewing DoD treatment records when completing an intake and identified barriers reviewing DoD treatment records.The OIG made five recommendations to the VA Under Secretary for Health related to the identification of barriers for providers documenting OUD in electronic health records; training on the use, navigation, and retrieval of DoD treatment record information; evaluation of the barriers to access and use of DoD treatment records; and evaluating and updating processes for the identification of patients with OUD.

The Office of the Inspector General audited the Tennessee Valley Authority’s (TVA) use of remote application and desktop virtualization client due to the risks of (1) potential system intrusion through misconfigurations and (2) continued elevated remote users during the COVID-19 pandemic. We found the configuration management control for TVA’s remote application desktop virtualization client was ineffective. However, we determined compensating access controls were in place to mitigate the risk to an overall acceptable level.

What We Looked AtEnsuring adequate staffing and training for air traffic controllers—an essential part of maintaining the safety and efficiency of the National Airspace System (NAS)—has been a challenge for the Federal Aviation Administration (FAA), especially at the Nation’s most critical facilities. In addition, the COVID-19 pandemic has impacted the Agency’s ability to maintain the required number of controllers at these facilities. Given the importance of minimizing the risks to the continuity of air traffic operations, as well as the potential impact of COVID 19 on staffing and training, we initiated this audit. Our objectives were to (1) assess FAA’s efforts to ensure that critical air traffic control facilities have an adequate number of controllers and (2) identify the impact of the COVID-19 pandemic on FAA’s controller training program. What We FoundFAA has made limited efforts to ensure adequate controller staffing at critical air traffic control facilities. The Agency also has yet to implement a standardized scheduling tool to optimize controller scheduling practices at these facilities, and FAA officials disagree on how to account for trainees when determining staffing numbers. As a result, FAA continues to face staffing challenges and lacks a plan to address them, which in turn poses a risk to the continuity of air traffic operations. For example, we determined that 20 of 26 (77 percent) critical facilities are staffed below the Agency’s 85-percent threshold, with New York Terminal Radar Approach Control (TRACON) and Miami Tower at 54 percent and 66 percent, respectively. Additionally, COVID-19 led to training pauses over a period of nearly 2 years—significantly increasing controller certification times. FAA will not know the full impact of the training suspension on certification times for several years because training outcomes vary widely, and it can take more than 3 years to train a controller. Due to these uncertain training outcomes, FAA cannot ensure it will successfully train enough controllers in the short term. Our RecommendationsFAA concurred with our two recommendations to improve its ability to ensure adequate staffing at its critical facilities. We consider both recommendations as resolved but open pending completion of the planned actions.

What We Looked AtThe Federal Aviation Administration (FAA) is responsible for safely managing the National Airspace System (NAS). This requires coordinating commercial and military aviation with increasing numbers of commercial space transportation launches and reentries. Citing this increasing frequency and the need to integrate commercial space operations into the NAS, the Ranking Members of the House Committee on Transportation and Infrastructure and its Subcommittee on Aviation requested that we examine the FAA’s Space Data Integrator (SDI) program and other actions taken by FAA and the aerospace industry related to commercial space integration. Our audit objectives were to assess (1) FAA’s progress in implementing the SDI program and (2) actions taken and planned by FAA and the aerospace and aviation industries to integrate commercial space operations into the NAS.What We FoundFAA deployed an SDI prototype in 2021, but its effectiveness in providing launch and reentry data to stakeholders is limited because it only receives data from one operator, only tracked one launch at a time until recently, and is only installed at the FAA Command Center. Additionally, FAA has not finalized plans and requirements for a successor program intended to leverage the SDI prototype. The Agency is not expected to make a Final Investment Decision regarding this new program until September 2027, with the intention of gradual implementation through fiscal year 2032. FAA has connected with stakeholders to provide input on commercial space integration issues and implemented some of their recommendations. However, FAA has postponed taking action on other identified shortfalls and recommendations pending final decisions on implementing a successor program for SDI, which is now delayed. Finally, while FAA has implemented procedures aimed at reducing the amount of time commercial space operations impact NAS airspace, the Agency faces operational and policy challenges to efficiently integrate these operations.Our RecommendationsWe made four recommendations to improve FAA’s ability to provide and capture information regarding its efforts to integrate commercial space operations. FAA concurred with all four recommendations and provided appropriate planned actions and completion dates.

What We Looked AtAdvanced Air Mobility (AAM) is a Government and industry initiative to develop an air transportation system between and within rural and urban locations. This new technology, including highly automated hybrid and electric vertical takeoff and landing (eVTOL) aircraft, promises many benefits. However, the Federal Aviation Administration's (FAA) regulations are still primarily intended for traditional small aircraft, creating challenges for FAA. Given these challenges, the Ranking Members of the House Committee on Transportation and Infrastructure and its Subcommittee on Aviation requested this audit. Our objective was to determine FAA's progress in establishing the basis for certification of AAM aircraft, including ensuring the safety of novel features and providing guidance to applicants.What We FoundRegulatory, management, and communication issues hindered FAA's progress in certifying AAM aircraft, and challenges remain. Given their unique features, AAM aircraft do not fully fit into FAA's existing airworthiness standards. For over 4 years, FAA made limited progress in determining which certification path to use. One issue is that, over 2 decades ago, FAA defined an aircraft category called powered-lift that is applicable to some AAM aircraft. However, FAA never established corresponding airworthiness standards and operational regulations, leading to significant internal debates and a lack of consensus on how to proceed. This lack of consensus affected rulemaking efforts that hindered the Agency's progress. Further, FAA changed its certification path, which caught industry by surprise. The Agency will likely continue to face challenges as it progresses through the certification process for AAM aircraft, including reviewing novel features and establishing new operational regulations. Finally, FAA has not sufficiently established policies and procedures for its Center for Emerging Concepts and Innovation, or communicated about its role in AAM certification. Continued ineffective coordination and communication, as well as the lack of timely decision making and established policies, could further hinder progress.Our RecommendationsFAA concurred with our four recommendations to enhance FAA's regulatory efforts and communication regarding the AAM aircraft certification process. We consider all recommendations resolved but open pending completion of planned actions.

The Veterans Appeals Improvement and Modernization Act of 2017 (the Appeals Modernization Act (AMA)), was designed to offer veterans faster resolution of disagreements with VA decisions. It established three review lanes: a direct appeal to the Board of Veterans’ Appeals (not covered in this report); a higher-level review by a senior technical expert in which no new evidence may be presented; and a supplemental claim. Higher-level reviews and supplemental claims each have a completion goal of an average of 125 days. VA must report its performance to Congress and on a public website.The OIG found that VA developed reporting metrics for AMA decision reviews but could be clearer on some veterans’ wait times. Specifically, veterans who submit a claim for a higher-level review of a benefits decision and where a processing error is identified will have a new supplemental claim established—each with a completion goal of 125 days. VBA reports these separately. However, when the veteran is notified that a new claim has been established, there is no mention that they may need to wait for its completion, with a stated goal of another 125 days for a final decision. The cumulative wait time for higher-level reviews finalized as supplemental claims is not fully transparent to veterans.The OIG interprets the AMA to mean that for decisions under VBA’s jurisdiction, VA also must report the average duration from when a veteran files an initial claim through one year after VBA’s closure of the last decision on the AMA claim. VA omits the initial claim and one year.The OIG recommended VA update the reporting methodology to reflect veterans’ total wait for a final claims decision on higher-level claims completed as supplemental claims and revise and clearly state how it calculates the average duration of these AMA claims.

An Amtrak Customer Service Representative based in Hammond, Louisiana, signed a civil settlement agreement on June 20, 2023, with the U.S. Attorney’s Office, Southern District of Mississippi, and agreed to pay $18,182 in restitution and a $4,500 penalty for a total civil settlement amount of $22,682. Our investigation found that the employee submitted a fraudulent application to obtain a Paycheck Protection Program (PPP) loan. We found that the employee falsely inflated the gross income of her business in the amount of $75,000 to qualify for the PPP loan, resulting in the receipt of funds to which she was not entitled.

What We Looked AtThe Infrastructure Investment and Jobs Act (IIJA) authorized about $660 billion in funding for new and existing U.S. Department of Transportation (DOT) programs for fiscal years 2022 through 2026—more than twice the amount in the previous 5-year authorization law. IIJA also changed existing surface transportation programs and created new programs. Federal programs face an increased risk of fraud when they experience unusually rapid growth or when new or changing laws significantly affect them. Because many IIJA-funded surface transportation programs experienced such growth and change, we initiated this audit to evaluate DOT’s fraud risk assessment processes. What We FoundDOT has an opportunity to expand its fraud risk assessment process for IIJA-funded surface transportation programs to better incorporate the Government Accountability Office's (GAO) leading practices. Following the passage of the Fraud Reduction and Data Analytics Act of 2015, DOT developed a Fraud Risk Management Plan (Plan). Although DOT anticipated fully implementing the Plan by October 2020, the Department has not yet completed two of its three planned phases. As DOT continues to implement its Plan, we found that the Department could enhance its fraud risk assessment processes to more fully incorporate leading practices identified in GAO’s Framework. Specifically, DOT could better incorporate leading practices related to planning and tailoring fraud risk assessments for all programs. DOT’s process could also better incorporate leading practices to identify and assess fraud risks and develop fraud risk profiles for its programs. By not more fully incorporating these leading practices, DOT may not be optimally positioned to comprehensively identify, properly assess, and appropriately prioritize resources to address the full spectrum of fraud risks across all of its programs, including its diverse surface transportation programs. Our RecommendationsDOT concurred with our two recommendations to improve the effectiveness of its fraud risk assessment processes. We consider these recommendations resolved but open pending completion of planned actions.

We investigated alleged underreporting of gas production from Federal wells and found a company owes unpaid Federal gas royalties.

Objective: To determine the extent of the disruptions to the Social Security Administration’s (SSA) telephone services and their impact on the public.