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Brought to you by the Council of the Inspectors General on Integrity and Efficiency
Federal Reports
Report Date
Agency Reviewed / Investigated
Report Title
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Department of Agriculture
Office of Inspector General Semiannual Report to Congress FY 2023 - First Half
The Inspector General Act of 1978 requires the Inspector General to prepare semiannual reports summarizing the activities of the Office of Inspector General for the preceding six-month period. The semiannual reports are intended to keep the Secretary and Congress fully informed of significant findings, progress the Agency has made, and recommendations for improvement.
The NASA Office of Inspector General issues its Semiannual Report to Congress summarizing the OIG’s activities and accomplishments from October 1, 2022 to March 31, 2023.
In 2019, Congress enacted the Payment Integrity Information Act (PIIA) to update required reporting on agencies’ improper payments. PIIA requires agencies to review and identify programs and activities that may be susceptible to significant improper payments, estimate the improper payments rates in agency programs, and report on their actions to reduce and recover those payments. The Inspector General of each agency assesses compliance with these requirements annually.AmeriCorps implemented corrective actions in FY 2022 that improved its compliance with PIIA reporting requirements. The agency met eight of 10 PIIA compliance requirements. Of the two remaining requirements, the agency reported improper payment rates above the ten percent compliance threshold for the Foster Grandparent Program (FGP), Senior Companion Program (SCP), and Retired and Senior Volunteer Program (RSVP). The agency also reported improper payment rates that were not accurate, reliable, or consistent with Office of Management and Budget guidance for AmeriCorps State and National, FGP, SCP, and RSVP. Further, AmeriCorps incorrectly concluded that there was no need to assess the National Service Trust (NST) for improper payments.AmeriCorps grantees did not have sufficient internal controls in place to verify the allowability of payments made with AmeriCorps grant funds, or to maintain documentation to support the allowability of these payments. AmeriCorps noted that the main drivers of improper payments and unknown payments occurred due to issues with eligibility documentation, non-compliance with the National Service Criminal History Check requirement, and policy issues. Also, some grantees did not maintain documentation to support the allowability of the temporary pay allowances paid to volunteers who were unable to serve during the COVID-19 pandemic.Management agreed to include the NST to the list of programs susceptible to improper payments, add additional provisions to its grant terms and conditions that address the root cause of improper payments, and develop and implement actions to reduce the improper payment rates below ten percent for FY 2023.
Audit of the Office of Justice Programs Victim Assistance Funds Subawarded by the Kentucky Justice and Public Safety Cabinet to the ION Center for Violence Prevention, Covington, Kentucky
The Office of Inspector General (OIG) is issuing this management advisory to bring to your attention concerns regarding the return of Paycheck Protection Program (PPP) funds. This issue requires immediate attention and action by the U.S. Small Business Administration (SBA) to ensure it has processes and procedures in place to adequately accept, process, and account for PPP funds returned by borrowers, lenders, and financial institutions. Expedited management action should mitigate the risk of financial loss to taxpayers.Establishing clear and detailed guidance for borrowers, lenders, and financial institutions on how to return PPP funds and implementing a process for SBA to accurately handle and track the returned funds should mitigate the risk of financial loss. SBA should take immediate action to ensure it has processes and procedures in place to adequately accept, process, and account for returned PPP funds.To ensure PPP funds are returned as appropriate, we suggest the Administrator direct the Associate Administrator for the Office of Capital Access to:1. Provide detailed guidance to borrowers on returning PPP funds to lenders if the loan was forgiven or guaranty purchased.2. Provide detailed guidance to lenders on their responsibilities for accepting PPP funds if the loan was forgiven, to include documenting reasons for the return of funds, returning the funds to SBA, conducting a fraud review, reversing forgiveness when appropriate, and handling loans with only a partial return of funds.3. Seek periodic assurance from lenders that all PPP funds returned to lenders have been reported and returned to SBA. The report to SBA should include details on the source of the returned funds.4. Provide detailed guidance to financial institutions that receive PPP fund deposits for borrowers regarding how to return PPP funds if there is suspected fraud or other issues that would warrant returning funds.
The Veterans Health Administration (VHA) established the beneficiary travel program to reimburse veterans and caregivers for travel expenses for approved healthcare appointments. VHA spent over $1.3 billion on this program in fiscal year 2021. Both VA and the Office of Inspector General (OIG) have identified the beneficiary travel program as susceptible to significant improper payments.In September 2016, VA awarded a contract to create a web-based system called the Beneficiary Travel Self-Service System (BTSSS) to automate the travel reimbursement claims process, reduce long-term costs, provide better oversight, and decrease the risk of improper payments. In November 2020, VA started using the new system nationwide. Complaints to the OIG suggested the new system had not been meeting its intended goals, prompting a review of its implementation.Although VHA has made improvements since BTSSS rollout, the OIG found it needs to do more to ensure successful implementation. The Veterans Transportation Program (VTP) office, which oversees the beneficiary travel program, established four goals to measure success. The OIG found that from February 2021 through July 2022 (the review period), BTSSS fell short of all four metrics on increased automated claims adjudication, reduced manual overrides, greater new system usage, and more self-service use.VA concurred with the OIG’s four recommendations. They included that the VTP director determine what system changes are needed to meet auto-adjudication goals and implement them, as well as conduct outreach to users, solicit feedback, and then consider whether system changes are needed to increase self-service portal usage. The OIG also recommended the assistant under secretary for health for operations create an action plan to phase out continued use of the legacy beneficiary travel function and coordinate with the VHA finance office and assess whether duplicate payments were made to veterans requesting travel reimbursement since the new system went live.
The OIG has learned that employees of thousands of contractors who receive funds from the U.S. Department of Housing and Urban Development (HUD) are not protected against retaliation for blowing the whistle on wrongdoing. The gap in protections exists because (1) the contracts pre-date July 1, 2013, the date on which the anti-retaliation law codified at 41 U.S.C. § 4712 (Section 4712) became effective; and (2) HUD has not modified the contracts to include Section 4712 anti-retaliation provisions that would protect the employees.1 The OIG identified this problem following recent investigations of allegations of whistleblower retaliation against several employees of contractors. Although the investigations revealed this problem with respect to Housing Assistance Payments (HAP) contracts, as discussed below, we believe that the same risk is present in many other HUD contracts.2 The OIG recommends that HUD address this serious risk by undertaking a comprehensive review of all contracts to determine whether they include Section 4712 anti-retaliation provisions. We also recommend that HUD be proactive in seeking to modify any HUD contracts that do not include Section 4712 anti-retaliation language to confer whistleblower protections on contractor employees.
What We Looked AtAs part of its oversight responsibilities, the Pipeline and Hazardous Materials Safety Administration's (PHMSA) Office of Pipeline Safety (OPS) conducts pipeline inspections, including integrated inspections that combine elements of various safety inspections. We conducted this audit because integrated inspections make up the majority of OPS' inspections and can identify possible impacts on pipeline safety. Our audit objective was to assess PHMSA's implementation of integrated inspections, specifically to assess the Agency's policies and procedures, risk-based approach, and conduct of integrated inspections.What We FoundPHMSA has established procedures and information systems to plan and conduct integrated inspections and document results. The integrated inspections we reviewed followed these procedures, were prioritized by risk, and resolved unsatisfactory conditions. In developing PHMSA's annual inspection plans, PHMSA's Risk Ranking Index Model (RRIM) uses risk factors to code high, medium, and low scores for when pipeline systems should be inspected. OPS also verifies that, to the extent possible, no system goes without inspection for more than 7 years and unsatisfactory conditions found in inspections are addressed. Nevertheless, PHMSA's guidelines for integrated inspections have control weaknesses. Specifically, while the manual covers most of the integrated inspection process, some sections are out of date and others do not reflect actual practices. Furthermore, 7 of 18 inspections we analyzed had missing or draft system profiles even though these profiles are integral to the inspection planning process. Finally, the risk factors that RRIM uses to calculate pipeline system risk scores inadequately considered several statutorily required factors for PHMSA's decisions on how frequently to inspect pipeline systems.RecommendationsWe made three recommendations to help PHMSA improve its integrated inspection program and the Agency concurs with all three recommendations.
What We Looked AtThe impacts of a motor vehicle safety defect can be significant. The National Traffic and Motor Vehicle Safety Act authorizes the National Highway Traffic Safety Administration (NHTSA) to investigate motor vehicle safety issues and requires manufacturers to notify the Agency of all safety-related defects involving unreasonable risk of accident, death, or injury. NHTSA’s Office of Defects Investigation (ODI) plays a key role by gathering and analyzing relevant information, investigating potential defects, identifying unsafe motor vehicles and items of motor vehicle equipment, and managing the recall process. Given the impact NHTSA’s efforts to adequately address safety defects have on the traveling public, we initiated this audit to assess ODI’s current processes for investigating and identifying safety defects. Specifically, we analyzed ODI’s risk-based oversight procedures for prioritizing its work, determining which issues were appropriate for investigation, and evaluating potential risks of harm posed by potential safety defects. What We FoundNHTSA’s ODI has made progress promoting a safer transportation system for the traveling public by restructuring its office, modernizing its data repository and analysis systems, and enhancing its risk-based investigative processes to assess safety-related defects. However, ODI did not meet its timeliness goals for the five types of investigations we examined, and the Agency did not upload investigation documentation to its public website in a timely manner. ODI does not have an integrated information system to facilitate the safety defect investigation and recall processes. Furthermore, ODI does not consistently document information used for investigating and identifying potential defects and unsafe motor vehicles or motor vehicle equipment in the Agency’s internal and external files. In addition, ODI does not consistently follow its procedures for issue escalation and lacks guidance for other pre-investigative efforts. Our RecommendationsWe made 12 recommendations to help NHTSA improve its risk-based processes for investigating and identifying potential motor vehicle and equipment safety defects. NHTSA concurred with 10 of our 12 recommendations, partially concurred with 1 recommendation, and did not concur with 1 recommendation. NHTSA proposed alternate action for the recommendation with which it did not concur. We consider all 12 recommendations resolved but open pending implementation.
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 San Diego Healthcare System, which includes the main medical center and multiple outpatient clinics in Southern 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 one recommendation for improvement in the Leadership and Organizational Risks review area regarding conducting institutional disclosures.
The Denali Commission Office of Inspector General issues its Semiannual Report to Congress summarizing the OIG’s activities and accomplishments from October 1, 2022 to March 31, 2023.
This report highlights the work of the Office of the Inspector General for the Nuclear Regulatory Commission (NRC) and the Defense Nuclear Facilities Safety Board (DNFSB) from October 1, 2022, to March 31, 2023. During this reporting period, we initiated thirteen audit reports and issued four. We also opened ten investigative cases and completed twelve, six of which were referred to the Department of Justice, and six of which were referred to NRC or DNFSB management for action.
This Semiannual Report to Congress reflects how the EPA OIG is achieving its mission of preventing and detecting fraud, waste, abuse, mismanagement, and misconduct related to the programs and operations of the U.S. Environmental Protection Agency and the U.S. Chemical Safety and Hazard Investigation Board during the reporting period, October 1, 2022, through March 31, 2023.
The objective for this unannounced inspection was to determine whether U.S. Customs and Border Protection (CBP) complies with National Standards on Transport, Escort, Detention, and Search (TEDS) and other relevant policies and procedures related to length of detention and conditions of detention at seven CBP short-term holding facilities. In May 2022, we conducted unannounced inspections of three Border Patrol stations in the Swanton sector, one port of entry in the Office of Field Operations (OFO) Boston Field Office area of responsibility, and three ports of entry in the OFO Buffalo Field Office area of responsibility; however, CBP had no migrants in custody.
The objective was to determine whether the Department of Homeland Security complied with the Payment Integrity Information Act of 2019 (PIIA) in fiscal year 2022. We determined that although DHS made improvements to reduce improper payments (IP) and unknown payments (UP), it did not comply with the PIIA.
We conducted an unannounced inspection of Northwest ICE Processing Center (Northwest) to assess ICE field offices’ management of these facilities and compliance with applicable standards. We also conducted a limited review of the facility’s COVID-19 requirements. We found that the facility complied with standards for intake and classification; facility conditions, including housing and hygiene; detainee access to law library and legal services; recreation; segregation; use of force; and providing timely responses to detainee requests. Northwest also complied with COVID-19 protocols and requirements set forth by a Federal court order. However, Northwest did not always provide timely responses to detainee grievances and did not always respond to detainee requests and grievances in a language understood by the detainee.
This report contains information about recommendations from the OIG's audits, evaluations, reviews, and other reports that the OIG had not closed as of the specified date because it had not determined that the Department of Justice (DOJ) or a non-DOJ federal agency had fully implemented them. The list omits information that DOJ determined to be limited official use or classified, and therefore unsuitable for public release.The status of each recommendation was accurate as of the specified date and is subject to change. Specifically, a recommendation identified as not closed as of the specified date may subsequently have been closed.
The objective for this unannounced inspection was to determine whether U.S. Customs and Border Protection (CBP) complied with National Standards on Transport, Escort, Detention, and Search (TEDS) and other relevant policies and procedures related to conditions of detention at nine CBP short-term migrant holding facilities in the Rio Grande Valley area of Texas. Our inspections and subsequent analysis showed Border Patrol held 1,736 detainees in custody in five facilities longer than the TEDS standard, which generally limits detention in these facilities to 72 hours. Increased migrant encounters was a contributing factor to time in custody, and exacerbated Border Patrol staffing challenges in the Rio Grande Valley.
Medicare Paid Millions More for Physician Services at Higher Nonfacility Rates Rather Than at Lower Facility Rates While Enrollees Were Inpatients of Facilities
We audited the U.S. Department of Housing and Urban Development’s (HUD) oversight of the physical condition of public housing developments. Our audit objective was to assess HUD’s oversight of the physical condition of public housing developments; specifically, whether HUD had adequate oversight of public housing agencies’ (PHA) (1) corrective actions in response to periodic Real Estate Assessment Center (REAC) inspections and (2) annual self-inspections to ensure that units were maintained in decent, safe, and sanitary condition.Properties receiving assistance through HUD’s public housing program are periodically inspected by a HUD contractor using standards established by REAC. These “REAC inspections” evaluate five areas of a public housing development: site, building exterior, building systems, common areas, and dwelling units. If deficiencies in these areas are identified, the inspector records their severity within one of the following four categories: (1) no health and safety hazards, (2) non-life-threatening health and safety, (3) life-threatening exigent health and safety, or (4) fire safety. HUD requires public housing agencies (PHA) to address life-threatening exigent health and safety and fire safety smoke detector deficiencies identified during REAC inspections within 24-hours. HUD monitors PHAs’ corrections of life-threatening deficiencies.We found that HUD field offices were inconsistent in overseeing whether PHAs corrected life-threatening deficiencies identified during REAC inspections. In addition, HUD does not track PHAs’ corrections of non-life-threatening health and safety deficiencies identified during REAC inspections. These conditions occurred because HUD did not have a standardized policy or a nationwide protocol to guide its field offices’ oversight of PHAs to ensure that all health and safety deficiencies were corrected after a REAC inspection. Instead, HUD relied on its field offices to maintain their own policies and procedures for monitoring PHAs’ unit conditions. However, the field offices generally did not maintain their own written policies and procedures, resulting in inconsistencies regarding what should be done. As a result, HUD lacked assurance that PHAs corrected identified life-threatening and non-life-threatening deficiencies. If HUD implements a nationwide protocol for monitoring and tracking PHAs’ efforts to address inspection results, it could have greater assurance that tenants residing in public housing are living in units that are decent, safe, and sanitary.In addition to the REAC inspection, HUD requires PHAs to perform routine self-inspections of public housing properties. These self-inspections include an annual visual assessment of the property to look for all deficiencies, and to determine the maintenance and modernization needs of the properties. We found that HUD staff had varying interpretations of its requirements regarding the number of public housing units PHAs should self-inspect annually. Further, HUD’s field office staff generally did not monitor PHAs for compliance with HUD’s requirements for self-inspections. These conditions occurred because HUD’s guidance was not clear regarding (1) the number of units PHAs should inspect annually and (2) how its field office staff should monitor PHAs to ensure that self-inspections of public housing units were conducted. Without clear guidance regarding its requirements for self-inspections, HUD lacked assurance that PHAs properly performed self-inspections of public housing units to determine maintenance and modernization needs. HUD could also miss opportunities to provide technical assistance to PHAs through early intervention when self-inspections identify systemic deficiencies. Further, because REAC’s inspection sampling methodology to select between 1 and 27 public housing units is based on the expectation that PHAs are completing self-inspections of 100 percent of their public housing units, REACs’ sampling methodology may no longer be appropriate.We recommend that HUD develop and implement a nationwide inspection review protocol and associated training for its field office staff; determine whether PHAs are required to perform inspections on 100 percent of their public housing units annually; and if so, develop clear, specific guidance on the number and frequency of the self-inspections. If 100 percent annual self-inspections are not required, we recommend that HUD determine whether the rationale for REAC to inspect a sample of public housing units, rather than 100 percent, remains appropriate.
Audit of the Schedule of Expenditures of Moona-A Space for Change, Bringing Professionals to Bridge Communities: Starter Program for Young Engineers in West Bank and Gaza, Cooperative Agreement 72029419CA00001, January 1 to December 31, 2021
Financial Audit of USAID India's Sustainable Enterprises for Water and Health Project Managed by Safe Water Network India, Cooperative Agreement 72038620CA00003, April 1, 2021 to March 31, 2022 (5-386-23-016-R)
Financial Audit of MCC Resources Managed by the MCA-Niger under the Grant and Implementation Agreement and the Millennium Challenge Compact between the Government of Niger and MCC for the period April 1, 2021 to March 31, 2022
During our unannounced inspection of U.S. Immigration and Customs Enforcement’s (ICE) Northwest ICE Processing Center (Northwest) in Tacoma, Washington, we found that the facility complied with standards for intake and classification; facility conditions, including housing and hygiene; detainee access to law library and legal services; recreation; segregation; use of force; and providing timely responses to detainee requests.
Evaluation of WAPS-FM, Board of Education, Akron City School District, Compliance with Selected Communications Act, Diversity, and Transparency Requirements, Report No. ECR2307-2308
Florida Did Not Ensure That Some Providers Complied With Requirements For Determining Eligibility For Its Projects for Assistance in Transition From Homelessness Program
This report details the Office of Inspector General's Spring 2023 Semiannual Report to Congress. The following topics are included:• Overview of the SBA and the OIG• Pandemic Response Oversight• Small Business Access to Capital• Disaster Loan Program• Procurement Assistance• Agency Management• Other Significant OIG Activities• Statistical Highlights• Appendices
The Office of Inspector General is tasked with ensuring efficiency, accountability, and integrity in the U.S. Postal Service. We also have the distinct mission of helping to maintain confidence in the mail and postal system, as well as to improve the Postal Service's bottom line. We use audits and investigations to help protect the integrity of the Postal Service. Our Semiannual Report to Congress presents a snapshot of the work we did to fulfill our mission for the six-month period ending March 31, 2023. Links are provided to the full reports featured in this report, as well as to the appendices. Our Congressional two-pager provides readers with easy access to facts and information, as well as succinct summaries of the work by area.
Financial Audit of the MCC resources managed by Millennium Challenge Account - Senegal under the Millennium Challenge Compact between the Government of the Republic of Senegal and MCC for the period June 6, 2017 to March 31, 2021
The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of care delivered at vet centers. This report focuses on North Atlantic district 1 zone 3 and four selected vet centers: Center City Philadelphia, Northeast Philadelphia, and Scranton in Pennsylvania; and Huntington in West Virginia. The OIG inspection focused on five review areas: leadership and organizational risks; quality reviews; suicide prevention; consultation, supervision, and training; and environment of care.Generally, district leaders had a good understanding of quality improvement principles and implemented quality improvement programs in response to VA All Employee Survey results. District 1 zone 3 Vet Center Service Customer Feedback survey results were above the national average in all areas except convenience of appointment scheduling and vet center location.The OIG conducted an analysis of vet center quality reviews required to ensure compliance with policies and procedures. The OIG made six recommendations for clinical and administrative quality reviews and one recommendation for morbidity and mortality reviews.The suicide prevention review included a zone-wide evaluation of electronic client records, and a focused review of the four selected vet centers. The OIG issued nine recommendations—two specific to electronic client records and seven for selected vet centers’ suicide prevention and intervention processes.The consultation, supervision, and training review evaluated the four selected vet centers. The OIG identified concerns with external clinical consultation, supervision, and training, and issued five recommendations.The environment of care review evaluated the four selected vet centers. The OIG made three recommendations.The OIG issued a total of 24 recommendations for improvement to the District Director.
Audit of the Office of Justice Programs Victim Assistance Funds Subawarded by the Colorado Division of Criminal Justice to the Rose Andom Center, Denver, Colorado
The Office of the Inspector General conducted a review of TVA Police and Emergency Management’s (TVAP&EM) organization to identify factors that could impact TVAP&EM’s organizational effectiveness. During interviews, TVAP&EM personnel revealed positive interactions within and outside TVAP&EM. However, we identified issues that have, or could, affect accomplishment of the TVAP&EM mission, if not addressed. These issues included (1) engagement risks, (2) employee concerns related to inconsistent practices within the organization, (3) risks related to TVAP&EM’s mobile software tool, and (4) risks to personnel security. We also identified an opportunity to strengthen risk assessment within TVAP&EM.
The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of care delivered at vet centers. This report focused on North Atlantic district 1 zone 4 and four selected vet centers: Baltimore and Dundalk in Maryland, Raleigh in North Carolina, and Richmond in Virginia. The OIG inspection focused on five review areas: leadership and organizational risks; quality reviews; suicide prevention; consultation, supervision, and training; and environment of care.Generally, district leaders had a good understanding of quality improvement principles and implemented district-wide quality improvement programs in response to VA All Employee Survey results. District 1 zone 4 Vet Center Service Customer Feedback survey results were below the national average in all areas except one regarding vet center location. High turnover and use of technology instead of face-to-face visits were noted as reasons.The OIG conducted an analysis of vet center quality reviews required to ensure compliance with policies and procedures. The OIG made five recommendations for clinical and administrative quality reviews and issued one finding for morbidity and mortality reviews.The suicide prevention review included a zone-wide evaluation of electronic client records, and a focused review of the four selected vet centers. The OIG issued ten recommendations—six related to the review of electronic client records and four specific to the selected vet centers’ suicide prevention and intervention processes.The consultation, supervision, and training review evaluated the four selected vet centers. The OIG identified concerns with external clinical consultation, supervision, chart audits and training, and issued four recommendations.The environment of care review evaluated the four selected vet centers. The OIG made three recommendations.The OIG issued a total of 22 recommendations for improvement to the District Director.
NASA is adapting heritage hardware from the Space Shuttle era, including solid rocket boosters and RS-25 rocket engines, to power the Artemis campaign’s Space Launch System rocket that will launch the Orion crew capsule to the Moon. This report examines whether NASA is meeting cost, schedule, and performance goals for its Booster and RS-25 Engine contracts and examines efforts to reduce the Agency’s financial risk and promote affordability.
The Semiannual Report to Congress summarizes the results of VA OIG oversight, provides statistical information, and lists all 103 work products issued from October 1, 2022, to March 31, 2023. During this reporting period, VA OIG audits, evaluations, investigations, inspections, and other reviews identified more than $401 million in monetary impact for a return on investment of $4 for every dollar spent. The OIG hotline received and triaged over 15,500 contacts in the past six months—to help identify wrongdoing and address concerns with VA activities. Also during the past six months, special agents opened 222 investigations and closed 217, with efforts leading to 122 arrests. Collectively, the OIG’s work also resulted in 595 administrative sanctions and corrective actions during the six-month reporting period.
I am pleased to submit the Amtrak Office of Inspector General (OIG) Semiannual Report to the United States Congress for the six months ending March 31, 2023, which summarizes our independent and objective reviews and investigations related to Amtrak’s programs and operations.The following report provides an overview of our oversight work during the reporting period, which underscores the dedication, experience, and value of our staff and the importance of our oversight mission. In the next six months, we will continue to focus our efforts on high-impact areas important to the company, the Board of Directors, Congress, and the public.
Financial Audit of the MCC resources managed by the Millennium Challenge Account - Mongolia (MCA-Mongolia) under the Compact Agreement between the MCC and the Government of Mongolia for the period of April 1, 2021 to March 31, 2022
Financial Closeout Audit of USAID Resources Managed by Legal Resources Centre in Ghana Under Cooperative Agreement 72064120CA00001, August 7, 2020, to August 30, 2022
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 Loma Linda Healthcare System, which includes the Jerry L. Pettis Memorial Veterans’ Hospital 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 (emergency department and urgent care center suicide prevention initiatives)The OIG issued five recommendations for improvement in three areas:1. Leadership and organizational risks• Sentinel events and institutional disclosures2. Quality, safety, and value• Adverse events3. Medical staff privileging• Focused Professional Practice Evaluation processes• Reprivileging reviews
Although the Department of Homeland Security has made improvements to reduce improper payments (IPs) and unknown payments (UPs), DHS did not comply with the Payment Integrity Information Act of 2019 (PIIA) in fiscal year (FY) 2022. According to Office of Management and Budget (OMB) Circular A123, an agency must meet all 10 PIIA requirements to be considered compliant.
In May 2022, we conducted unannounced inspections of seven U.S. Customs and Border Protection (CBP) facilities along the United States–Canada (northern) border, specifically three Border Patrol stations in the Swanton sector, one port of entry in the Office of Field Operations (OFO) Boston Field Office area of responsibility, and three ports of entry in the OFO Buffalo Field Office area of responsibility.
We investigated allegations that two U.S. Park Police officers used excessive force against two members of the news media during the operation to disperse protesters in and around Lafayette Park on June 1, 2020.
For our evaluation of the U.S. Economic Development Administration’s (EDA’s) plan for the implementation of Coronavirus Aid, Relief, and Economic Security Act (CARES Act) funding through its Revolving Loan Fund (RLF) program, our objective was to determine whether EDA followed federal and U.S. Department of Commerce (Departmental) guidelines to award and disburse CARES Act funding through the program. Specifically, we focused on (1) how EDA selected applicants to receive CARES Act funds through the RLF program, (2) whether EDA ensured that RLF pre-disbursement requirements were met prior to disbursing CARES Act funds, and (3) how EDA is monitoring CARES Act funds after they have been disbursed to RLF recipients. We found that EDA I. had a process to select applicants and award CARES Act funds on a competitive and noncompetitive basis through the RLF Program; II. generally ensured that RLF pre-disbursement requirements were met before disbursing CARES Act funds; and III. had a process for monitoring the CARES Act funds after the funds were disbursed.
Objective: To determine whether the Social Security Administration (SSA) properly applied res judicata for waiver requests made after a previous request was denied.
Performance Audit of Orange County Public Libraries for the Universal Service E-Rate Schools and Libraries Program Disbursements Related to Funding Year 2020
Final Report on the Performance Audit of Fiscal Year 2022 Compliance with Payment Integrity Information Act of 2019 for the Federal Communications Commission
This audit report shows Kearney noted five findings and 10recommendations.forThree of the five findings resulted in non-compliance with PIIA for three of FCC’s 10 programs,the Universal Service Fund (USF) Lifeline (LL) program, USF Schools and Libraries (S&L)program, and the USF High Cost (HC) Legacy program. Additionally, Kearney identified othermatters related to the PIIA activities that are recommended for improvement.
What We Looked AtThe Personal Identity Verification (PIV) card is the Department’s foundation for securely identifying every individual seeking access to the Department of Transportation’s (DOT) secure facilities and information systems. Once contractor employees no longer need that access, DOT officials must promptly collect and deactivate their PIV cards. In fiscal years 2020 and 2021, just over 1,000 DOT service contracts—which may have granted contractor staff access to secure DOT facilities and information systems—came to an end. Given that most of these contracts ended during the COVID-19 pandemic when DOT employees were in a state of maximum telework, there is an elevated risk that prompt and appropriate PIV card collection and deactivation may not have occurred. Accordingly, DOT-OIG initiated this audit to assess DOT’s oversight of contractor employee PIV cards issued in connection with performance of agency contracts. What We FoundDOT’s timely collection and deactivation of contractor employee PIV cards is compromised by fragmented processes and a lack of clear accountability. Counter to Federal and departmental procurement regulations and policies, DOT contracting officials do not always include required PIV card-related security clauses in contracts that grant contractor employees routine physical access to a federally controlled facility or information system. Without these required clauses in its contracts, DOT neglected to establish an important and legally enforceable accountability mechanism to help protect its secure facilities and systems. Further, DOT does not always promptly collect and deactivate contractor employee PIV cards as required, because it has not established clear accountability over this process. As a result, DOT is exposed to heightened security risks, potentially compromising the safety of its staff and achievement of its mission. Our RecommendationsWe made six recommendations to improve DOT’s collection and deactivation of contractor employee PIV cards. DOT concurred with all six recommendations and provided appropriate actions and completion dates. We consider all recommendations resolved but open pending completion of the planned actions.
We audited the Stark Metropolitan Housing Authority’s public housing program based on significant deficiencies noted during our prior audit of the Authority. Our audit objective was to determine whether the Authority complied with Federal and its own requirements for procuring goods and services.The Authority did not always comply with Federal and its own procurement requirements. Specifically, for the contracts reviewed, it did not always (1) maintain complete and consistent documentation detailing the significant history of procurements, (2) properly execute contracts for pest control services, (3) maintain sufficient documentation to support the reasonableness of contract costs, and (4) include the minimum and maximum quantity or amount in its indefinite-quantity delivery contracts. Further, the Authority paid more than the contract value for services procured with one contractor. These issues occurred because the Authority lacked adequate oversight, procedures, and controls over its procurements to ensure compliance with Federal and its own requirements. As a result, HUD and the Authority lacked assurance that the Authority used Federal funds to pay for goods and services at reasonable costs.We recommend that the Director of HUD’s Cleveland Office of Public Housing require the Authority to (1) support the reasonableness of the costs paid for its unsupported procurement and contracting activities or repay its Public Housing Operating Fund or Capital Fund program from non-Federal funds for any amount determined not to be reasonable; (2) ensure that its staff is appropriately trained on Federal procurement requirements; and (3) implement adequate procedures and controls, including but not limited to, ensuring that proper documentation is maintained, contracts are procured in accordance with Federal and the Authority’s procurement requirements, procurement staff complies with Federal procurement requirements, and payments are appropriately reconciled. We also recommend that the Director of HUD’s Cleveland Office of Public Housing determine whether the Authority qualifies for an exemption from preaward review.
National Credit Union Administration (NCUA) Office of Inspector General (OIG) Semiannual Report to the NCUA Board and the Congress highlighting our accomplishments and ongoing work for the 6-month period ending March 31, 2023.
This Office of Inspector General Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient settings of the Northern Arizona VA Health Care System, which includes the Bob Stump VA Medical Center in Prescott 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 two areas:1. Medical staff privileging• Focused and Ongoing Professional Practice Evaluation processes2. Environment of care• Damaged or compromised sterile supplies• Safe and clean environment and clinical areas in good repair• Notices in areas subject to photography or video recording
We audited the U.S. Department of Housing and Urban Development’s (HUD) Real Estate Assessment Center’s inspection process. The audit objectives were to determine whether the Center (1) ensured that public housing properties were inspected within required timeframes before the coronavirus disease 2019 (COVID-19) pandemic; (2) could improve its Big Inspection Plan for inspecting high-priority non-National Standards for the Physical Inspection of Real Estate (NSPIRE) demonstration public housing properties; and (3) had experienced delays in inspecting the physical condition of public housing properties approved under the NSPIRE demonstration.Before HUD postponed physical inspections due to COVID-19, the Center did not consistently ensure that public housing properties were inspected within required timeframes. The Center developed its Big Inspection Plan to inspect all NSPIRE demonstration and non-NSPIRE public housing and multifamily properties by March 31, 2023; using for its public housing portfolio, a phased approach to inspect non-NSPIRE properties. We found that under phase I of the Plan, the Center did not inspect all of the high-priority non-NSPIRE public housing properties by December 2021. Under phase II, the inspections for these properties were generally not given priority. Further, the Center experienced delays in inspecting public housing properties approved to participate under the NSPIRE demonstration. HUD can improve its procedures and controls, including the coordination of the procurement for inspection services, to ensure that public housing properties are inspected in a timely manner. Making such improvements will better position HUD’s Office of Public and Indian Housing to know whether the physical conditions in public housing properties are decent, safe, and sanitary. These improvements could also result in Public Housing Assessment System scores better reflecting the current conditions of the properties.We recommend that the Deputy Assistant Secretary for the Center prioritize the inspection of public housing properties that were (1) not included in the NSPIRE demonstration but were identified as high priority under the Center’s Big Inspection Plan and (2) approved to participate under the NSPIRE demonstration that the Center was unable to inspect by March 31, 2023. We also recommend that the Deputy Assistant Secretary for the Center implement adequate policies, procedures, and controls to ensure that public housing properties will be inspected within required timeframes.
Audit of Producer-Owned Women Enterprises Project in India Managed by Indus Tree Crafts Foundation Under Cooperative Agreement 72038619CA00003, April 1, 2021, to March 31, 2022
Northern Central America Humanitarian Response: USAID Took Steps to Mitigate Fraud Risks, but Opportunities Exist to Clarify Guidance on Assessing Sanctioned Group Risk
Audit of MCC Resources Managed Municipality of Ttouan, Under the Grant and Implementation Agreement and the Millennium Challenge Compact Between MCC and the Government of Morocco, for the period January 1, 2021 to March 31, 2021
For our final report on fiscal year (FY) 2022 improper payment reporting, our review objective was to determine the U.S. Department of Commerce's (the Department’s) compliance with the Payment Integrity Information Act of 2019 (PIIA). To determine FY 2021 compliance, we reviewed the “Payment Integrity” section of the Department’s FY 2021 Agency Financial Report (AFR), accompanying materials to the AFR, and other improper payment-related documentation. We also assessed the Department’s efforts related to preventing and reducing improper payments and unknown payments. Based on our review, we concluded that the Department complied with the PIIA criteria for FY 2021. We did not identify any actions needed to further improve prevention and reduction measures within the Department.