Federal Reports

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We audited the U.S. Department of Housing and Urban Development (HUD) to determine whether HUD had adequate oversight of the physical condition of the public housing units that converted to non-Federal Housing Administration (FHA)-insured project-based vouchers (PBV) under RAD.

We found HUD needs to improve its oversight of the physical condition of converted projects.  Before the implementation of its PBV monitoring pilot program, HUD performed limited monitoring of RAD PBV projects.  HUD also did not have a standardized process for monitoring the projects for compliance with its requirements.  Additionally, for converted units that were PHA owned, HUD did not consistently receive required housing quality standards (HQS) inspection reports.

These conditions occurred because HUD did not specifically target converted projects for review.  It also did not have a system to collect and maintain information about the physical and financial condition of RAD PBV projects.  Instead, HUD relied on the contract administrators (PHAs) to oversee the converted projects.  Additionally, HUD did not have a protocol or procedures for its field offices to ensure that HQS inspection reports for PHA-owned projects had been received and reviewed, as applicable, before HUD eliminated the requirement in June 2024.  

As a result of HUD’s limited monitoring and lack of a system to collect and maintain data, HUD did not have information to assess whether the contract administrators effectively performed their oversight responsibilities of ensuring that (1) families resided in units that were decent, safe, and sanitary; (2) the converted projects’ reserve for replacement accounts were sufficiently funded to address extraordinary maintenance, repair, and replacement of capital items; and (3) project owners’ withdrawals from reserve accounts were appropriate.  When we inspected a sample of RAD PBV units from 28 converted projects associated with three PHAs, we found that more than 74 percent of the units failed to meet HQS.  Further, based on our calculations, the reserve for replacement accounts for 12 of the 28 projects were underfunded.  Therefore, unless HUD specifically selects projects for review, it is unable to adequately monitor the long-term sustainability of these projects.

We made several recommendations to HUD to improve its oversight of projects converted under RAD.  Specifically, we made recommendations related to (1) targeting projects for review and developing policies and procedures for monitoring, (2) reviewing reserve for replacement accounts to ensure sufficient account balances and compliance with applicable HUD requirements, (3) implementing a process to ensure reserve for replacement requirements in HUD’s business documents are consistent for converted projects, and (4) collecting data on projects’ reserve for replacement accounts to support the Office of Field Operations’ monitoring activities.  We also made a recommendation for HUD to provide inspection reports showing that units meet HUD’s current physical condition standards.

The Pandemic Response Accountability Committee’s (PRAC) Semiannual Report to Congress, covering the period from October 1, 2024 through March 31, 2025.

The OIG’s Mental Health Inspection Program (MHIP) evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on care delivered on the inpatient mental health unit at the VA Salem Healthcare System in Virginia. 

The inpatient unit had some aspects of a recovery-oriented physical environment, including artwork, natural lighting, and secure outdoor spaces. The local recovery coordinator was integrated into recovery-oriented activities and staff provided the required interdisciplinary programming on weekdays but not on weekends. 

The facility had an established local Mental Health Executive Council; however, the OIG could not verify that all required participants attended meetings. The facility had an admission procedure that addressed involuntary hospitalization but lacked a written process to monitor and track compliance with involuntary commitment state laws. 

Staff involved veterans in treatment planning, but did not comply with requirements to document medication risks and benefits discussions. Staff also did not consistently complete suicide screening within 24 hours before discharge, complete or review safety plans, or consistently address ways to make veterans’ environments safer from lethal means beyond access to firearms and opioids. Many staff did not have evidence of completed lethal means safety and suicide risk trainings. Additionally, most discharge instructions included abbreviations that could be difficult for veterans to understand.

The OIG was unable to determine whether Interdisciplinary Safety Inspection Team members completed the required environment of care training. Staff reported using a restraint chair; while the facility had a local policy on the use of restraints, it did not include the use of restraint chairs. 

As a result of its findings, the OIG issued 15 recommendations to facility leaders. These recommendations, once addressed, may improve the quality and delivery of veteran-centered, recovery-oriented care on the inpatient mental health unit.

The OIG’s Mental Health Inspection Program (MHIP) evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on inpatient care delivered at the VA Philadelphia Healthcare System (facility) in Pennsylvania.

The facility met some VHA requirements for the inpatient mental health unit, such as completion of twice-yearly environment of care inspections, and had some aspects of a recovery-oriented environment. However, not all areas met VHA standards for a safe, hopeful, and healing setting. Facility leaders did not establish written processes for staff to accompany veterans on outdoor breaks.

The facility did not have an established mental health executive committee for local oversight or a plan for continued transformation to recovery-oriented services. Additionally, inpatient staff did not offer the required daily hours of interdisciplinary programming. Facility leaders did not have formal written guidance to monitor and ensure compliance with state involuntary commitment laws. 

Not all electronic health records (EHRs) reviewed included documentation of a treatment plan. Most EHRs did not have evidence of required discussions with veterans on the risks and benefits of prescribed medications. Some EHRs did not have evidence of timely suicide risk screenings. Most reviewed safety plans did not address ways to make the environment safer from potentially lethal means beyond access to firearms and opioids. 

Inpatient unit clinical staff were compliant with suicide prevention trainings, but nonclinical staff did not consistently complete the required training.

The Interdisciplinary Safety Inspection Team did not adhere to VHA requirements, including staff’s completion of annual environmental safety hazards training, and did not address safety hazards, including ligature risks.

The OIG issued 20 recommendations to the Facility Director, Chief of Staff, and Associate Chief of Staff for Behavioral Health. These recommendations, once addressed, may improve the quality and delivery of veteran-centered, recovery-oriented care on the inpatient mental health.

The Smithsonian Institution (Smithsonian) relies on funding from external sponsors such as governments, foundations, and corporations to support projects that further its mission to increase and diffuse knowledge.

The Office of Sponsored Projects (OSP) provides centralized support, guidance, and training for Smithsonian units receiving sponsored project funding. Together they manage sponsored projects in compliance with Smithsonian policies and procedures and sponsors’ terms and conditions.

OSP oversaw $189 million in sponsored project funding provided during fiscal years 2022 and 2023. 

This audit determined the extent to which OSP and recipient units complied with: (1) Smithsonian policies and procedures and (2) sponsors’ terms and conditions concerning administering and overseeing sponsored projects.

OIG reviewed a sample of 25 sponsored projects totaling $33.8 million—approximately 18 percent of sponsored project funding provided through OSP in fiscal years 2022 and 2023. OIG also analyzed OSP’s sponsored project universe for balances and transactions determined to be of higher risk of noncompliance. 

During the two fiscal years under audit, OSP managed a 65 percent increase in sponsored project funding while maintaining high-quality service reported by Smithsonian units. However, OIG identified opportunities to improve the administration and oversight of projects throughout their lifecycle. 

The Postal Regulatory Commission (PRC) is an independent establishment of the executive branch that exercises regulatory oversight of the U.S. Postal Service. The PRC offers a range of benefits to its employees including, but not limited to, transit benefits, bonuses, time-off-awards, telework, remote work, flexible work schedules, recruitment and retention incentives, and paid leave. By providing these options, the PRC seeks to attract and retain a high-performing, varied workforce with workplace flexibility.

In August 2023, the Office of Inspector General received an allegation that a contractor had not provided any deliverables supporting the National Nuclear Security Administration’s (NNSA) $90 million Safety, Analytics, Forecasting, Evaluation, and Reporting (SAFER) system. The allegation claimed that the project was halfway through its 5-year contract period, but it had been “staggeringly unproductive given the money spent.” 

We initiated this inspection to determine the facts and circumstances regarding alleged productivity weaknesses and lack of deliverables from the contractor supporting NNSA’s SAFER system.

We did not substantiate the allegation that a contractor had productivity weaknesses and had not provided any deliverables on its project with NNSA. However, we identified inadequate project planning and management of the SAFER system by NNSA. For instance, key performance indicators were not developed to measure project success. In addition, user acceptance criteria was not established to measure the success of the development process and ensure that delivered functionality aligned with user requirements. Further, a required Contractor Performance Assessment Report was not completed for the base year of the contract but was completed in subsequent years.   

Based on feedback provided by SAFER users and a lack of acceptance criteria to measure the success of the development process for the safety programs, we question whether SAFER is meeting user needs. Although not fully implemented, we were unable to obtain evidence that SAFER had produced widespread benefits and improved oversight across the NNSA enterprise.

As a result of the weaknesses identified, NNSA may be unable to determine the overall health of its safety programs and potential improvements needed to those programs. The lack of progress in completing actions outlined in the Federal Data Strategy may also have hindered effective data-driven decision making. Without improvements, NNSA may continue to encounter weaknesses related to managing the SAFER project, which could delay project progress.

We made three recommendations related to establishing quantifiable metrics to measure the performance of NNSA’s investments and ensuring that data management practices and project management requirements are followed. These recommendations should improve the management of the SAFER project and help inform future technology projects.  

The National Endowment for the Humanities (NEH) Office of Inspector General (OIG) reviewed established policies and procedures for the audit function of U.S. AbilityOne (AbilityOne) OIG in effect at September 30, 2024.  Based on our review, the established policies and procedures for the audit function at September 30, 2024, were current and consistent with applicable professional standards, as stated.

In addition to reviewing established policies and procedures for the audit function of AbilityOne OIG, we applied certain limited procedures in accordance with guidance established by the Council of the Inspectors General on Integrity and Efficiency (CIGIE) Guide for Conducting Peer Reviews of Audit Organizations of Federal Offices of Inspector General related to AbilityOne OIG’s monitoring of generally accepted government auditing standards (GAGAS) engagements performed by Independent Public Accountants (IPAs) under contract where the IPA served as the auditor.  It should be noted that monitoring of GAGAS engagements performed by IPAs is not an audit; therefore, it is not subject to the requirements of Government Auditing Standards.  The purpose of our limited procedures was to determine whether AbilityOne OIG had controls in place to ensure that IPAs performed contracted work in accordance with professional standards.  We conclude that AbilityOne OIG has such controls in place.  

Our objective was not to express an opinion; accordingly, we do not express an opinion on AbilityOne OIG’s monitoring of work performed by IPAs.

Why We Did This Report

Under the Infrastructure Investment and Jobs Act, or IIJA, the U.S. Environmental Protection Agency was provided with over $60 billion in appropriations for Agency programs, including the Clean Water and Drinking Water State Revolving Fund Programs, the Superfund Program, geographic programs, and more. Since the IIJA’s enactment, the EPA Office of Inspector General has been conducting timely and relevant oversight to ensure that IIJA funds—taxpayer dollars—are used effectively. Our third annual IIJA progress report covers February 1, 2024, through January 31, 2025, and provides an update on our oversight of the EPA’s use of IIJA funds.

Summary

This report provides updates on the oversight work the OIG planned, initiated, or completed during its third year of IIJA oversight. It also details the OIG’s declaration of 2025 as the “Year of Innovation” and highlights the OIG's continued efforts to engage IIJA stakeholders. 

Why We Did This Report

This fourth edition of the U.S. Environmental Protection Agency Office of Inspector General’s Infrastructure Investment and Jobs Act Oversight Plan summarizes our ongoing and planned audits, evaluations, and other engagements concerning the EPA’s implementation of the Infrastructure Investment and Jobs Act, Pub. L. No. 117-58 (2021).

Summary 

This document provides an update to our plan for oversight of the EPA’s implementation of the IIJA.

The 24 projects summarized in this plan relate to the EPA’s IIJA implementation work, although some of these projects have received or will receive partial support from annual appropriations. The appendix to this IIJA Oversight Plan illustrates which of the EPA’s IIJA programs our 24 projects address.

We concluded that the postsecondary institutions’ written policies complied with laws and policies, but documentation and training could be improved.

Final Management Letter: Potential Opportunity to Consolidate the SEC’s Disclosure Review Information Technology Systems

The Tennessee Valley Authority (TVA) has developed a dam safety program to protect lives and property by ensuring that structures within the program are designed, constructed, and maintained as safely and reliably as practicable.  This program applies to dams, dikes, impoundments, levees, water barrier components, pumping stations, and other appurtenant structures that are included in TVA’s Dam Safety Program inventory.  Due to the importance of maintenance and inspections to the reliable operation of assets, we performed an evaluation of TVA dams to determine if maintenance and inspections had been performed in accordance with established schedules.  TVA has generally performed maintenance but has not performed all inspections in accordance with established schedules for TVA dams.  We identified 43 inspections that were between 1 and 99 months late and 33 that were not performed.  We also determined that TVA had not taken actions to address 34 recommendations from inspections completed in fiscal years 2022 through 2024 or the most recent risk assessments.  Additionally, we identified some areas where governance could be improved related to inaccuracies in inspection manuals and inspections.

Customers can receive mail and packages from the U.S. Postal Service in a variety of locations, including through private mailboxes at Commercial Mail Receiving Agencies (CMRA). Over 1.6 million customers nationwide (through nearly 12,000 CMRAs) were registered for this service as of February 2025. The Postal Service does not collect any related revenues but manages CMRA applications, quarterly reporting, mail sample tests, and overall program data quality. In 2018, we reported that insufficient oversight made CMRAs vulnerable to drug traffickers, and the Postal Service subsequently invested in an automated database to better track and monitor CMRA documentation.

An Amtrak Passenger Conductor based in Philadelphia, Pennsylvania, pleaded guilty on June 24, 2025, in U.S. District Court, Eastern District of New York, to one count of wire fraud involving the fraudulent submission and subsequent receipt of $52,500 for two Paycheck Protection Program (PPP) loans and one Economic Injury Disaster Loan. The employee’s spouse pleaded guilty on May 20, 2025, to one count of wire fraud involving the fraudulent submission of three PPP loans and the subsequent receipt of $53,845. Our investigation found that the couple provided fraudulent documents and made false representations to obtain the loans totaling $106,345 to which they were not entitled.

An Amtrak director based in Chicago, Illinois, received verbal counseling on June 24, 2025, as the result of our investigation. We found that the employee violated company policies by failing to properly off-board a former employee upon termination and by failing to secure the former employee’s company-issued property.

NASA leads the nation’s planetary defense efforts to address the potential hazards of asteroids and comets impacting Earth. While the Agency has made significant progress in its planetary defense mission, multiple challenges hinder its ability to fully execute its planetary defense strategic goals. Further, actions are needed to address the role of ground-based assets in the future as new observatories with more advanced capabilities come online.  

AmeriCorps OIG initiated this investigation after receiving a referral from OIG’s Office of Audits. The referral alleged that, in 2019, Delaware’s Governor's Commission on Community & Volunteer Service, an AmeriCorps State and National Program grantee also known as Volunteer Delaware, was not providing adequate oversight of its subrecipient, Delaware’s Division of Parks and Recreation (DPR). AmeriCorps OIG found that Volunteer Delaware did not provide adequate monitoring of DPR and that DPR falsely certified AmeriCorps members’ education awards even though service hours had not been performed, were outside the scope of the grant, were adjusted after service, or were otherwise questionable such as having duplicate entries or excessive hours in a day. The OIG also found that DPR shortened the terms of service for some members who exited the program before completing their original approved terms of service, which allowed those members to collect education awards to which they otherwise would not have been entitled. The case resulted in a disallowance of $111,369.

Our Objective(s)To evaluate PHMSA's (1) collection and tracking of hazardous materials (HazMat) registration fees and (2) monitoring and reporting of grantees' use of funds for the Hazardous Materials Emergency Preparedness (HMEP) Grant Program.
Why This AuditPHMSA administers grants, for emergency planning and first responder training related to the transport of HazMat. To fund these grants, PHMSA collects fees from HazMat transporters for their required annual registrations. We conducted this audit due to a recent significant increase in HazMat grant funding authorized under IIJA and the important roles the grants play in preparation for and response to emergency HazMat incidents.
What We FoundPHMSA's processes for registration fee collection and data tracking make data verification difficult.

PHMSA uses an online registration portal to collect registrants' data and fees to support the HazMat Grant Program. The Agency requires registrants to determine their business' sizes using the Small Business Administration's (SBA) business-size regulations and then self-certify the accuracy of their data. These SBA business-size regulations include complex variables and increase the risk for inaccurate fee assessments.
Data quality issues impact PHMSA's ability to monitor the quantity and accuracy of the information in its registry. PHMSA could not readily explain why the data issues we found"such as business size and fee mismatches"occurred. A PHMSA standard operating procedure (SOP) includes a daily error reporting process to identify data quality issues, but staff were unfamiliar with and could not locate any daily error reports or anyone who was familiar with them.

PHMSA did not always comply with its grant monitoring procedures or congressional reporting requirements.

PHMSA did not always complete all monitoring activities as required by its HazMat Grants SOP. Forty of 64 (62.5 percent) low and medium risk grantees we evaluated did not receive required annual spot checks, and 25 of 43 (58.1 percent) medium and high-risk grantees did not receive required desk reviews. PHMSA also did not receive or review all grantees' financial and performance reports in a timely manner.
PHMSA did not meet the annual reporting requirements to Congress but has implemented a redesign of its report and data collection process to meet these requirements.

RecommendationsWe made four recommendations to improve PHMSA's oversight of HMEP grants.

The U.S. Postal Service transitioned its primary air cargo contract from one carrier to another on September 30, 2024, to further align its transportation strategy with anticipated Delivering for America network changes. This new agreement, valued at approximately $10 billion for the contracting period, is expected to streamline operations by consolidating volumes and reducing overall transportation costs. During the first quarter of fiscal year (FY) 2025, the Postal Service assigned 7 percent less volume to the air network and reduced spending by 43 percent compared to FY 2024.

An assistant passenger conductor based in Kansas City, Missouri, resigned from his position on June 23, 2025, as a result of our investigation. We found that he violated company policies by engaging in a sex act with a passenger while in the performance of his official duties—as the train was in operation. He allegedly extorted the passenger for a sexual favor. During an interview, the former employee admitted to receiving oral sex from the passenger but claimed that it was consensual. He also admitted that he previously engaged in sexual activity with other passengers on three or four other occasions. The former employee is not eligible for rehire.

We audited Flat Branch Mortgage, Inc., to evaluate its quality control (QC) program for originating and underwriting Single Family FHA-insured loans.  Our audit covered the period October 2020 through September 2022.  We selected Flat Branch for review based on its loan volume and delinquency rate and because its rate of self-reporting loans to HUD when it identified fraud, material misrepresentations, and other material findings that it could not mitigate was below average for more than a 5-year period.

We found that Flat Branch’s QC program for originating and underwriting FHA-insured loans was not sufficient.  Specifically, Flat Branch (1) did not select the proper number of loans for review and maintain complete and accurate data to document its loan selection process; (2) did not complete all loan reviews in a timely manner; (3) did not always complete key review steps and sometimes missed material deficiencies; and (4) did not adequately assess, mitigate, and report loan review findings, which included self-reporting loans to HUD when required.  These issues occurred because Flat Branch had insufficient controls over its QC program, was not always familiar with HUD requirements, and experienced staffing constraints.  As a result, HUD did not have assurance that Flat Branch’s QC program fully achieved its intended purposes, which include, among other things, protecting the FHA insurance fund and lender from unacceptable risk, guarding against fraud, and ensuring timely and appropriate corrective action.

We recommend that HUD require Flat Branch to (1) update its QC plan and related procedures to align with HUD requirements; (2) provide training to staff and management on HUD requirements for lender QC programs; (3) review the loans that it had not selected and take appropriate actions when applicable; (4) obtain credit reports and reverifications of borrower information for QC reviews in which it did not complete these steps and evaluate the risk of findings identified for these loans; and (5) evaluate its QC files for the loans in which it identified material findings to confirm whether it self-reported to HUD all findings of fraud or material misrepresentation, along with any other material findings that it did not acceptably mitigate.

Our investigation determined that a Clerk based in New Brunswick, New Jersey, violated company policies by using her company-issued computer and other company equipment, such as printers and copiers, to conduct personal business by selling items online on company time. We also confirmed that she was selling company property on Poshmark for personal profit. She was terminated on June 20, 2025, and she is not eligible for rehire.

New York based health care providers Muhammad Mirza, a medical doctor, and Punson Figueroa, an acupuncturist, were excluded June 19, 2025, from participating in federal health care programs by the Health and Human Services Office of Inspector General (HHS OIG). The two providers previously pleaded guilty for their participation in an Amtrak-OIG investigated health care fraud conspiracy in which they conspired with dozens of Amtrak employees to use the employees’ health insurance information to file fraudulent claims. In exchange, the two providers paid cash kickbacks to the employees.

Mirza was sentenced on May 10, 2024, to 26 months in prison and ordered to pay restitution of $1.37 million, and Figueroa was sentenced on September 26, 2024, to 34 months in prison and ordered to pay restitution of $9.05 million. Both Mirza and Figueroa were excluded from participating in federal health care programs for 25 and 30 years, respectively.

The U.S. AbilityOne Commission (AbilityOne) Office of Inspector General (OIG) conducted an investigation of employee conduct in response to a complaint received.

Agency program officials, chief information officers, and inspectors general must annually review information security programs and report to the Department of Homeland Security and Congress on agency compliance with the Federal Information Security Modernization Act (FISMA). The OIG contracted with an independent public accounting firm, CliftonLarsonAllen LLP (CLA), to evaluate VA’s information security program for FY 2024. After assessing 49 major applications and general support systems hosted at 23 VA facilities and on the VA Enterprise Cloud, CLA concluded that VA continues to face significant challenges meeting FISMA requirements because of the nature and maturity of its information security program.

The audit found continuing deficiencies related to access controls, configuration management controls, security management controls, and service continuity practices designed to protect mission-critical systems from unauthorized access, alteration, or destruction. These deficiencies can be remedied by addressing security-related issues that contributed to the information technology material weakness reported in the FY 2024 audit of VA’s consolidated financial statements; improving the deployment of security patches, system upgrades, and system configurations; improving performance monitoring to ensure controls operate as intended; and communicating identified security deficiencies to appropriate personnel.

Of CLA’s 23 recommendations, VA concurred with 12 and did not concur with 11. Some of the 23 recommendations addressed repeat deficiencies from previous FISMA reports spanning multiple years. CLA will follow up on the outstanding recommendations and evaluate the adequacy of corrective actions in the FY 2025 audit of VA’s information security program.

To learn how communities across the nation responded to the pandemic, we initiated a multi-part review of six communities—two cities, two rural counties, and two Tribal reservations. This report is the sixth community-specific report and focuses on our work in Jicarilla Apache Nation Reservation in New Mexico, where we previously identified that recipients, including city government, small businesses, and individuals, received almost $80 million from 42 pandemic relief programs and subprograms. This report provides a closer look at ten pandemic programs and subprograms provided to Jicarilla Apache Nation Reservation by six federal departments.

The purpose of this report is to provide the results of our survey of the Peace Corps’ compliance with the anti-gag provision requirement in the Whistleblower Protection Enhancement Act (WPEA) (5 U.S.C. § 2302(b)(13)). We initiated this assessment at the request of Senator Chuck Grassley. (See attached Senator Grassley Letter, dated March 11, 2024). 

The audit objective was to determine if the U.S. Nuclear Regulatory Commission (NRC) is effectively managing and monitoring selected research and development grants in accordance with applicable federal requirements, agency policies and guidance, and award terms and conditions.

The OIG found that the NRC was not effectively managing or monitoring selected research and development grants.  Specifically, the OIG found that staff in the Office of Nuclear Regulatory Research assumed grants officer responsibilities without a grants officer appointment or through a delegation as a grants officer representative.  We also found that NRC staff did not request or review source documents to support equipment purchased using grant funds.  Additionally, we found that the NRC does not have a public repository for final performance reports or other means to share the results of federally funded research grants.

The OIG further determined that the grants officer had not ensured that all relevant documents were contained in the official grant files; 11 grants were not closed out within one year of the performance end date and the NRC had not deobligated more than $321,000 in funds that could have been put to better use; and, grants awarded through the Integrated University Program (the predecessor to the University Nuclear Leadership Program) with periods of performance ending in 2021 and 2022 had more than $920,000 of funds that were not deobligated and could be put to better use.  The report contains nine recommendations to improve management and monitoring of research and development grants. 

The Office of the Inspector General conducted an audit of TVA’s cloud inventory due to the Tennessee Valley Authority’s (TVA) increased use of cloud services.  Our objective was to determine if TVA maintained an accurate and complete cloud inventory.  Although we determined TVA’s (1) defined processes related to managing cloud inventory were designed in alignment with identified best practices, and (2) access controls for the cloud inventory were operating effectively, TVA does not maintain an accurate and complete cloud inventory.  Specifically, (1) cloud services procured outside of the IT organization’s procurement process were not included in inventory, (2) reconciliation controls did not include all available sources to identify cloud services, and (3) required fields in existing inventory data were incomplete. 

This report, specifically identifies Center for Internet Security, a nongovernmental organization/business entity.  Pursuant to the James M. Inhofe National Defense Authorization Act for Fiscal Year 2023, Pub. L. No. 117-263 §5274, any such organization may submit a written response to the report within 30 days, clarifying or providing additional context for each instance within the report in which the organization is specifically identified.  Any response provided for that purpose will be appended to the final, published report.  If you have any questions about this process, please contact Jeffrey McKenzie at (865) 633-7374 or jtmckenzie@tvaoig.gov within 30 days of publication.

OIG reviewed APHIS’ Horse Protection Act horse show inspection and disqualification processes. 

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the Hershel “Woody” Williams VA Medical Center in Huntington, West Virginia. 

This evaluation focused on five key content domains:
     •    Culture
     •    Environment of care
     •    Patient safety
     •    Primary care
     •    Veteran-centered safety net

The OIG issued one recommendation for improvement in one domain:
   1.    Environment of care
     •    Safe and clean environment

To view this interactive report, visit: https://oig.justice.gov/reports/concurrent-inspections-bop-food-service-operations

The Office of Inspector General is issuing this inspection report to assess the U.S. Small Business Administration’s (SBA) initial response to Hurricane Helene, including staffing, loan application volume, and timeliness of disaster loan approvals.

We found that in SBA’s initial disaster assistance response to Hurricane Helene, the agency promptly established a field presence, adequately staffed recovery centers, responded timely to applicant queries, and processed loans in a timely manner.

We found that SBA processed loan applications in 20 days on average but was unable to disburse many of those loans due to a 68-day funding lapse. As a result, the overall processing time was 69 days on average with the funding lapse and 64 days on average without it. In addition, we identified opportunities for SBA to optimize its outreach efforts so disaster survivors are aware of the assistance available to them.

We recommended SBA review current outreach strategies; immediately conduct outreach efforts in North Carolina and South Carolina and perform a root cause analysis to determine the basis of insufficient outreach efforts in these two states; and implement appropriate changes to ensure maximum awareness of available assistance to disaster survivors that account for rural areas.

Management’s planned actions to review staffing assignments to ensure adequate coverage for future disasters and immediately conduct outreach efforts in North Carolina and South Carolina resolved Recommendations 1 and 2. Management’s response did not resolve Recommendation 3; therefore, we will seek resolution in accordance with our audit follow-up policy.

The National Oceanic and Atmospheric Administration’s (NOAA’s) Office of Marine and Aviation Operations (OMAO) operates NOAA’s fleet of specialized environmental data-collecting aircraft, including three “hurricane hunter” aircraft: one Gulfstream-IV-SP (G-IV) that is 29 years old and flies high-altitude storm surveillance missions and two Lockheed WP-3D aircraft that are 48 and 49 years old and fly directly into tropical cyclones (low-altitude storm reconnaissance). The G-IV has exceeded its original estimated service life, and the WP-3Ds will reach the end of their estimated service lives in 2030. 

NOAA has initiated replacement efforts for its aging hurricane hunter aircraft and Congress has appropriated funds for replacement aircraft. NOAA will replace the G-IV with two modified Gulfstream 550s and will replace the WP-3Ds with Lockheed C-130Js. The objective of our audit was to assess NOAA’s progress replacing its hurricane hunter aircraft.

We found that (1) hurricane hunter replacement programs started late, delayed definition of requirements, and did not identify and manage key risks; (2) hurricane hunter replacement programs need more effective management and executive oversight; and (3) technically complex acquisition and development programs require mature systems engineering practices.

We made seven recommendations to help NOAA apply effective program management and oversight to these major acquisitions.

The U.S. Postal Service needs effective and productive operations to fulfill its mission of providing prompt, reliable, and affordable mail service to the American public. It has a vast transportation network that moves mail and equipment among approximately 315 processing facilities and 31,200 post offices, stations, and branches. The Postal Service is transforming its processing and logistics networks to become more scalable, reliable, visible, efficient, automated, and digitally integrated. This includes modernizing operating plans and aligning the workforce; leveraging emerging technologies to provide world-class visibility and tracking of mail and packages in near real time; and optimizing the surface and air transportation network. The U.S. Postal Service Office of Inspector General reviews the efficiency of mail processing operations at facilities across the country and provides management with timely feedback to further the Postal Service’s mission.

Why We Did This Report

The U.S. Environmental Protection Agency Office of Inspector General contracted this audit to assess the U.S. Chemical Safety and Hazard Investigation Board’s compliance with Fiscal Year 2023–2024 Inspector General Federal Information Security Modernization Act of 2014 Reporting Metrics during fiscal year 2024. We contracted with SB & Company LLC to perform this audit under our direction and oversight.

Summary of Findings

SB & Company concluded that the CSB achieved an overall maturity of Level 2, Defined, in fiscal year 2024. This means that the CSB’s information security policies, procedures, and strategies are formalized and documented but not consistently implemented. SB & Company identified an area of needed improvement associated with the Reporting Metrics’ Risk Management domain in the Identify function area. SB & Company concluded that the CSB should ensure that its information can be reliably accessed in a timely manner even if key personnel are absent. Specifically, the CSB should ensure that its deputy chief information officer position is filled or that another CSB representative is available to respond to Federal Information Security Modernization Act of 2014 inquiries.

As part of its Delivering for America plan, the U.S. Postal Service plans to create a modernized network based around Regional Processing and Distribution Centers (RPDC), local processing centers and sorting and delivery centers. RPDCs merge mail processing into a central facility within a region to reduce transportation and improve service reliability. In July 2023, the Postal Service began consolidating operations into the Boise facility and in October 2024, officially recognized it as the fifth RPDC in its network. Efficient and effective RPDCs are critical to the success of the Postal Service’s Delivering for America plan and its goal of being financially self-sustaining.

Why We Did This Report

The U.S. Environmental Protection Agency Office of Inspector General conducted this audit to determine the extent to which the EPA prioritizes and awards Infrastructure Investment and Jobs Act funds to tribes through the Clean Water Indian Set-Aside Grant Program and the Drinking Water Infrastructure Grants—Tribal Set-Aside Program, in accordance with applicable statutes, regulations, and EPA guidance.

Summary of Findings

The EPA’s Infrastructure Investment and Jobs Act, or IIJA, funds for the Clean Water Indian Set-Aside, or CWISA, Program and the Drinking Water Infrastructure Grants—Tribal Set-Aside, or DWIG-TSA, Program, collectively referred to as the tribal set-aside programs, were not awarded in a timely manner. About $86.3 million, or roughly 57 percent, of the $152.1 million allocated in fiscal year 2022 IIJA tribal set-aside funds were not awarded to tribes in a timely manner. At the time of our data collection, about $125.3 million, or roughly 76 percent, of the $164.1 million allocated in FY 2023 IIJA tribal set-aside funds had not been awarded to tribes.

As of December 2023, about $140.6 million, or roughly 93 percent, of $152.0 million of the FYs 2022 and 2023 DWIG-TSA funds allocated for emerging contaminants and lead service line replacements had not been awarded to tribal projects.

U.S. Customs and Border Protection (CBP) did not fully leverage its large-scale non-intrusive inspection (NII) systems to detect contraband coming into the United States, potentially wasting taxpayer funds, missing opportunities to detect and seize contraband, and losing an important tool to fight the fentanyl epidemic.

The GPO OIG Investigations Division investigated GPO-issued cell phones, comparing application data against GPO policy, particularly Section 7, Subsection C, paragraphs 6 and 14 of GPO Directive 825.29E on Internet and Email Policy.

Amtrak (the company) contracted with the independent public accounting firm of Ernst & Young LLP to audit its consolidated financial statements as of and for the fiscal year then ended, September 30, 2024, and to provide a report on internal control over financial reporting and compliance with certain provisions of laws, regulations, contracts and grant agreements, and other matters, which they issued on December 12, 2024.1 Because the company receives federal financial assistance, it must obtain an audit performed in accordance with U.S. generally accepted government auditing standards.

The contract also required Ernst & Young to perform a Single Audit of the company’s federal financial assistance for the fiscal year ended September 30, 2024, in accordance with the audit requirements of 2 C.F.R. 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). The objective of the Single Audit was to test internal control over compliance with major federal program award requirements and determine whether the company complied with the laws, regulations, and provisions of contracts or grant agreements that may have a direct and material effect on its major federal programs.

As required by the Inspector General Act of 1978, we monitored the audit activities of Ernst & Young to help ensure audit quality and compliance with auditing standards. Our review disclosed no instances in which Ernst & Young did not comply, in all material respects, with U.S. generally accepted government auditing standards and Uniform Guidance requirements.

Our investigation determined that a former Lineman Trainee based in New Brunswick, New Jersey, violated company policies by offering company employment under false pretenses in exchange for sexual favors, as well as lying in an OIG interview about his interaction with the complainant. Specifically, the former trainee offered the complainant a job with the company that did not exist and that he did not have the authority to offer, and he lied to our agents about his communications with the complainant. He was terminated on June 13, 2025, and he is not eligible for rehire.

The U.S. Postal Service selected the South Atlanta Sorting and Delivery Center (S&DC) as one of the first facilities for fleet electrification. It contracted for the design and installation of 236 parking spaces with charging ports to support the electrical vehicle (EV) rollout. In January 2024, 51 EVs were sent to the facility and following staff training were deployed on delivery routes. An external contractor performed the commissioning, including the electrical, network, charging, and safety testing in early March 2024. 

OIG reviewed USDA’s performance measures and monitoring for the Partnerships for Climate-Smart Commodities.

Audit of the Railroad Retirement Board's Representative Payee Program from Fiscal Year 2023 through Fiscal Year 2024 - Abstract

To address occupational shortages and support hiring efforts, VA leverages federal regulations that allow agencies to offer recruitment, relocation, and retention incentives to encourage candidates to accept positions that are difficult to fill or to keep high-quality staff. The OIG conducted this audit to evaluate VA’s controls over and governance of the use of these incentives for VHA positions. Although these types of incentives were used mostly for positions on staffing shortage lists, VA did not effectively govern the incentive process to ensure responsible VHA officials consistently captured mandatory information necessary to support an incentive award. The OIG team estimated 30 percent of incentives paid during fiscal years 2020 through 2023 were missing forms, lacked a sufficient justification, or were missing signatures. As a result, VHA paid employees about $340.9 million in incentives that were not adequately supported. Furthermore, the OIG team found VHA did not consistently include sufficient workforce and succession plan narratives for an estimated 20 percent of retention incentives, note employee performance ratings for 7 percent of relocation incentives, or obtain self-certifications for about 71 percent of employees who relocated. The team also identified 28 employees who received retention incentive payments up to an additional 11 and a half years after their award period had expired. VA improperly paid about $4.6 million to these employees for incentives that should have been terminated. The OIG made eight recommendations to improve the oversight of these incentives.

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Atlanta Healthcare System in Decatur, Georgia. 

This evaluation focused on five key content domains:
     •    Culture
     •    Environment of care
     •    Patient safety
     •    Primary care
     •    Veteran-centered safety net

The OIG issued seven recommendations for improvement in five domains:
   1.    Culture
     •    Infrastructure issues
     •    Unanswered veteran phone calls
   2.    Environment of care
     •    Parking garage emergency call boxes
   3.    Patient safety
     •    Local test result policies and memorandums
     •    Institutional disclosures for adverse events
   4.    Primary care
     •    Panel sizes and access to care
   5.    Veteran-centered safety net
     •    Medical clearances for veterans in the Compensated Work Therapy program

During the week of January 13, 2025, we performed a self-initiated audit at the Phoenix and West Valley Processing and Distribution Centers (P&DC) and five delivery units serviced by the P&DCs. The delivery units included the Boulder Hills, Mesa Four Peaks, and Scottsdale Stations; Avondale Goodyear Main Post Office; and Sunnyslope Carrier Annex in the Phoenix, AZ area.

We issued individual reports for the five delivery units and two P&DCs. We will also issue another report summarizing the results of our audits at all five delivery units with specific recommendations for management to address.

Why We Did This Report

The U.S. Environmental Protection Agency Office of Inspector General conducted this evaluation to determine South Carolina’s capacity to manage and use Infrastructure Investment and Jobs Act funds for its Clean Water State Revolving Fund program.

Summary of Findings

South Carolina’s Clean Water State Revolving Fund, or CWSRF, program sufficiently meets two of the four dimensions of capacity: financial and organizational. South Carolina faces challenges related to stakeholder and human capital capacity. If South Carolina does not take steps to address those challenges, millions of IIJA dollars intended for water infrastructure improvements may not reach the state’s communities.