Federal Reports

We determined that the BIA Great Plains Region did not hold three Tribes accountable for submitting CARES Act financial reports or narrative reports.

This management advisory sets forth an issue identified with a target range grant awarded to the Maine Department of Inland Fisheries and Wildlife.

The Safety and Health Program is intended to provide guidance through effective training to support and sustain the U.S. Postal Service’s work environment. Industrial accidents involve personal injuries as well as property damage that can include motor vehicle damage under certain conditions. Nationwide, most industrial accidents involved mail carriers assigned to retail and delivery facilities from fiscal years 2017 to 2021.

Umer Hassan Mir, of South Amboy, New Jersey, was sentenced on February 8, 2023, in U.S. District Court, District of New Jersey, to five months’ imprisonment and ordered to pay restitution of $78,000. Mir pleaded guilty on July 12, 2022, to entering fraudulent charges on General Service Administration fuel cards and other corporate credit cards, including at least four cards assigned to Amtrak vehicles. Mir made the fraudulent charges from February 2018 through August 2021 while working as the manager and attendant at a gas station in Metuchen, New Jersey. Mir would manually enter credit card information he collected during legitimate fuel transactions into the point-of-sale terminal at the station and withdraw cash from the register in the amount of the fraudulent transactions. He used the funds from the fraudulent transactions to pay for personal expenses and to pay another gas station employee for working extra hours on Mir’s behalf.Agents and personnel from the Amtrak Office of Inspector General; General Services Administration OIG; and the U.S. Postal Inspection Service, Philadelphia Division, investigated this case.

The VA Office of Inspector General (OIG) assessed the oversight and stewardship of funds by the Northern Arizona VA Health Care System. The review team looked at four areas to determine if appropriate controls and oversight were in place for open obligations oversight, purchase card use, inventory and supply management, and pharmacy operations. The team reviewed available data from fiscal year 2022. The report includes the following findings:• Inactive obligations were not always being reviewed, some were not deobligated, and quality assurance reviews were not always completed.• The healthcare system did not always reconcile transactions promptly or consider using contracts.• The healthcare system needs to improve the accuracy of inventory data.• The healthcare system could increase inventory turnover and needs to ensure the required reconciliation process is completed.The OIG made 10 recommendations to the healthcare system director: ensure finance office staff and initiating services know to conduct reviews on all inactive open obligations and deobligate any identified excess funds; ensure finance office staff are conducting the accounting operations finance quality assurance review, including the review of undelivered orders; establish controls to confirm approving officials and purchase cardholders review their purchases and make sure contracting is used when appropriate; review for overcharges all invoices for continuous positive airway pressure machines; develop a control to ensure supporting documentation is received from vendors that ship directly to veterans; ensure all supplies are entered into the Generic Inventory Package; implement a plan to achieve an inventory turnover rate closer to the Veterans Health Administration-recommended level; develop a plan to align inventory management practices with VHA policy; and ensure reconciliation of invoices with purchase orders as required under the B09 reconciliation process, which is how VA medical center pharmacies assure they are making correct payments for the drugs they receive.

The Federal Emergency Management Agency (FEMA) did not provide sufficient oversight of Project Airbridge, a COVID-19 initiative. Under unprecedented pressure to mitigate disruptions in global medical supply chains, FEMA established Project Airbridge.

The VA Office of Inspector General (OIG) conducted this inspection to assess the stewardship and oversight of funds by the VA Palo Alto Health Care System in California. This inspection assessed financial activities and administrative processes to determine whether appropriate controls and oversight were in place. These included open obligations, purchase card use, inventory and supply management, and pharmacy operations.Because personnel were not aware of review requirements, the team could not verify that anyone reviewed 10 obligations as required. VA’s reconciliation reports in the financial and accounting systems reflected accurate dates and order amounts for the 10 obligations; however, two had residual funds totaling approximately $3,102 that should have been deobligated.When assessing purchase card use, the team estimated that the healthcare system could have identified noncompliance errors in approximately 7,200 of 16,700 transactions, totaling about $26.9 million in costs. The team found that the effectiveness and efficiency of inventory management could improve by ensuring stock levels and inventory values are correct, establishing processes and procedures for monitoring inventory, implementing a training plan, and ensuring supply chain performance measures are maintained.The team found that pharmacy efficiency could improve by narrowing the gap between observed and expected costs, bringing turnover rates closer to the recommended level, and meeting reconciliation reporting requirements.The OIG made nine recommendations to the healthcare system director and one to the director of contracting for the Network Contracting Office 21 including making staff aware of requirements, conducting reviews on inactive open obligations, deobligating excess funds, complying with record retention requirements, and establishing controls for purchase card and contract use. The recommendations also specified providing supply chain procedures training, improving inventory system data reliability, ensuring physical inventory compliance, implementing a plan to increase inventory turnover, and consistent and timely reconciliation.

What We Looked At This report presents the results of our quality control review (QCR) of Allmond & Company, LLC’s management letter regarding the audit it conducted, under contract with us, of the National Transportation Safety Board’s (NTSB) financial statements for fiscal years 2022 and 2021. In addition to its audit report on NTSB’s financial statements, Allmond issued a management letter that discusses internal control matters that it was not required to include in its audit report. What We Found Our QCR of the management letter disclosed no instances in which Allmond did not comply, in all material respects, with generally accepted Government auditing standards. Our Recommendations Allmond made three recommendations in its management letter. NTSB concurred with all three recommendations. 

What We Looked AtThis report presents the results of our quality control review (QCR) of KPMG LLP’s management letter for its audit, conducted under contract with us, of the Department of Transportation’s (DOT) consolidated financial statements for fiscal years 2022 and 2021. The management letter discusses six internal control matters that KPMG was not required to include in its audit report. What We FoundOur QCR of the management letter disclosed no instances in which KPMG did not comply, in all material respects, with U.S. generally accepted Government auditing standards. Our RecommendationsKPMG made 12 recommendations in its management letter. DOT concurred with all 12 recommendations.

What We Looked AtThis report presents the results of our quality control review (QCR) of the management letter that KPMG issued on its audit, under contract with us, of the Federal Aviation Administration’s (FAA) consolidated financial statements for fiscal years 2022 and 2021. This management letter discusses internal control matters that KPMG was not required to include in its audit report. What We FoundOur QCR disclosed no instances in which KPMG did not comply, in all material respects, with U.S. generally accepted Government auditing standards. RecommendationsKPMG made 17 recommendations to FAA in its management letter. FAA concurred with all 17 recommendations.

The unclassified version of the SAR covers the period from 1 April 2021 – 30 September 2022, and reflects what the NSA OIG could release publicly about its work for that SAR Report Cover reporting period. The OIG made 327 recommendations that we believe will be impactful in improving the economy, efficiency, and effectiveness of this critical Agency's operations. The Director of the NSA and Congress previously received the classified version of the SAR in accordance with the IG Act.

This report summarizes the results of our fiscal year (FY 2022) Federal Information Security Modernization Act (FISMA) evaluation and assesses the maturity of controls used to address risks in each of the nine information security areas, called domains. We assessed the effectiveness of information security programs on the required maturity model spectrum, which is a rating scale for information security. We rated the Denali Commission’s overall program of information security as “effective.” A majority of the FY 2022 FISMA metrics were rated Defined (Level 2). Three of four recommendations for corrective action from the FY 2021 evaluation have been implemented.

We performed a corrective action verification review of the actions taken by the Government National Mortgage Association (Ginnie Mae) to implement the recommendations cited in Audit Report 2016-KC-0002, issued September 21, 2016. The HUD Handbook places the responsibility on HUD’s Office of Inspector General to perform selected corrective action verifications of significant audit recommendations when final actions have been completed. Our audit objectives were to verify that Ginnie Mae had implemented the corrective actions from the report that (1) established a maximum time during which single-family loans could remain pooled without insurance and (2) established a process for requiring removal of pooled loans that remained uninsured after that time. We found Ginnie Mae established a maximum time during which single-family loans could remain pooled without insurance and established a process for requiring removal of pooled loans that remained uninsured after that time. However, the loan-matching process used by Ginnie Mae did not ensure that pooled loans would be insured by an agency of the Federal Government as required by the Mortgage-Backed Securities (MBS) Guide. The process matched pooled loans to agency insurance files but was not adequately designed to cure unmatched loans within the timeframes established in the MBS Guide. As a result, at least 3,206 pooled loans with a principal balance of at least $903 million were not matched to agency insurance data files before the certification date. We recommend that Ginnie Mae update and synchronize its procedures. The updates should include notifications that provide issuers with unmatched loans adequate time to take corrective action to comply with the requirements of the MBS Guide.

Using a risk-based, tiered approach in developing this work plan to best focus our limited resources, AIE will initiate work in nine focus areas in 2023-2024, including oversight of IIJA, IRA and other supplemental funding provided to the DOI.

We reviewed the deaths of five individuals in custody reported by U.S. Immigration and Customs Enforcement (ICE) and the deaths of five individuals in custody reported by U.S. Customs and Border Protection (CBP) in fiscal year 2021. We found that no underlying systemic factors, policies, or processes played a role in the deaths of 9 of these 10 individuals and that both components reported their deaths to the Office of Inspector General as required. We were unable to evaluate the remaining individual’s death due to an ongoing criminal investigation

During our unannounced inspection of U.S. Immigration and Customs Enforcement’s (ICE) Port Isabel Service Processing Center (Port Isabel) in Los Fresnos, Texas, we found that Port Isabel complied with standards for the voluntary work program, access to legal services, and medical care for detainees.

Williams, Adley & Company – DC, LLP (Williams Adley), under contract with the Department of Homeland Security Office of Inspector General, issued an Independent Accountant’s Report on U.S. Coast Guard’s (USCG) Detailed Accounting Report. USCG management prepared the Table of FY 2022 Drug Control Obligations and related assertions to comply with the requirements of the ONDCP Circular, National Drug Control Program Agency Compliance Reviews, dated September 9, 2021.

We contracted with the independent public accounting firm Williams, Adley & Company – DC, LLP (Williams Adley) to review USCG’s Drug Control Budget Formulation Compliance Report. Williams Adley is responsible for the attached Independent Accountant’s Report, dated January 20, 2023, and the conclusions expressed in it. Williams Adley’s report contains no recommendations

Williams, Adley & Company – DC, LLP (Williams Adley), under contract with the Department of Homeland Security Office of Inspector General, issued an Independent Accountant’s Report on the U.S. Customs and Border Protection’s (CBP) Detailed Accounting Report. CBP management prepared the Table of FY 2022 Drug Control Obligations and related assertions to comply with the requirements of the ONDCP Circular, National Drug Control Program Agency Compliance Reviews, dated September 9, 2021.

The VA Office of Inspector General (OIG) evaluated allegations that a patient presented unscheduled to the Chico Community-Based Outpatient Clinic in California (Chico CBOC) and later was involved in a violent incident with family members, and facility leaders did not address employee concerns related to the adverse clinical outcome and mental health staffing. The OIG also identified concerns related to facility staff’s failure to provide same-day access, adequate mental health assessment, mental health triage, medication management, and facility leaders’ failure to consider completing an institutional disclosure and address concerns about the Chico CBOC building design.The OIG substantiated that the patient presented to the Chico CBOC Mental Health Clinic “highly agitated,” “was sent home,” and later had a violent altercation. The OIG did not substantiate that facility leaders failed to address employee concerns regarding staff well-being and inadequate mental health staffing levels.The OIG found that a nurse practitioner did not have same-day availability to evaluate the patient the day of the unscheduled visit. When the patient was unable to engage in a risk assessment, the OIG found that a triage social worker did not document the patient’s risk and protective factors, reasons for the patient’s inability to complete the assessment, or attempt to ask the patient’s family member about risk and protective factors.The OIG found that the nurse practitioner did not align medication management with treatment guidelines, document a comprehensive rationale for medication choices, document medication instructions accurately, or schedule a follow-up appointment within the expected time frame. Following the patient’s adverse clinical outcome, the OIG found that facility leaders did not complete an institutional disclosure.The OIG made five recommendations to the Facility Director related to same-day mental health access, risk assessment documentation, medication management continuity of care, institutional disclosure, and environmental changes to the Chico CBOC.

As part of our annual audit plan, we performed an audit of costs billed to the Tennessee Valley Authority (TVA) by Baker's Construction Services, Inc. (BCS) for field labor support services provided for TVA's civil construction organization under Contract No. 14743. Our audit objective was to determine if costs were billed in compliance with the contract's terms. Our audit scope included about $19.26 million in costs billed to TVA from January 1, 2020, through August 31, 2021.In summary, we determined BCS billed TVA:From $116,763 to $421,683 in unapproved temporary living allowance (TLA) costs. In addition, we identified other areas where the administration of TLA and TLA certifications could be improved.$44,941 in other ineligible and unsupported costs, including (1) $21,582 for ineligible and unapproved subcontractor costs, (2) $11,269 for ineligible equipment costs, <br> (3) $8,845 for duplicate and ineligible material costs, and (4) $3,245 for unsupported noncraft labor costs. We also noted opportunities to improve contract administration by TVA. Specifically, (1) the contract contained inconsistent language related to compensating noncraft labor, and <br> (2) several invoice and payment errors resulted in incorrect payments by TVA, which could have been identified with a proper invoice review.(Summary Only)

The VA Office of Inspector General (OIG) evaluated allegations that a primary care provider did not timely identify a liver abnormality nor inform a patient about a terminal cancer diagnosis at Overton Brooks VA Medical Center (facility) in Shreveport, Louisiana. The OIG identified additional concerns related to care coordination, resident supervision, communication of abnormal results, surrogate provider coverage, and patient safety event reporting.In early 2019, a primary care provider referred the patient to the facility’s Emergency Department for evaluation of leg pain. The patient was admitted and had imaging tests that showed a liver lesion with further testing recommended. The inpatient medicine provider (resident) included the imaging results in the patient’s progress note; however, the resident did not document findings or follow-up needs in the patient’s discharge summary. During four subsequent visits, the primary care provider’s notes lacked documentation of the lesion and recommended follow-up. In summer 2019, the patient reported having imaging at a community hospital that identified a liver tumor, and the primary care provider ordered a liver scan. The scan showed a liver mass and lesion. The primary care provider was on leave during the time the scan was conducted and an Emergency Department physician assistant was assigned as a surrogate for coverage. The OIG found no documentation that the primary care provider or the surrogate informed the patient of the abnormal findings.The patient died in fall 2019, after a confirmed liver cancer diagnosis.Facility leaders and staff did not take timely administrative action in response to the patient’s adverse event. Staff did not initiate a patient safety report and review the episode of care and the issues related to coordination of care.The OIG made four recommendations related to communication of abnormal test results, resident supervision, provider surrogate assignments, and patient safety reporting.

We contracted with the independent public accounting firm Williams, Adley & Company – DC, LLP (Williams Adley) to review CBP’s Drug Control Budget Formulation Compliance Report. Williams Adley is responsible for the attached Independent Accountant’s Report, dated January 20, 2023, and the conclusions expressed in it. Williams Adley’s report contains no recommendations.

This letter responds to the Government Charge Card Abuse Prevention Act of 2012 (Charge Card Act) reporting requirement for the Federal Trade Commission (FTC) for fiscal year 2023.

What We Looked AtThis report presents the results of our quality control review (QCR) of Allmond & Company, LLC’s (Allmond) management letter regarding the audit conducted, under contract with us, of the Surface Transportation Board’s (STB) financial statements as of and for the fiscal years ended September 30, 2022, and September 30, 2021. The management letter discusses internal control matters that Allmond was not required to include in its report on the audit of STB’s financial statements. What We FoundOur QCR of the management letter disclosed no instances in which Allmond did not comply, in all material respects, with generally accepted Government auditing standards. RecommendationsAllmond made six recommendations in its management letter. STB concurred with all six recommendations.

What We Looked AtThe Department of Transportation (DOT) and its Operating Administrations (OA) are charged with overseeing billions of dollars in grant funds for projects aimed at building, maintaining, and enhancing our Nation’s transportation system. Between fiscal years 2014 and 2019, the City of Seattle’s Department of Transportation (SDOT) received $259.8 million in grants and cooperative agreements from the Federal Highway Administration (FHWA), the Federal Railroad Administration (FRA), and the Federal Transit Administration (FTA). Over the past few years, our office received hotline complaints concerning federally funded SDOT projects that are subject to DOT’s oversight. Given the significant amount of Departmental funds allocated to SDOT projects and concerns raised by the hotline complaints we received, we initiated this review. Our objective was to assess the Department’s oversight of Federal funds received by SDOT. What We FoundOur review identified weaknesses in the OAs’ oversight regarding (1) execution of change orders that lacked required approval signatures, (2) approval of a $140 million project estimate and contingency amounts with limited support, (3) the inability to track where and how Federal funds were spent, and (4) procedures to ensure that Federal funds transferred from FHWA to FTA are used in a timely manner or put to better use. In addition, weaknesses related to OST’s and FRA’s oversight of a project’s cost estimates and contingency rates resulted in $21 million in lapsed funds that could be put to better use. Also, as part of our efforts to determine how the grant funds were used, we identified $10.7 million in questioned costs due to a lack of adequate supporting documentation. Further, we identified $3.6 million in transferred FHWA funds that remain unobligated more than 6 years after being transferred, resulting in these funds lapsing. Lastly, we found that FTA had not deobligated $3.8 million in other transferred funds that have been inactive since 2017. By increasing focus on these issues, DOT will be better positioned to ensure the City of Seattle and SDOT effectively manage and use the Federal taxpayer dollars they receive. Our RecommendationsWe made 14 recommendations to improve DOT’s management and oversight of Federal funds provided for SDOT projects. DOT concurred with recommendations 1, 2, and 4–14, and provided an alternative action from FHWA for recommendation 3 that meets the intent of our recommendation. We consider all recommendations as resolved but open pending completion of the planned actions.

SIGPR's 11th Quarterly Report to Congress

We conducted an attestation review of the U.S. Department of Housing and Urban Development’s drug control accounting for the fiscal year ended September 30, 2022. We performed this review pursuant to section 705(d) of Public Law 105-277, which requires National Drug Control Program agencies to submit to the Director of ONDCP a detailed accounting of all funds spent by the agencies for National Drug Control Program activities during the previous fiscal year and that the accounting be authenticated by agency Inspectors General before submission. We conducted our attestation review in accordance with attestation standards established by the American Institute of Certified Public Accountants and the standards applicable to attestation engagements contained in Government Auditing Standards, issued by the Comptroller General of the United States. Based upon our review, we are not aware of any material modifications that should be made to HUD’s Detailed Accounting Report and Budget Formulation Compliance Report in order for them to be in accordance with (or based on) ONDCP’s Circular, National Drug Control Program Agency Compliance Reviews, dated September 9, 2021.

The VA Office of Inspector General (OIG) evaluated allegations that VA North Texas Health Care System (VA North Texas) domiciliary substance use disorder treatment program (DOM SUD) staff placed patients on waitlists and failed to offer non-VA community residential care (community residential care) referrals, as required by the Veterans Health Administration (VHA).Domiciliary care is aligned under mental health residential rehabilitation treatment programs (MH RRTPs), which provide 24-hour treatment and rehabilitative services. VA North Texas includes a DOM SUD at the Dallas VA Medical Center (Dallas DOM SUD) and a DOM SUD at the Sam Rayburn Memorial Veterans Center in Bonham (Bonham DOM SUD).The OIG reviewed 15 VA North Texas DOM SUD consults placed for 10 patients and substantiated that staff placed patients on waitlists and failed to offer community residential care referrals. Failure to discuss alternative treatment options, including community residential care, may have contributed to patients’ increased risk of negative outcomes due to delayed access to DOM SUD services.The OIG also determined that the Veterans Integrated Service Network (VISN) 17 Chief Mental Health Officer lacked authority to ensure national MH RRTP policy adherence. Effective oversight is critical to ensuring efficiency of DOM SUD operations and patients’ access to care.The OIG found that the Bonham MH RRTP standard operating procedure was inconsistent with VHA’s scheduling requirements. Further, VA North Texas policy did not include the requirement for staff to ensure a Mental Health Treatment Coordinator (MHTC) assignment for patients awaiting MH RRTP admission.The OIG made two recommendations to the Under Secretary for Health related to VISN MH RRTP oversight and MHTC assignment procedures and three recommendations to the VA North Texas Director related to alternative treatment options when DOM SUD admission wait times exceed 30 days, management of community residential care referrals, and scheduling procedures.

Alain Galette, a resident of Miami, Florida, was sentenced on January 31, 2023, in U.S. District Court, Southern District of Florida, to 13 months in prison, two years of probation, and was ordered to pay $150,000 in restitution to the Small Business Administration. He previously pleaded guilty to one count of wire fraud in relation to his application for a Payroll Program Protection (PPP) loan and in obtaining an Economic Injury Disaster Loan (EIDL) in the amount of $149,900. The PPP loan was in the amount of $163,577 but was denied. Our investigation found that Galette used an invalid social security number and included other false information on the PPP and EIDL applications. Upon receipt of the EIDL funds, Galette did not use the money for authorized purposes.

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.

We have completed a review of the DOI’s progress in implementing our past audit recommendations addressing Government charge card internal controls.

The VA Office of Inspector General (OIG) conducted a national review to assess elements of the Veterans Health Administration’s (VHA’s) Intensive Community Mental Health Recovery programs (ICMHR). ICMHR provides highly intensive community-based care to veterans with serious mental illness. Visit frequency is a measure of ICMHR service intensity. This review examined the visit frequency for ICMHR-enrolled veterans from April 1, 2019, through March 31, 2021. The time frame represents approximately one year prior to and one year after the onset of the COVID-19 pandemic. Additionally, the OIG evaluated VHA healthcare systems’ contingency planning for veteran medication access during emergencies.The OIG found ICMHR did not meet VHA’s required visit frequency for high-intensity services. ICMHR staff are expected to have, on average, two to three weekly visits with ICMHR-enrolled veterans, typically in the veterans’ communities or homes, to provide high-intensity services. The OIG reviewed ICMHR-related data from VHA, calculated the weekly average number of visits in a veteran’s treatment period, and found that ICMHR did not meet VHA’s required visit frequency for high-intensity services.The OIG also evaluated VHA’s contingency planning for veteran medication access during emergencies. Community-based programs, such as ICMHR, should have program-specific contingency plans for veterans’ medication access, including to long-acting injectable antipsychotic medications, during emergencies. A disruption in medication access could be destabilizing for veterans with serious mental illness. The OIG found the majority of VHA healthcare systems did not have ICMHR-specific contingency plans for veteran medication access.The OIG made three recommendations to the Under Secretary for Health. The recommendations address ICMHR visit frequency and intensity of care provided; the ongoing role of virtual care in the delivery of ICMHR; and ICMHR-specific contingency planning related to medication access during emergencies, with a focus on long-acting injectable antipsychotic medications.

Charge Card Risk Assessment

We audited the U.S. Department of Housing and Urban Development’s (HUD) efforts to proactively communicate information related to the coronavirus disease of 2019 (COVID-19) to homeowners with Federal Housing Administration (FHA)-insured mortgages. We initiated this work based on a U.S. Government Accountability Office report that identified helping borrowers understand the protections available to them as a key challenge and prior audit and evaluation work that found issues related to communication and COVID-19. Our audit objective was to assess HUD’s communication to homeowners with FHA-insured mortgages through its website, joint website, and other proactive methods about protections, repayment options, loss mitigation options, and responsibilities related to COVID-19.HUD proactively communicated critical information to homeowners during the COVID-19 pandemic. However, there are several areas in which HUD could improve its communication. For example, HUD’s COVID-19 Resources for Homeowners webpage did not (1) clearly present the deadline for requesting forbearance, (2) detail loss mitigation options available after forbearance, and (3) include detailed information for homeowners with reverse mortgages. Additionally, letters mailed to homeowners may not have been timely for some and did not discuss loss mitigation. This condition occurred in part because HUD chose to direct certain information to lenders only and relied on them to communicate with borrowers, and because it did not have a strategy for sending letters. As a result, homeowners may not have been aware of available protections and loss mitigation options. If HUD addresses the issues identified, it could better serve homeowners through the end of the COVID-19 pandemic and during future disasters and national emergencies.We recommend that HUD’s Office of Single Family Housing update its COVID-19 Resources for Homeowners webpage to adequately cover key information related to forbearance for forward mortgages, extension periods for reverse mortgages, loss mitigation, and other assistance available. We also recommend that HUD develop a communication strategy detailing how and when it plans to use websites, letters, and other methods to proactively notify homeowners about relief programs, protections, and loss mitigation options during disasters and national emergencies.

Ever since Congress created the Special Inspector General for the Troubled Asset Relief Program (SIGTARP) under the Emergency Economic Stabilization Act (EESA), SIGTARP has delivered for American taxpayers. As a law enforcement office, SIGTARP has a proven record of identifying and investigating fraud and other crime. SIGTARP investigations have resulted in the recovery of at least $11.3 billion, criminal prosecutions by the Department of Justice and others of 469 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. As an independent watchdog, SIGTARP has consistently identified fraud, waste, abuse, ineffectiveness, inefficiency, and risk in EESA programs, and brought transparency to EESA.

The PRAC’s Pandemic Analytics Center of Excellence (PACE) data scientists identified $5.4 Billion in potential identity fraud associated with over 69,000 questionable Social Security Numbers (SSNs) used on applications across disbursed loans in the Small Business Administration’s COVID-19 Economic Injury Disaster Loan Program and Paycheck Protection Program. Through collaborative verification methods with the Social Security Administration, we identified that these SSNs were used in connection with over 99,000 applications and warrant further scrutiny. The results of this Fraud Alert demonstrate the benefit of a consent-based verification process to authenticate basic applicant information. This leading practice can be facilitated by legislative language requiring federal agencies to use a such a process when making applicant eligibility determinations and by authorizing agencies such as SSA to verify information.

An Amtrak trainmaster based in New Orleans, Louisiana, was terminated from employment on January 27, 2023, after our investigation found that the employee violated company policies by intentionally submitting an application containing false statements and information to the Small Business Administration in order to qualify for a CARES Act Economic Injury Disaster Loan for a business that does not exist. Additionally, when interviewed by our agents, the employee failed to be forthright, honest, or cooperative. We also found that the employee violated company policy by not disclosing any outside business activities on his certificates of compliance.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review an allegation of abuse and quality of care concerns for a patient at the Fort Harrison VA Medical Center and the Miles City Community Living Center (CLC) in Montana. The OIG identified issues related to a pattern of patient mistreatment in the CLC, care coordination and discharge planning, and facility leaders’ noncompliance with state licensing board requirements.The OIG substantiated the allegation that a physical therapist and nursing staff forced the patient to participate in physical therapy in the CLC even though the patient objected. During the review, the OIG discovered additional findings related to facility oversight processes including three previous investigations of patient abuse in the CLC. The OIG concluded that leaders’ failures in responding to a pattern of mistreatment and in reviewing and reporting licensed healthcare professionals to state licensing boards may have fostered a culture of mistreatment at the CLC. Additionally, the OIG found that facility leaders did not assess the CLC physician’s performance and competence for treating patients in the CLC as required and determined that failure in care coordination between physicians led to an absence of a suggested follow-up plan for a suspected lung mass in the discharge summary to a state veterans home.The OIG made one recommendation to the Rocky Mountain Network Director related to the review of facility staff’s actions taken in response to the allegations and concerns related to the identified patient. The OIG made six recommendations to the Facility Director related to ensuring the rights of CLC patients, reviewing the care provided to the patient by the CLC nursing staff and physician and during the patient’s acute care hospitalization, reviewing the screening and admissions process for CLC patients, and complying with the state licensing board reporting policy.

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Our 2022 organizational assessment highlights our significant accomplishments in overseeing the DOI’s programs and operations.

The OIG engaged the independent public accounting firm CliftonLarsenAllen (CLA) to conduct the performance audit and issue its report. The objective of the audit was to determine whether the Compliance Program, as implemented by the Commission and CNAs, is effectively providing reasonable assurance of NPA and CNA compliance with applicable laws, regulations, and policies. The auditors concluded that although the Commission’s policies and procedures governing the Compliance Program comply with applicable laws and regulations, there are opportunities for improvement in four key areas. The report contains 11 recommendations to improve the Commission’s controls over the Compliance Program.