Federal Reports

FSA had adequate processes for waiving R2T4 requirements, cancelling borrowers’ obligation to repay Direct Loans, and excluding Pell disbursements from Pell lifetime usage for impacted students. FSA also designed adequate processes for schools to report the number and amounts of R2T4 waivers applied.

The VA Office of Inspector General (OIG) conducted an inspection to review allegations that providers at the Charlie Norwood VA Medical Center in Augusta, Georgia, delayed care and failed to “provide services,” for a patient who died by suicide on the grounds of the Aiken Community Based Outpatient Clinic and the facility director “. . . covered it up.” The OIG also reviewed leaders’ responses to these allegations.The OIG substantiated the patient received deficient clinical care, which hindered referrals for mental health and pain management services. The deficiencies included (1) a primary care provider’s failure to follow up on positive mental health screenings, (2) a primary care provider’s failure to follow up on a discontinued mental health consult and order testing, (3) facility staff failures to ensure a timely pain management appointment, (4) pain management clinic providers’ failure to perform required mental health screenings, (5) a nurse’s failure to communicate a Veterans Crisis Line (VCL) referral prior to the Emergency Department encounter, and (6) suicide prevention staff failures to act after the VCL referral.The OIG did not substantiate that facility leaders “covered up” the patient’s death by suicide and could not determine the basis for this allegation due to the complainant being anonymous. Facility leaders immediately responded per Veterans Health Administration guidance; however, they failed to initiate a timely investigation of the death as a sentinel event.The OIG also identified completion of an inaccurate Behavioral Health Autopsy, failure to complete a Family Interview Tool Contact, delayed peer reviews, and a clinical review that did not identify and address deficiencies in care.The OIG made nine recommendations regarding mental health screenings, consult management, community care referral, suicide risk assessments, communication and closure of a VCL referral, completed suicides on VA campuses, and accurate completion of quality management reviews.

Peter Port, a resident of Palm Beach County, Florida, pleaded guilty on May 10, 2023, in the U.S. District Court, Southern District of Florida, to Conspiracy to Commit Health Care Fraud. Port owned and controlled Safe Haven, a substance abuse center, which was purportedly in the business of providing clinical treatment for persons suffering from alcohol and drug addiction.Our investigation found that Port and others paid kickbacks and bribes in the form of cash, free or reduced sober homes rent, and other benefits to individuals who agreed to be patients at Safe Haven. Fraudulent claims were subsequently submitted to insurance plans for unnecessary urine testing and addiction treatment services that were not provided. As a result of the scheme, Amtrak’s insurance providers were fraudulently charged approximately $86,130. Port and three co-defendants will be sentenced at a future date.

The Coronavirus Aid, Relief, and Economic Security (CARES) Act appropriated about $17.2 billion in supplemental funds to the Veterans Health Administration (VHA) to support VA’s efforts to prevent, prepare for, and respond to the COVID-19 pandemic. The OIG conducted this audit to assess the effectiveness of VA’s controls over VHA’s use of these funds.Because VA’s financial management system does not support the direct obligation of supplemental funds for all expenses, staff used expenditure transfers to shift funds between appropriation accounts. Expenditure transfers are documented using journal vouchers, which are written documents explaining the purpose and details of the transaction. However, as VHA did not develop guidance for the type of documentation required, staff did not always sufficiently prepare the vouchers. As a result, staff could not always identify what was purchased or provide evidence the purchase was a proper use of CARES Act funds.Further, even when medical staff directly obligated from the CARES Act fund, they did not always (a) have documented purchase authority, (b) segregate duties, (c) properly track the receipt of goods to ensure the quantities ordered were received, or (d) properly certify and pay invoices. This occurred because VHA did not develop guidance with protocols for accounting processes and procedures or outline clear roles and expectations for the oversight of supplemental funds purchases. As a result, the OIG questioned an estimated $187.2 million.Until VHA strengthens controls over payments, it cannot be sure that payments have been properly made. Further, Congress lacks reasonable assurance that funds allocated for veterans’ COVID-19-related care are being spent as intended. The OIG recommended VA assess whether it can integrate its financial management system with other systems to reduce the need for expenditure transfers; the OIG also made eight recommendations to VHA to improve oversight of supplemental funds.

Ketrick Barron, a former Amtrak General Foreman, based in Washington, D.C., was sentenced on May 9, 2023, to three years’ probation and ordered to pay restitution of $6,580 to Amtrak. On February 21, 2023, Barron pleaded guilty in U.S. District Court, District of Maryland, to one misdemeanor count of Theft of Government Property related to his use of a General Services Administration fuel card issued to Amtrak to fuel personal vehicles at a cost of approximately $6,580.20.

We issued this management advisory report to bring immediate attention to risks we identified during a visit to an Amtrak facility for a separate audit. During the visit, most of the 26 employees interviewed told us, often unsolicited, about significant safety and security risks they regularly face. Specifically, the employees raised concerns about trespassers and their impact on employees’ safety and the security of company assets, such as locomotives, track switches, and inventory stored outside the facility’s warehouse. According to the employees interviewed, trespassers have assaulted and threatened multiple employees on the property, including one incident in which a trespasser threw a hammer at an employee. It is also a general practice for Mechanical foreman to confront trespassers, who employees said are sometimes violent and dangerous. One such incident occurred during our visit when a trespasser with a weapon gained access to a rail car and defecated inside it. Additionally, employees told us—and company records supported—that trespassers break into rail cars and locomotives, access the rail lines, and steal company property. We identified three key vulnerabilities that created these risks. The company agreed with our observations and is taking corrective action. Until the company implements longer-term plans, however, the risks related to employee safety and that of company assets will remain imminent unless interim solutions are put in place.

Our objective was to evaluate the Risk Management Agency's administration and oversight of the Apiculture Pilot Insurance Program.

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 Central Texas Veterans Health Care System, which includes the Olin E. Teague Veterans’ Center in Temple, the Doris Miller VA Medical Center in Waco, and multiple outpatient clinics in central Texas. 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 prevention initiatives)The OIG issued two recommendations for improvement in two areas:1. Leadership and organizational risks• Institutional disclosures2. Medical staff privileging• Ongoing Professional Practice Evaluations

To view the survey, please visit: https://oig.justice.gov/reports/inmate-perceptions-federal-bureau-prisons-management-coronavirus-disease-2019-pandemic

What We Looked AtWe performed a quality control review (QCR) on the single audit that Accuity LLP performed for the Highways Division, Department of Transportation for the State of Hawaii’s (HIDOT) fiscal year that ended June 30, 2021. During this period, HIDOT expended approximately $226.5 million from U.S. Department of Transportation programs. Accuity determined that DOT’s major programs were the Federal Highway Administration’s Highway Planning and Construction Cluster, and the National Highway Traffic Safety Administration’s Alcohol Open Container Requirements program. Our QCR objectives were to determine whether (1) the audit work complied with the Single Audit Act of 1984, as amended and 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) HIDOT’s reporting package complied with the reporting requirements of the Uniform Guidance. What We FoundAccuity complied with the requirements of the Single Audit Act, the Uniform Guidance, and DOT’s major programs. We found nothing to indicate that Accuity’s opinion on DOT’s major programs was inappropriate or unreliable. However, we identified deficiencies that require correction in future audits. Accordingly, we assigned Accuity an overall rating of pass with deficiencies.

The owner of a company contracted to do work for Amtrak signed a pre-trial diversion agreement on May 8, 2023, in Marion County Superior Court, Indiana. Our investigation found that the contractor stole two train horns from the Beech Grove Maintenance Facility and later sold them to individuals he met on various train-related internet sites and online forums. The contractor agreed to pay $10,000 in restitution, including $4,750 to the company.

The Office of Special Education Programs (OSEP) provided general guidance and technical assistance for State educational agencies (SEA), to assist them in implementing significant disproportionality regulatory requirements. OSEP also performed ongoing monitoring of SEAs’ compliance with Individuals with Disabilities Education Act requirements and program results. However, we determined that OSEP has not performed a risk assessment to determine if the change in the regulation affects the control activities that it has established for monitoring significant disproportionality, particularly regarding data reliability.

Objective: To determine whether the Social Security Administration (SSA) met all requirements of the Payment Integrity Information Act of 2019 (PIIA) in the Fiscal Year (FY) 2022 Agency Financial Report and accompanying materials.

Evaluation of the SEC’s FY 2022 Compliance With the Payment Integrity Information Act of 2019, Report No. 578

The Office of Special Operations (OSO), part of the Office of Environment, Health, Safety and Security, is authorized to provide protective measures for the Secretary of Energy (Secretary) through its executive protection mission. On September 29, 2021, the Office of Inspector General Hotline received an allegation that members of the Secretary’s protective detail, OSO agents, misused their positions. Specifically, the complainant alleged that protective detail agents upgraded airline flights to first and business class while the Secretary sat in economy class, used tobacco products in Government-owned vehicles (GOVs), and operated GOVs for personal use. We initiated this inspection to determine the facts and circumstances surrounding the allegation concerning the misuse of position within the Secretary’s protective detail.We did not substantiate the allegation that members of the Secretary’s protective detail misused their positions. While we substantiated that members of the Secretary’s detail did not follow procedures pertaining to two of the three examples in the allegation, we do not believe that it was a misuse of their position. Specifically, we found that OSO protective detail agents upgraded airline seats to first or business class while the Secretary, the principal whom they were protecting, sat in economy class on 2 of 10 trips reviewed. We also found that protective detail agents used tobacco products in GOVs. However, we did not substantiate the allegation regarding the agents’ personal use of GOVs. We also identified a potential ethics violation. Specifically, it appeared that the OSO Director accepted a ticket or tickets to an athletic event from a private industry official. Although the Director stated that he did not use the tickets, it appeared to us, and likely to the official, that the Director did accept the gift, thereby creating the appearance of violating 5 Code of Federal Regulations 2635.202, General prohibition on solicitation or acceptance of gifts.The issues we identified occurred, in part, because the Secretary’s travel practices made it difficult to ensure that an agent was in the same class as the Secretary, and agents did not take supervisory direction seriously. This report contains three recommendations that, if fully implemented, should help ensure that the issues identified are corrected. Management agreed with our findings and recommendations, and its corrective actions, taken and planned, are consistent with our recommendations.

The audit objective was to determine the adequacy of the NRC’s handling and processing of irretrievable well logging source abandonments.

U.S. Customs and Border Protection (CBP) and U.S. Immigration and Customs Enforcement (ICE) support complex and intersecting missions related to immigration, trade, and travel. Since 2019, shifts in U.S. immigration and border security policies, migrant surges, COVID-19, and the overall rising number of migrant encounters along the Southwest border have exacerbated staffing challenges

EAC OIG performed this review to determine whether EAC complied with the Payment Integrity Information Act of 2019 reporting requirements for fiscal year 2022.

This report transmits the results of the Federal Election Commission (FEC) OIG FY 2022 annual review of the FEC’s compliance with the Payment Integrity Information Act of 2019 (PIIA).

The VA OIG issued a management advisory memorandum to highlight concerns regarding outdated policies governing the Veterans Health Administration’s (VHA’s) mental health services and requested follow-up action. Two policies cited in the memorandum, VHA Handbook 1160.01(1), Uniform Mental Health Services in VA Medical Centers and Clinics, and VHA Handbook 1160.06, Inpatient Mental Health Services, are beyond expected recertification dates by almost 10 and 5 years, respectively. In lieu of recertifying policies, VHA has issued operational memoranda, which was cited as a concern by the Government Accountability Office (GAO), resulting in VA’s placement on GAO’s high risk List. Additionally, outdated policies may impact the quality of care veterans receive and create challenges for oversight. The Under Secretary for Health is responsible for ensuring VHA compliance with policy management requirements. VHA advised it expects to issue updated handbooks by September 2023. The OIG will continually monitor VHA’s progress through final publication.

We evaluated the Defense Intelligence Agency’s compliance with the Payment IntegrityInformation Act (PIIA) for fiscal year (FY) 2022.

NASA is a leader in AI usage across the federal government including on experiments in low Earth orbit to conduct weather modeling and in deeper space to map hazards for landing sites. In this audit, we examine NASA’s AI governance framework, standards, and cybersecurity controls.

The VA Office of Inspector General (OIG) assessed allegations that San Diego VA Medical Center (facility) staff provided an inadequate evaluation of cognitive functioning, suicide risk, grave disability, and care coordination for a patient who died approximately six hours after leaving the facility. The OIG also evaluated a concern about mental health emergency response (code green) policy and practice inconsistencies.In early 2022, facility police officers (Officers 1 and 2) responded to a report that the patient “was loitering.” The patient denied needing assistance and planned to remain on VA property overnight. The patient made threatening statements after being told the patient’s vehicle would be towed due to a suspended vehicle registration and the patient not having a valid drivers’ license. Officer 2 escorted the patient to the Emergency Department, and a nurse called a code green.The code green team resident physician determined that the patient did not meet criteria for a psychiatric hold. Officer 2 provided the patient with transportation options. Later the Officers saw the patient, who refused to check in to the Emergency Department. The Officers walked the patient off VA property. Approximately six hours later, the patient’s death was reported to the Medical Examiner’s Office after an interstate driver reported having struck the patient.The OIG did not substantiate that facility staff failed to adequately evaluate the patient’s cognitive functioning, suicide risk, and grave disability. The OIG substantiated that staff failed to coordinate the patient’s care. The code green team leader inaccurately documented having “passed care.” The OIG concluded that staff appropriately respected the patient’s right to decline care when the patient later refused services.The OIG found inconsistencies between policy and practice in the patient’s code green event.The OIG made two recommendations to the Facility Director related to code green documentation and policy.

To see the interactive report, click here: https://oig.justice.gov/reports/federal-bureau-prisons-efforts-maintain…

What We Looked AtWe queried and downloaded 74 single audit reports prepared by non-Federal auditors and submitted to the Federal Audit Clearinghouse between January 1, 2023 and March 31, 2023, to identify significant findings related to programs directly funded by the Department of Transportation (DOT). What We FoundWe found that reports contained a range of findings that impacted DOT programs. The auditors reported 36 incidents of significant noncompliance with Federal guidelines related to 15 grantees that require prompt action from DOT’s Operating Administrations (OA). Of the 36 findings, 21 were repeat findings related to 8 grantees. The auditors also identified questioned costs totaling $14,886,138 for six grantees. Of this amount, $7,612,623 was related to the Crow Tribe of Indians, $5,472,288 was related to Pit River Tribe, and $1,146,291 was related to the COVID-19 formula grants of the Suburban Mobility Authority for Regional Transportation, Detroit, MI. Additionally, we identified nonmonetary repeat findings that caused a disclaimer of opinion for the Crow Tribe of Indians, Crow Agency, MT. RecommendationsWe recommend that DOT coordinate with the impacted OAs to develop a corrective action plan to resolve and close the findings identified in this report. We also recommend that DOT determine the allowability of the questioned transactions and recover $14,886,138, if applicable.

Evaluation of the FLRA's Preparedness Against Cyber Security Attacks

OIG identified the prevention measures that Forest Service established for recreation sites in response to the COVID-19 pandemic.

The lack of vulnerability scans increases the risk that vulnerabilities are not identified and remediated in a timely manner and could result in data loss or disruption to Agency operations.

The Federal Information Security Modernization Act of 2014 (FISMA) requires the Office of Inspector General to conduct an annual independent evaluation to determine whether the Department of Energy’s unclassified cybersecurity program adequately protected its data and information systems. As part of that evaluation, the Office of Inspector General is required to assess the Department’s cybersecurity program according to FISMA security metrics issued by the Office of Management and Budget and the Council of the Inspectors General on Integrity and Efficiency.We conducted this evaluation to determine whether the Department’s unclassified cybersecurity program adequately protected data and information systems. Our fiscal year 2022 FISMA evaluation determined that the Department, including the National Nuclear Security Administration, had not taken appropriate actions to address many previously identified weaknesses related to its unclassified cybersecurity program. Although actions were taken to close 23 of 61 recommendations from our prior evaluations, 38 recommendations remained open. We also issued 35 new recommendations, many of which were similar in type to the deficiencies identified in our previous reports.The weaknesses identified occurred for a variety of reasons. For instance, weaknesses related to system integrity of web applications generally occurred because the applications were configured without adequate security controls designed to reject malicious input. In addition, identity and access management weaknesses occurred because officials were unaware of, or had not implemented, current account management requirements.To correct the cybersecurity weaknesses identified throughout the Department, we made 73 recommendations (of which 38 were made during prior evaluations) to the Department’s programs and sites, including those identified during this evaluation and in other issued reports. Specific recommendations were made to each of the locations where weaknesses were identified. Corrective actions to address each of the recommendations, if fully implemented, should enhance the Department’s unclassified cybersecurity program. Management concurred with all but two recommendations issued to programs and sites related to improving the Department’s cybersecurity program.

This report summarizes the results of the CliftonLarsonAllen (CLA) audit and contains four recommendations that will assist the agency in strengthening cybersecurity controls related to its firewalls and the Security Information and Event Management (SIEM) tool. NCUA management concurred with and has taken or planned corrective actions to address the recommendations.

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA Black Hills Health Care System (facility) in Fort Meade and Hot Springs, South Dakota, to evaluate how facility leaders addressed an administrative investigation board’s (AIB) findings and recommendations.The OIG received complaints alleging failures in leadership and management, and misconduct and inappropriate relationships between leaders and staff and between clinical staff and patients within the Mental Health Service. In response, the former Facility Director convened an AIB and detailed two leaders out of the Mental Health Service, in compliance with VA policy. Prior to retirement, the former Facility Director met with the acting Facility Director to discuss the AIB report and advised that two action items required follow-up. The former Facility Director did not share the AIB report with other senior facility leaders, citing not enough time before retirement. As a result, a lapse of understanding and follow-up of the AIB’s recommendations occurred when the former Facility Director retired. After being contacted by the OIG, the acting Facility Director and other senior facility leaders read the AIB report and developed an action plan to address the 11 recommendations. The OIG confirmed that facility leaders were addressing each recommendation and taking steps to address the mental health leader and a staff member, who was a student at the time, identified within the AIB report as having inappropriate relationships with patients. The facility reported the mental health leader to the state licensing board. The facility did not independently verify that the student self-reported the inappropriate relationship to the state licensing board. The OIG made two recommendations to the Facility Director related to completing the action plan, and independently determining if the state licensing board should be notified.

The VA Office of Inspector General (OIG) reviewed the administrative and clinical responses by facility leaders and staff to allegations of a patient’s report of sexual harassment at the VA Black Hills Health Care System (facility) in Fort Meade and Hot Springs, South Dakota.A patient participating in the Compensated Work Therapy program and the Transitional Residence program reported being sexually harassed by a food service coworker and subsequently died by suicide. The patient initially reported being sexually harassed to a Transitional Residence staff member while a permanent employee residing in a Transitional Residence house. Later that same year, the patient reported to the VA police that the sexual harassment began while participating in the Compensated Work Therapy program. Participants in Compensated Work Therapy and Transitional Residence programs are considered patients and not employees.The OIG determined facility leaders did not take administrative actions that aligned with policy when the patient reported being sexually harassed. Facility leaders understood that the interactions occurred after hours, off VA property, and between two employees, and therefore, no action could be taken. Although the Compensated Work Therapy and Transitional Residence program manager knew that the patient was a participant in the Transitional Residence program, and therefore considered a patient, the program manager took no action, such as speaking with the patient, upon learning of the patient’s report of sexual harassment.The OIG determined that the Transitional Resident staff member and counselor provided clinical support.The OIG made three recommendations related to the reviews of the sexual harassment policy and the actions of the Transitional Residence program manager, and to ensure that the facility policy addresses the safety and rights of patients who are both VA employees and participants in the Transitional Residence program.

The lack of vulnerability scans increases the risk that vulnerabilities are not identified and remediated in a timely manner and could result in data loss or disruption to Agency operations.

What We Looked AtThe Federal Aviation Administration (FAA) employs approximately 5,000 maintenance technicians who install, maintain, repair, and certify roughly 74,000 pieces of equipment in the National Airspace System. Citing concerns with staffing and training for this important workforce, the House Committee on Appropriations directed our office to assess the Agency’s plans for hiring, training, and placing maintenance technicians. Previously, we reported on FAA’s process for hiring and placement. Our objective for this review was to evaluate FAA’s process for prioritizing and providing training to maintenance technicians. What We FoundFAA projects training and hiring requirements only 1 year in advance and does not proactively identify and prioritize maintenance technician training and hiring needs in anticipation of pending retirements. According to Federal internal control standards, management should consider how best to plan for employees’ eventual departure and retain needed skills and abilities. As a result, FAA has developed workforce plans for air traffic controllers and aviation safety inspectors that target training and hiring needs 10 years in advance—but does not do so for maintenance technicians. It takes 1.5 years on average to promote a newly hired maintenance technician to the journeyman level, so 1 year of advance planning is not adequate to prepare for future workforce needs. Two FAA lines of business that fall under three different vice presidents are responsible for the maintenance technician training process, which makes it difficult to establish a collaborative training process and make budgetary decisions. Travel funding and other factors have also hindered FAA’s ability to increase the number of technicians who can receive training in a given year. Although the Agency is using e-learning options, it has not documented lessons learned or formally analyzed student feedback to determine course formats. The lack of a strategic approach hinders FAA’s ability to develop a sustainable workforce model. Our RecommendationsWe made four recommendations to improve FAA’s approach to prioritizing and providing technical training to maintenance technicians. FAA concurred with all four recommendations.

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

Final Management Letter: Review of Upward Mobility Program

This Semiannual Report summarizes the OIG's activities and accomplishments for October 1, 2023, through March 31, 2023. The OIG issued three audits and two evaluations. The Office of Inspector General received 419 hotline contacts during the reporting period.

Inspector General's Semiannual Report to Congress

The report summarizes the FTC OIG’s activities and accomplishments during the first half of the FY 2022 reporting period.

As a law enforcement office, SIGTARP has a proven record of identifying and investigating fraud and other crimes. SIGTARP investigations have resulted in the recovery of more than $11.3 billion while coordinating with the Department of Justice (DOJ) and other law enforcement agencies to criminally prosecute 471 defendants - 321 of them sentenced to prison, including 75 bankers. Our investigations have also resulted in enforcement actions against 25 corporations/entities, including enforcement actions against many of the largest U.S. financial institutions.The Home Affordable Modification Program (HAMP) is the largest ongoing EESA program and is ending on April 28, 2023. According to March 2023 data, HAMP is still providing much needed foreclosure relief to more than 550,000 participating homeowners living in all 50 states. The Department of the Treasury paid $122.9 million in fiscal year 2023 and made its final advance payment of eligible incentives in March 2023. SIGTARP's investigations into the HAMP program have protected consumers seeking access to HAMP and who subsequently became the victims of scams. To date, SIGTARP has brought to justice 121 convicted scammers.

SIGPR Quarterly Report to Congress

Semiannual Report to Congress for the period October 1, 2022 – March 31, 2023

This report summarizes work we initiated and completed during this semiannual period on a number of critical Departmental activities. Over the past 6 months, our office issued 13 products related to our audit, evaluation, and inspection work. These products addressed programs and personnel associated with the Bureau of Industry and Security, United States Census Bureau, First Responder Network Authority, National Institute of Standards and Technology, National Oceanic and Atmospheric Administration (NOAA), United States Patent and Trademark Office (USPTO), and the Department itself. This report also describes our investigative activities addressing programs and personnel associated with the United States Economic Development Administration, NOAA, and USPTO.