Federal Reports

The Office of Enforcement and Compliance Assurance, or OECA, is not on track to achieve ten (25 percent) of the 40 measures and deliverables in its National Compliance Initiative, or NCI, strategic plan.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess concerns regarding a primary care provider (provider) potentially falsifying blood pressure readings (blood pressures) at the North Las Vegas VA Medical Center (facility) in Nevada.The OIG determined the provider knowingly documented false blood pressures in patients’ electronic health records (EHRs) during VA Video Connect (VVC) visits. The provider attributed the falsifications to the belief that the VVC template required documentation of a blood pressure when a blood pressure was not obtained and to a lack of VVC training. The OIG confirmed that the VVC template did not require documentation of blood pressures and determined the provider completed required VVC trainings.The provider reported patients were not harmed by the falsifications because mitigation strategies were used. From a review of a sample of EHRs, the OIG determined the provider did not use the mitigation strategies with most patients; however, the OIG did not find evidence that any patients experienced an adverse clinical outcome as a result of the false blood pressures.Upon learning of the provider’s falsification of blood pressures, facility leaders took actions that included retraining and facilitating an EHR review. Despite the retraining, the provider continued to display difficulty demonstrating the use of technology and locating the VVC template. The OIG evaluated a sample of EHRs from the facility’s review and found that not all entries with a blood pressure of 120/80 were clinically reviewed and amended. Additionally, the OIG determined that facility leaders failed to initiate state licensing board reporting processes.The OIG made five recommendations to the Facility Director related to verifying the provider’s ability to complete and document VVC visits, considering administrative action, initiating state licensing board reporting processes, and ensuring the provider’s blood pressure entries in EHRs are reviewed and amended.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess an allegation that a patient received poor care in the Emergency Department at the Baltimore VA Medical Center (facility) in Maryland, which resulted in an amputation at the patient’s left forearm at a non-VA hospital days later. The OIG identified additional concerns related to the patient’s primary care provider not maintaining the patient’s problem list in the electronic health record and Emergency Department providers’ failure to address the patient’s second chief complaint of knee pain.The OIG reviewed the care the patient received at the facility’s Emergency Department on two consecutive days in early fall 2021. During the first visit, the patient, with a medical history of poorly controlled type II diabetes, presented to the facility complaining of left hand pain with a ring stuck on the middle finger after sustaining a fall. The following day, the patient returned with left hand pain; redness, swelling, and a superficial open wound to the finger; and knee pain.The OIG substantiated the patient received poor Emergency Department care during the second visit when a physician assistant failed to obtain laboratory studies for a patient with diabetes and a hand infection, to complete a comprehensive clinical assessment of the patient, and to document a clinical consultation with an attending physician. Additionally, the overseeing attending failed to identify concerns with the physician assistant’s documented care of the patient. The OIG determined these failures may have contributed to the patient’s amputation. An institutional disclosure was conducted, which included a plan for staff training.The OIG made four recommendations to the Facility Director related to ensuring Emergency Department providers conduct comprehensive clinical assessments and address patients’ presenting complaints, evaluation of clinical consultation processes, staff training, and maintaining problem lists.

What We Looked AtThe Federal Aviation Administration's (FAA) Office of Audit and Evaluation (AAE) investigates alleged lapses in aviation safety and oversight; violations of FAA regulations, orders, standards, or policies; and other whistleblower disclosures. In December 2020, a Senate committee reported that AAE did not necessarily conduct independent, objective, or impartial investigations and evaluations. In January 2021, the Federal Aviation Administrator asked our office to conduct a review of the office's practices. Our objectives were to evaluate whether AAE (1) aligned its practices for investigations of internal whistleblower safety disclosures with applicable investigative standards, benchmarks, or best practices; (2) documented sufficiency reviews of hotline investigations it referred to FAA lines of business (LOB) with best practices; and (3) complied with requirements in the Aircraft Certification, Safety, and Accountability Act of 2020.What We FoundAAE's investigative practices align with applicable quality standards. However, the office lacks comprehensive written standard operating procedures to reinforce its internal controls. In addition, AAE does not have a method to track and document sufficiency reviews of hotline investigations it referred to FAA's LOBs. Specifically, AAE reviewers did not maintain documentation supporting their sufficiency review conclusions. As a result, AAE cannot demonstrate that its review of investigations it referred to LOBs was of quality and consistent. Finally, FAA has only partially met the Aircraft Certification, Safety, and Accountability Act's requirements for AAE's organizational structure. FAA reorganized AAE in February 2022--renaming one sub-office as the Office of Whistleblower Aviation Safety Investigations and adding an Office of Whistleblower Ombudsman. However, until FAA limits the duties of the AAE Director, which are currently broader, to the specific activities listed in the act, AAE will not have fully implemented the law's requirements.Our RecommendationsWe made four recommendations to improve AAE's compliance with applicable standards and statutory requirements for whistleblower investigations and hotline sufficiency reviews. FAA concurred with all four recommendations and provided appropriate actions and completion dates.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations related to the mental health care of a female patient at the VA Greater Los Angeles Healthcare System (facility) in California, which included that a psychiatry physician resident (psychiatry trainee) was inappropriate during treatment discussions with the patient. The psychiatry trainee utilized a modality called Intensive Short-Term Dynamic Psychotherapy in which a therapist seeks to understand a patient’s interpersonal difficulties, intensify and challenge resistance, analyze transference, explore conflict, and work through unconscious issues.The OIG did not substantiate that the psychiatry trainee’s behavior with the patient was inappropriate. Although the psychiatry trainee did not always engage in effective therapeutic intervention, the OIG was unable to determine that the treatment resulted in a decline in the patient’s mental health causing decreased trust and mental functioning.The OIG found the supervisor did not provide adequate supervision to the psychiatry trainee, to include the psychiatry trainee’s documentation and the supervisor’s documented oversight. The inadequate supervision may have impeded the supervisor’s ability to inform the therapy and hinder the opportunity to achieve a more desirable therapeutic outcome. In addition, the OIG substantiated that Mental Health Department leaders were not responsive to the patient’s concerns. During the inspection, the OIG identified an additional concern regarding the improper creation, storage, and disposition of video recordings and consent forms.The OIG made one recommendation to the Under Secretary for Health to assess the possible scope of current and former VA psychiatry residents being in possession of patients’ personal health information; two recommendations to the Veterans Integrated Service Network Director related to supervision, documentation, document control, and treatment protocols; and three recommendations to the Facility Director related to responses to the patient’s concerns, records, and utilization of video recordings.

We audited the U.S. Department of Housing and Urban Development’s (HUD) information technology (IT) infrastructure to support mandatory telework. During mandatory telework, more employees simultaneously needed remote access to HUD’s network and agency resources for an extended period, which presented unique risks and security requirements. While HUD is no longer operating under mandatory telework, understanding the challenges it faced is key to managing a flexible workforce and preparing for future emergencies.HUD experienced challenges with its IT infrastructure while under mandatory telework. We found (1) there were significant delays in processing computer security updates, (2) users encountered months of network performance issues, (3) the user password expiration policy was not enforced, and (4) the help desk system did not capture complete data. These conditions occurred because HUD’s virtual private network (VPN) bandwidth was not sufficient to accommodate the significant increase in users’ simultaneously needing remote access and because there were limitations in the technical environment and weaknesses in the help desk system’s controls. As a result, (1) HUD was vulnerable to cyber-attacks and unauthorized access, (2) HUD’s ability to accomplish its mission could be affected, and (3) HUD did not have assurance that all IT problems reported by users were resolved. Although HUD experienced challenges during mandatory telework, HUD continued its operations; increased network capacity; and plans to make additional network improvements, resume password policy enforcement, and potentially replace its help desk system. HUD needs to fully address the underlying causes of the issues identified so that it can manage its flexible workforce in a way that minimizes risk and prepares it for future emergencies.We recommend that HUD’s Office of the Chief Information Officer research, evaluate, and implement technical or alternative solutions to (1) deploy essential computer software updates using secure methods to ensure that computer security updates occur in a timely manner to minimize risk to HUD’s systems and operations; (2) provide additional improvements to VPN-related remote working capabilities, including performing routine VPN stress tests as part of its contingency planning and testing processes; (3) resolve user account management issues; and (4) assess its help desk system against other technical solutions and ensure that the help desk solution used captures complete data on technical support requests. These measures include but are not limited to ensuring that sequence gaps are properly documented or do not occur, valid transactions are accepted by the help desk system, rejected transactions are identified, and the history of each transaction is retained.

FLRA's Compliance with the Payment Integrity Information Act of 2019 in the Fiscal Year 2022 PAR

In accordance with the GPRA Modernization Act of 2010, the Department’s framework for performance management begins with the Strategic Plan, which serves as the foundation for establishing and implementing priorities, highlighting performance goals and objectives, and developing performance indicators to gauge progress and outcomes. Progress toward the Department’s strategic goals and its two-year Agency Priority Goals (APGs) are measured using data-driven review and analysis.

FSA, a principal office of the U.S. Department of Education, is required by law to produce an annual report, which details the organization’s fiscal year financial and program performance. The Federal Student Aid FY 2022 Annual Report (Annual Report) is a comprehensive document that provides an analysis of FSA’s financial and program performance results for FY 2022 and exhibits the organization’s effectiveness in accomplishing its mission.

Inspector General's FY 2022 Letter to OMB on SEC's Implementation of Purchase Card Program Audit Recommendations

In 2022, the EEOC Office of Inspector General (OIG) procured the services of KAI Partners, Inc. (KAIP) to perform an evaluation of the Equal Employment Opportunity Commission’s (EEOC) Digital Process Transformation and Automation (DPTA) progress, with an emphasis on evaluating EEOC’s DPTA plans, capabilities, and requirements. DPTA is the digitization and automation of business processes to improve effectiveness and efficiency to continually enhance the customer experience.

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We audited the U.S. Department of Housing and Urban Development (HUD), Office of Native American Programs’ (ONAP) Coronavirus Aid, Relief, and Economic Security (CARES) Act and American Rescue Plan (ARP) Act to identify drawdown levels for its block grant programs and assessed information ONAP made publicly available.As of October 4, 2022, grantees had drawn $231.6 million of the $300 million in CARES Act block grant funds and $135.8 million of the $735 million in ARP Act block grant funds. A total of $19.1 million of the appropriated funds was not authorized for access to grantees because grantees opted not to apply for funding, declined to accept funding after it was awarded, or were still in the approval process. The remaining undrawn funds could be the result of unique challenges faced by each grantee or the remaining time left to expend the funds. However, most grantees had an approved plan in place to spend the funds, and the Indian Housing Block Grant (IHBG)-ARP funds without a plan will be reallocated by ONAP to other grantees with specific needs under the Indian Community Development Block Grant (ICDBG)-ARP program. HUD stated that it would continue to monitor congressional legislation and will reallocate the remaining IHBG-CARES funding if a statutory fix to allow reallocation to the ICDBG-ARP gets enacted into law.In addition, ONAP updated grantees and the public concerning its CARES Act and ARP Act block grant funds through PIH notices, guidance, training, and frequently asked questions. As a result, the grantees and other stakeholders were generally informed of the program requirements and which grantees received funding. In addition, we noted a less significant matter regarding the publishing of award information which we communicated to ONAP in a separate memorandum.There are no recommendations in this report.

We found a former nonprofit official misused funds received under a U.S. Fish and Wildlife Service program assisting in recovering endangered or threatened species.

Audit of the FLRA Charge Card Program and Risk Assessment for FY 2022

We did not substantiate allegations that a former DOI Secretary violated the Ethics Pledge and Federal conflict of interest rules.

Independent Review of 4003(b) Loan Recipient’s Validation Memo – Eastern Airlines, LLC

As part of our annual audit plan, we audited costs billed to the Tennessee Valley Authority (TVA) by Fisher Contracting Company (Fisher) under Contract No. 13155 for coal combustion residual construction services. Our audit objectives were to determine if (1) costs were billed in accordance with the terms of the contract and (2) tasks were issued using the most cost efficient pricing methodology. Our audit scope included about $47.9 million in costs billed to TVA from February 12, 2018, through February 28, 2022. This included approximately $42.5 million for fixed price projects, $5.3 million for cost reimbursable projects, and $89,985 for time and material projects. In summary, we determined:Fisher overbilled TVA $80,324, including (1) $48,183 for overbilled labor costs, (2) $23,383 for duplicate material costs, (3) $7,758 for ineligible equipment costs, and (4) $1,000 for ineligible insurance costs.The use of fixed price payment terms on projects caused TVA to pay at least $4.35 million more than it would have if cost-reimbursable payment terms had been used for those projects. Additionally, if TVA utilized cost-reimbursable pricing for the remaining contract spend, it could potentially avoid $28.7 million in future costs.(Summary Only)

The Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered at vet centers. This report focuses on Midwest district 3 zone 1 and four selected vet centers: Cleveland, Columbus, and Toledo in Ohio; and South Bend in Indiana. 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 3 zone 1 Vet Center Service Customer Feedback survey results were below the national average in all areas except satisfaction with overall quality of services at the vet center. The OIG issued one recommendation to the district director specific to annual in-service training; this recommendation was closed at the time of publication.The OIG conducted an analysis of vet center quality reviews required to ensure compliance with policy and procedures. The OIG made five recommendations for clinical and administrative quality reviews and two recommendations 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—seven specific to electronic client records and two 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, audits, and training, and issued four recommendations. The environment of care review evaluated the four selected vet centers. The OIG made two recommendations.

Federal and State agencies and tribes share responsibility for addressing orphaned wells with Infrastructure Investment and Jobs Act funds.

The Infrastructure Investment and Jobs Act authorizes $11.3 billion in appropriations to address abandoned mine lands.

The DOI has no policies or guidance specifically addressing foreign government sponsored talent recruitment programs or conflicts of commitment.

The U.S. Postal Service holds its cash in the Postal Service Fund with the Federal Reserve Bank of New York and, traditionally, has invested its excess cash in highly liquid, overnight investments (Overnight Treasuries) issued by the U.S. Department of Treasury (Treasury), where interest rate changes are more pronounced than in longer-term investments. Postal Service cash has grown from $2.3 billion in fiscal year (FY) 2013 to $19.6 billion at year-end FY 2022.

The VA Office of Inspector General (OIG) conducts information security inspections to assess whether VA facilities are meeting federal security requirements. These inspections focus on four security control areas that apply to local facilities and have been selected based on their levels of risk: configuration management, contingency planning, security management, and access controls. During this inspection, the OIG found deficiencies with configuration management, security management, and access controls.Configuration management controls were deficient in vulnerability remediation, the process to identify, classify, and fix weaknesses. Without an effective vulnerability management program, opportunities for exploitation increase.The security management control deficiency was in system security planning, which is needed for authorizing a system to operate. Without a system security plan or an authorization to operate, and without requiring contractors to adhere to federal and VA security requirements, the facility cannot be sure that security controls will be implemented as required.The security management deficiencies were in network segmentation, physical access, environmental, audit and monitoring, and records management controls. Without these safeguards, breaches are more likely to occur and harder to detect, and assets are at risk of accidental or intentional destruction.The assistant secretary for information and technology and chief information officer concurred with all but one of the OIG’s nine recommendations. Regarding his nonconcurrence, the assistant secretary reported that the devices identified by the OIG as lacking required isolation—the finding that resulted in recommendation 4—do not meet the definition for devices subject to this requirement. However, these devices were identified by the facility as containing medical systems and therefore, per VA policy, fall under the medical device isolation architecture guidance. The OIG thus stands by its recommendation.

The VA Office of Inspector General (OIG) conducts information security inspections to assess whether VA facilities are meeting federal security requirements. They are typically conducted at selected facilities that have not been assessed in the sample for the annual audit required by the Federal Information Security Modernization Act of 2014 (FISMA) or at facilities that previously performed poorly. The OIG selected the Tuscaloosa VA Medical Center in Alabama because it had not been previously visited as part of the annual FISMA audit.The OIG’s information security inspections focus on four security control areas that apply to local facilities and have been selected based on their levels of risk: configuration management, contingency planning, security management, and access controls. During this inspection, the OIG found deficiencies with configuration management, security management, and access controls. Deficiencies in configuration management included critical-risk vulnerabilities that VA’s Office of Information and Technology did not identify, uninstalled patches, and unscannable database servers, all of which deprive users of reliable access to information and could risk unauthorized access to, or the alteration or destruction of, critical systems. The team identified a security management weakness concerning missing or insufficiently detailed action plans to address identified vulnerabilities. Weak access controls, such as missing logs, insufficient climate controls for communications equipment, and uninstalled backup power supplies, compromised the security and maintenance of the information system and its ability to withstand power disruptions.The OIG made six recommendations to the assistant secretary for information and technology and chief information officer to improve controls at the facility because they are related to enterprise-wide information security issues similar to those identified on previous FISMA audits and information security inspections. The OIG also made two recommendations to the Tuscaloosa VA Medical Center director.

NASA’s plan to land humans on the Moon by the end of 2025 and send a crewed mission to Mars in the 2030s rest in part on significant participation and partnerships with international space agencies and their long-term commitments to the Artemis campaign. In this audit, we examined NASA’s efforts to partner with other space agencies on Artemis missions.

The VA Office of Inspector General (OIG) assessed allegations at the Richard L. Roudebush VA Medical Center (facility) that a newly trained interventional cardiologist was hired despite poor training and references. Further allegations claimed that the interventional cardiologist provided poor quality of care to patients and that facility leaders did not respond to staff concerns regarding this provider.The OIG did not substantiate that the interventional cardiologist was hired despite poor training and references, but identified deficiencies in the processes used to credential, privilege, and evaluate performance of the interventional cardiologist. Inexperienced staff used a third-party wage verification form instead of the required verification directly from the school or program director to verify completion of an interventional cardiology fellowship training program.The OIG did not substantiate that the interventional cardiologist provided poor quality of care to patients that resulted in adverse clinical outcomes. Despite staff complaints of clinical concerns related to the interventional cardiologist, none identified instances of adverse clinical outcomes related to poor patient care.The OIG did not substantiate that facility leaders failed to act on staff members’ concerns about the interventional cardiologist’s practice. As a result of multiple concerns shared with facility leaders by cardiology nursing staff, the interventional cardiologist’s cardiac catheterization laboratory privileges were suspended and a factfinding investigation was initiated. The OIG found that actions taken were not done timely.While not an allegation, the OIG determined that the volume of percutaneous coronary intervention (PCI) procedures performed at the facility was not sufficient to maintain interventional cardiologists’ competence and patient safety.Five recommendations were addressed to the Facility Director related to credentialing and privileging, mentoring newly trained interventional cardiologists, focused professional practice evaluations, factfinding investigations, and PCI procedure volume.

Florida residents Jean Barbier and Bryan DeCastro pleaded guilty to conspiracy to commit wire fraud on January 10, 2023, and January 17, 2023, respectively, in U.S. District Court, Southern District of Florida. Both defendants were employed by a company contracted by Amtrak to provide food services. Our investigation found that DeCastro fraudulently altered the timecards of Barbier and another individual to make it appear they worked more hours than they did, resulting in payment for hours they did not work. Barbier then paid DeCastro kickbacks for falsely inflating the timecards. Both defendants are scheduled to be sentenced on a future date.

Our objective was to determine whether the University of Cincinnati (University) used the Student Aid (Assistance Listing Number (ALN) 84.425E) and Institutional (ALN 84.425F) portions of its Higher Education Emergency Relief Fund (HEERF) funds for allowable and intended purposes.The University spent $109.9 million (83 percent) of its total HEERF allocation of $132.8 million as of September 30, 2021. The University generally used the Student Aid ($42.1 million) and Institutional ($67.8 million) portions of its HEERF grant funds for allowable and intended purposes but needs to strengthen its review and documentation processes for its use of Student Aid grant funds and certain other processes to ensure compliance for its use of Institutional grant funds. We also found that the University did not fully comply with cash management and reporting requirements.

What We Looked AtTunnels are important parts of the Nation’s highway infrastructure. According to the Federal Highway Administration (FHWA)—the Agency responsible for overseeing tunnels—an average of 15 million vehicles a day travel through more than 500 tunnels on public roads across the country. The majority of these tunnels have exceeded their designed service lives, and timely and reliable inspections help detect safety problems and prevent failures. The Moving Ahead for Progress in the 21st Century Act of 2012 (MAP-21) required FHWA to implement a tunnel safety program. Given the importance of FHWA’s role in tunnel safety, we conducted this audit to assess the Agency’s progress in implementing its tunnel safety program. Specifically, we focused on FHWA’s (1) maintenance of a national tunnel inventory, (2) compliance review process, and (3) monitoring of critical risks to tunnel safety.What We FoundFHWA has made progress implementing a comprehensive tunnel safety program as required by MAP-21 by establishing a national tunnel inventory, inspection standards, training for tunnel inspectors, and annual compliance reviews. However, we found that FHWA’s national tunnel inventory is incomplete because the Agency has not provided clear guidance to its Divisions and the State DOTs on how to classify some types of structures as tunnels and verify that they have inventoried all tunnels. Inaccurate and unreliable data also persist in the inventory due to inadequate data processing procedures that do not flag errors or require corrections. In addition, some internal controls for FHWA’s tunnel safety compliance review process are ineffective, resulting in compliance determinations that do not reflect the severity of deficiencies or adhere to the Agency’s review criteria. Lastly, FHWA has created an internal database to monitor critical tunnel safety risks, but the database lacks a clear scope and detailed guidance to help ensure that Division staff input complete and accurate data.Our RecommendationsWe made 12 recommendations to help FHWA improve the implementation of its tunnel safety program. FHWA concurred with seven recommendations and partially concurred with the other five. In response, we requested that FHWA clarify and reconsider its actions. 

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 Midwest district 3 zone 3 and four selected vet centers: Columbia, Missouri; Fargo, North Dakota; Omaha, Nebraska; and Sioux Falls, South Dakota. 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 and implemented quality improvement programs in response to VA All Employee Survey results. District 3 zone 3 Vet Center Service Customer Feedback survey results exceeded national scores. The OIG issued one recommendation to the District Director related to annual training. The OIG closed the recommendation because overdue trainings were completed and future trainings were scheduled.The OIG conducted an analysis of vet center quality reviews required to ensure compliance with policy and procedures. The OIG made two recommendations to the District Director for clinical and administrative quality reviews. The OIG made two recommendations specific to morbidity and mortality reviews: one recommendation to the District Director and one to the Readjustment Counseling Service Chief Officer (RCS).The suicide prevention review included zone-wide evaluation of electronic client records, and a focused review of the four selected vet centers. The OIG issued seven recommendations—six specific to electronic client records and one 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, audits, and training, and issued four recommendations.The environment of care review evaluated the four selected vet centers. The OIG made two recommendations.

This Office of Inspector General Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the outpatient care provided at the El Paso VA Health Care System in Texas. This evaluation focused on four key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of careThe OIG issued three recommendations for improvement in two areas:1. Quality, safety, and value• Patient safety events2. Medical staff privileging• Focused and Ongoing Professional Practice Evaluations

The Office of Inspector General (OIG) Care in the Community healthcare inspection program examines clinical and administrative processes associated with providing quality outpatient healthcare to veterans. This report provides a focused evaluation of Veterans Integrated Service Network (VISN) 7 and its oversight of the quality of care delivered in community-based outpatient clinics and through its community care referrals to non-VA providers. Although it is difficult to measure the value of well-delivered and coordinated care between VA and non-VA providers, the findings in this report may help VISN leaders identify vulnerable areas of community care that, if properly addressed, should improve healthcare quality for veterans.The OIG reviewed care coordination (congestive heart failure management), primary and mental health care (diagnostic evaluations following positive screenings for depression or alcohol misuse), quality of care (home dialysis), and women’s health (mammography care and communication of results). The OIG issued two recommendations for improvement in two areas, quality of care and women’s health:• Monitoring the quality of home dialysis contracted clinical services for patients receiving non-VA home dialysis services• Ensuring that ordering providers communicate normal mammography results to patients within 14 calendar days

The objective of our audit was to determine the extent to which Federal Student Aid (FSA) had processes for planning and managing the transition to the Next Generation (Next Gen) loan servicing environment to achieve the project’s intended outcomes.Although FSA had processes in place for planning and managing the transition to the Next Gen loan servicing environment, FSA did not perform key steps within those processes or follow best practices for acquisition planning that could have better ensured the proper planning and managing of the transition.

NASA utilizes thousands of software products from hundreds of vendors, enabling Agency scientists and engineers to drive advances in science, technology, aeronautics, Earth studies, and human and space exploration. In this audit we assessed whether NASA is managing its software assets in an effective and efficient manner while maintaining compliance with applicable requirements and security best practices.

Since our 2020 audit, the Department of Homeland Security has made progress towards fulfilling the 13 responsibilities in the GDA.

What We Looked AtFAA relies on its highly-trained Air Traffic Control Specialists (ATCS) to safely and efficiently manage the flow of air traffic across the National Airspace System. In 2012, FAA undertook a review of the ATCS hiring process that identified the need to update its ATCS pre-employment test. In response, FAA deployed the Air Traffic Skills Assessment (ATSA) test in November 2016. The National Defense Authorization Act for Fiscal Year 2020 mandated that the Office of Inspector General (OIG) assess the assumptions and methodologies used to develop the ATSA. Accordingly, we initiated this audit to assess FAA’s (1) validation of the assumptions and methodologies used to develop the air traffic controller pre-employment test and (2) administration of the test and its plans to evaluate the test’s effectiveness in identifying successful ATCS candidates. What We FoundFAA has taken steps to validate the assumptions and methodologies used to develop the ATSA. FAA worked with a human resource consulting organization, APTMetrics, to identify the critical skills, abilities, and other characteristics (SAO) required to perform important ATCS responsibilities. FAA then worked with APTMetrics, NATCA, and various subject matter experts to ensure that the ATSA evaluates the SAOs required for entry level ATCS. Also, the ATSA identifies sufficient applicants to meet FAA’s trainee hiring goals but the Agency has not established a plan for evaluating the ATSA’s effectiveness. As a result, it is unclear whether the test is effective at helping the Agency identify successful ATCS candidates. Furthermore, FAA’s lengthy hiring process and COVID-19 restrictions have slowed FAA’s onboarding and training activities for newly hired ATCS. As a result, few applicants who have taken the ATSA and were selected as trainees have completed their training and obtained certification. Our RecommendationsFAA concurred with our recommendation that the Agency evaluate the ATSA’s effectiveness in identifying successful ATCS candidates. We consider the recommendation resolved but open pending completion of the planned actions.

The Postal Service has weathered tremendous changes since the turn of the 21st century. Despite financial challenges and declining mail volume, USPS remains a foundational institution that continues to deliver for the people of this country.In this white paper, the OIG sought to provide a high-level overview of the Postal Service’s operational environment since 2000. The paper identifies major postal trends over the past 22 years and contextualizes those trends against the broader social, economic, and legislative environment.

An Amtrak vendor in Boston, Massachusetts, did not properly secure and protect Wright Express (WEX) fuel cards assigned to three vehicles, which Amtrak leases from the General Services Administration (GSA). This resulted in GSA billing the company for fraudulent or otherwise inappropriate transactions totaling $2,745. The company’s contract requires the vendor and its onsite employees to comply with the company’s policies concerning conduct and security. The contract also states that the vendor will be exclusively responsible for the theft or loss that occurs as a result of their failure to maintain adequate security. The vendor agreed to reimburse Amtrak $2,745 for the fraudulent charges. On January 10, 2023, Amtrak management implemented procedures to ensure compliance and proper use of the WEX fuel cards.We also determined that the vendor’s failure to adequately control the WEX cards allowed a former vendor driver to use these fuel cards to fuel his personally owned vehicles for fraudulent fuel purchases totaling $760. The vendor terminated the driver on October 28, 2022.

EAC OIG requested that the Department of Interior OIG investigate allegations that an administrative officer for EAC improperly signed contracts for EAC when she did not have a contracting officer warrant.

This report presents the results of our self-initiated audit of the efficiency of operations at the Delaware Processing and Distribution Center (P&DC) in Wilmington, DE. We conducted this audit to provide U.S. Postal Service management with timely information on operational risks at this P&DC. We selected the Delaware P&DC based on Congressional interest in Delaware and concerns raised during a recent House Oversight and Reform Committee hearing. The Delaware P&DC is in the Chesapeake Division and processes letters, flats, and parcels. The Delaware P&DC services multiple 3-digit ZIP Codes in urban and rural communities.

This report presents the results of our audit of efficiency of operations at the Philadelphia Processing and Distribution Center (P&DC) in Philadelphia, PA. We conducted this audit to provide U.S. Postal Service management with timely information on operational risks at this P&DC. We selected the Philadelphia P&DC based on a Congressional request from Senator Robert P. Casey Jr. and Representative Dwight Evans. The Philadelphia P&DC is in the Chesapeake Division; and processes letters, flats, and parcels; and services multiple 3-digit ZIP Codes in urban and rural communities.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Germantown Station in Philadelphia, PA. The Germantown Station is in the Delaware-Pennsylvania 2 District of the Atlantic Area and services ZIP Codes 19119 and 19144. These ZIP Codes serve about 71,239 people in a predominantly urban area. This unit has 58 city routes. We judgmentally selected the Germantown Station based on a request from Senator Robert P. Casey and Representative Dwight Evans.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Logan Station in Philadelphia, PA. The Logan Station is in the Delaware – Pennsylvania 2 District of the Atlantic Area and services ZIP Codes 19126 and 19141. These ZIP Codes serve about 48,708 people in an urban area. This delivery unit has 28 city routes. We judgmentally selected the Logan Station based on the number of Stop-the-Clock scans occurring at the delivery unit, rather than at the customer’s point of delivery, and i¬¬ndicators for undelivered mail.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the North Philadelphia Station in Philadelphia, PA. The North Philadelphia Station is in the Delaware- Pennsylvania 2 District of the Atlantic Area and services ZIP Codes 19121, 19132, and 19133. These ZIP Codes serve about 99,657 people and are considered to be an urban area. This delivery unit has 49 city routes. We judgmentally selected the North Philadelphia Station based on the number of Stop the-Clock scans occurring at the delivery unit, rather than at the customer’s point of delivery, and indicators for undelivered mail.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Marshallton Branch in Wilmington, DE. The Marshallton Branch is in the Delaware-Pennsylvania 2 District of the Atlantic Area and services ZIP Code 19808. This ZIP Code serves about 38,296 people and is considered to be an urban area. This delivery unit has 33 city routes. We selected the Wilmington, DE area based on Congressional interest in Delaware and concerns raised during a recent House Oversight and Reform Committee hearing. We judgmentally selected the Marshallton Branch based on the number of Stop the-Clock scans occurring at the delivery unit, rather than at the customer’s point of delivery, and indicators for undelivered mail.