Federal Reports

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

The Infrastructure Investment and Jobs Act authorizes $4.7 billion in appropriations for fiscal years 2022 through 2030 to address orphaned wells.

As part of our annual audit plan, we audited costs billed to the Tennessee Valley Authority (TVA) by Delta Dental of Tennessee (Delta Dental) for dental plan administrative services. Our audit objective was to determine if the costs billed to TVA were in compliance with the terms of Contract No. 12179. Our audit included approximately $15.6 million in claim costs and associated administrative fees billed to TVA during calendar years 2020 and 2021. In summary, we determined the costs billed by Delta Dental generally complied with the contract, except for $14,618 in overbilled costs due to a duplicate billing. Delta Dental agreed with the overbilling and issued TVA a credit for the full amount on April 18, 2022.(Summary Only)

This report presents a summary of the results of our self-initiated audits assessing the efficiency of selected processes at three selected retail units in the Texas 1 District (Project Number 22-092). These retail units included the Dallas, TX Main Post Office (MPO), the Mesquite, TX Post Office (PO), and the Wylie, TX PO in the Southern Area. We previously issued interim reports to district management for each of these retail units regarding the conditions we identified.

Free Matter for the Blind or Other Physically Handicapped Persons (Free Matter) is a legally mandated program that allows eligible participants to receive and send mail for free. Mail that qualifies as Free Matter includes large-type (14-point or larger) documents, braille, audio recordings, and talking book players. When Free Matter is mailed domestically, it should be treated as First Class Mail for processing and service measurement. U.S. Postal Service regulations also require packaging to remain unsealed to facilitate inspection by Postal Service employees to ensure the mailpieces qualify for postage-free mailing. The Postal Service is reimbursed the cost of delivering Free Matter through congressional appropriations every year.

An Amtrak Red Cap/Baggageman based in Chicago was terminated from employment on July 21, 2022, following his administrative hearing. Our investigation found that the former employee violated company policies by failing to remit parcel check revenue for cash paying customers on 22 occasions between March 18 and March 26, 2022 and kept the cash for himself instead. We also found that he falsified a parcel check form in order to remit only half of the revenue he collected and was observed putting the cash in his pocket.

VA recognizes exposure to smoke from the large burn pits used by the US military to dispose of waste from its bases in Iraq, Afghanistan, and Djibouti as a potential cause of disabilities. Veterans Benefits Administration (VBA) staff processed more than 21,100 burn pit-related claims from June 2007 through September 2021. Given the potential impact on many eligible veterans, the VA Office of Inspector General (OIG) conducted this review to determine whether VBA staff followed regulations and procedures when addressing conditions that could be associated with burn pit exposure.VBA treats burn pit-related claims like most other disability compensation claims, though it also considers exposure to environmental hazards based on a veteran’s service location. VBA provides medical examiners a burn pit fact sheet to help ensure any opinion is fully informed based on all known objective facts.The review team examined three distinct samples of claimed conditions potentially related to burn pit exposure completed from May 1, 2020, to May 1, 2021, and found VBA could improve its processing and oversight. Though VBA staff nearly always made the correct decision in granting compensation for conditions identified as burn pit-related, the OIG found most denials were premature.The OIG made seven recommendations to VBA management, including correcting four errors involving improperly granted conditions, and reviewing denied cases, correcting errors they identify, and certifying that corrections were made. VBA should also update its adjudication procedures manual to provide separate and specific guidance for handling claims based on burn pit exposure and modify its examination request application to add specialty language from the burn pit fact sheet into medical opinion requests. Finally, VBA should update training materials and ensure they are consistent with the adjudication procedures manual guidance.

AmeriCorps’ security program has not been effective in accordance with Federal Information Security Management Act (FISMA) since Fiscal Year 2017. In order to determine its current status, AmeriCorps OIG engaged an independent certified public accounting firm to conduct an internal penetration test of AmeriCorps’ network. The independent auditors tested AmeriCorps’ network to evaluate the effectiveness of its information security program and to identify areas of weakness. This evaluation was comprised of three phases: network penetration testing, a phishing campaign, and the testing the effectiveness of controls in preventing and detecting the execution of malicious code. The independent auditors found two weaknesses related to preventive and detective security controls. AmeriCorps concurred and agreed to implement our recommendations to (1) develop and implement a plan to modify external emails to include information to assist the recipient of the level of risk posed by external email, (2) implement a plan to increase the frequency of behavior training directed at the identification of unwanted spam emails, and (3) implement a process to improve the detection rate to reduce the occurrence of email spam that reaches the users’ inboxes. AmeriCorps Management’s response can be found in Appendix II of the report.

Since 1990, some 3.5 million veterans have served in areas that potentially exposed them to airborne hazards and open burn pit toxins, which have been associated with health problems. In 2013, Congress ordered VA to establish a registry to research the potential health impacts of exposures. The VA Office of Inspector General (OIG) reviewed the management of registry exams, including whether VA medical facilities conducted them within the 90-day prescribed period.The Veterans Health Administration (VHA) began collecting and recording data in the registry in May 2014 through an online questionnaire and free in-person exams. The OIG found many veterans did not complete the 140-item questionnaire, which is not clear and veteran-centric. Veterans also did not always realize they were responsible for scheduling their own exams.Improvements in the registry exam process would help ensure more eligible and interested veterans receive them. VHA plans to establish a call center to assume some of the scheduling and coordination responsibilities by October 2022. This is well-timed given the number of veterans indicating they would like an exam has further increased since August 2021, when VA established a presumptive “service connection” for respiratory conditions due to exposure to particulate matter, such as asthma, sinusitis, and rhinitis. Whether the call center will mitigate the issues identified by the OIG cannot yet be determined, and its rollout does not negate the need for corrective actions.The OIG made seven recommendations to the under secretary for health that include revising the questionnaire to be more veteran-centric, identifying whether veterans with unscheduled exams are still interested in one, and implementing processes and metrics to ensure exams are completed. Further, the OIG recommended developing guidance to ensure responsible parties review and discuss performance data and the enhancement of registry information systems.

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The three regional procurement offices (RPO) of the Veterans Health Administration (VHA) procure supplies and services to support the medical facilities within their regions: Central, East, and West. In fiscal year 2021, RPO West obligated about $2.7 billion in contracts. The VA Office of Inspector General (OIG) reviewed whether RPO West contracting officials administered contracts and accepted supplies and services in accordance with federal and VA regulations. To protect veterans and taxpayer dollars, contracting officials must maintain the necessary evidence to demonstrate compliance with contract terms and conditions.The review team examined files for a random sample of 49 contracts, valued at over $100,000 each, awarded from January 1 through June 30, 2020, and 93 invoices associated with these contracts. The OIG found RPO West contracting officers and contracting officers’ representatives did not always maintain documentation to demonstrate proper acceptance of supplies and services. The team determined several factors contributed to noncompliance, including officials not understanding their responsibilities, heavy workload, ineffective oversight, and prioritization of awarding contracts.RPO West contracting officials’ noncompliance with developing and maintaining required documentation resulted in $12.8 million in questioned cost. Until VHA improves oversight of contracting officials and ensures their compliance with federal regulations, it lacks assurance that veterans are receiving critical supplies and services.The OIG made eight recommendations to RPO West’s executive director, including establishing controls to ensure electronic files are created for all contracts requiring a representative, delegation memorandums are completed when required, and representatives upload required acceptance documentation. The executive director should also assess existing contracts for compliance and correct as needed. In addition, branch chiefs should consistently monitor contract administration documentation, and create a quality assurance process that ensures requirements are met.

What We Looked AtTo help combat highway fatalities, the Fixing America’s Surface Transportation Act (FAST Act) of 2015 authorized over $2.7 billion in highway safety grant funds for fiscal years 2016 through 2020. The National Highway Traffic Safety Administration (NHTSA) awarded these safety grants to States, which distributed them to a network of sub-grantees, then monitored the funds’ use for each State Highway Safety Office. Due to the significant amount of grant funding authorized by the FAST Act and the importance of NHTSA’s oversight, we initiated this audit as a follow up to our 2014 recommendations to help the Agency improve oversight controls for safety grants. Specifically, we reviewed NHTSA’s actions to improve controls over (1) mitigation of deficiencies identified by the Agency’s triennial management reviews of States, (2) monitoring States’ compliance with Federal grant requirements, (3) States’ timeliness in expending grant funds, and (4) developing and implementing an electronic database to identify and monitor recurrent or systemic grant oversight findings. What We FoundNHTSA implemented our 2014 recommendations to improve the Agency’s oversight of highway safety grants. Specifically, NHTSA worked with States to mitigate deficiencies and revised its grant oversight policies and procedures to require documentation of States’ corrective actions and management approval for closing actions. The Agency also implemented updated monitoring procedures and a risk assessment process for improving States’ compliance with Federal grant requirements and for monitoring the timeliness of States’ expenditure of highway safety grant funds. Finally, NHTSA is evaluating options to replace its grant information system. RecommendationsWe made no recommendations.

For our final report on our audit of the United States Patent and Trademark Office’s (USPTO’s) patent legacy systems, our audit objective was to review USPTO’s progress towards retiring its patent legacy systems. Specifically, we assessed USPTO’s (1) cost, schedule, and capabilities of select patent legacy systems and (2) ongoing activities to transition from the legacy systems to next-generation systems. We found the following: I. USPTO’s cost estimating and scheduling processes are not comprehensive and II. USPTO needs to improve Agile adoption practices when developing next-generation patent systems.

What We Looked AtThe Federal Highway Administration (FHWA) oversees about $52 billion in Federal-aid Highway Program funds for fiscal year 2022. The Agency makes these funds available to State Departments of Transportation for highway and infrastructure projects. Modifications to a project’s contract specifications are frequently done through change orders, which are an important component of the Federal-aid Highway Program since they can affect projects’ cost, schedule, design details or specification requirements, or a combination of these key elements. Given the possible risks to program oversight posed by change orders, we initiated this audit to assess FHWA’s oversight of contract change orders. What We FoundWe found data limitations that could impact FHWA’s ability to monitor and oversee change orders. Furthermore, FHWA’s methodology for its compliance assessment program (CAP) reviews can lessen the reviews’ usefulness for oversight and monitoring of change orders. The Agency also lacks a consistent definition of change order as well as clear guidance on what constitutes a major change. Lastly, FHWA’s policy and guidance on change orders in its Contract Administration Core Curriculum (CACC) Manual are outdated, and its guidance for monitoring and tracking its change order reports and associated findings lacks clarity. RecommendationsWe made recommendations to help FHWA strengthen its oversight role and help to mitigate potential exposure to risks related to change orders. FHWA concurred with four recommendations and partially concurred with the other two. We consider all six recommendations resolved but open pending completion of planned actions.

Deficiencies and a lack of transparency in the 1,3 D pesticide cancer assessment process has undermined scientific credibility and public confidence.

As SBA shifts from reviewing applications to servicing COVID-19 Economic Injury Disaster Loans (EIDL) and Targeted EIDL Advances, the potential for identifying additional fraudulent loans increases significantly as borrowers default. The ability to recover funds and prosecute fraud relies on having continued access to loan and grant data, especially regarding evidential matter for audits and investigations.In February 2022, OIG found that SBA had been migrating data from its software provider without a data migration plan. This software service provider is an outside company contracted to provide cloud-based software solutions. Without advance planning for data migration and defined acceptance criteria, SBA took reactive measures to prevent the loss of vital program data when the contract ended on June 30, 2022.To address concerns about data migration challenges for SBA’s COVID-19 EIDL pandemic relief program, we suggest the SBA design and implement a comprehensive migration plan for the COVID-19 EIDL program, to include defined acceptance criteria and robust testing, with detailed project milestones and defined areas of responsibility for program management, information technology, and procurement groups so that data is preserved to meet the needs of all stakeholders.SBA managers stated they were working to modify the software service provider contract to ensure data will remain available for future litigation efforts. Management’s plan to modify the contract would ensure data is preserved. Once the contract modification is complete, the risk of data loss will be mitigated. Safeguarding the data from destruction beyond the June 30, 2022 contract expiration will allow SBA to support legal proceedings for the immediate future.

This interim report presents the results of our self-initiated audit of the efficiency of selected processes at the Stone Mountain Post Office in Stone Mountain, GA (Project Number 22-124). This audit was designed to provide U.S. Postal Service management with timely information on potential financial control risks at Postal Service locations. The Stone Mountain Post Office is in the Georgia District of the Southern Area. We judgmentally selected the Stone Mountain Post Office for our audit.

This interim report presents the results of our self-initiated audit of the efficiency of selected processes at the Marietta Main Post Office (MPO) in Marietta, GA (Project Number 22- 123). This audit was designed to provide U.S. Postal Service management with timely information on potential financial control risks at Postal Service locations. The Marietta MPO is in the Georgia District of the Southern Area. We judgmentally selected the Marietta MPO for our audit.

This interim report presents the results of our self-initiated audit of the efficiency of selected processes at the Atlanta Main Post Office (MPO) in Atlanta, GA (Project Number 22‑122). This audit was designed to provide U.S. Postal Service management with timely information on potential financial control risks at Postal Service locations. The Atlanta MPO is in the Georgia District of the Southern Area. We judgmentally selected the Atlanta MPO for our audit.

The VA Office of Inspector General (OIG) conducted an inspection to assess the Veterans Health Administration’s (VHA) process in responding to a December 2020 medication recall. The recall included two medications, an antidepressant and erectile dysfunction treatment, which were incorrectly packaged together in the same bottle by the distributor.The OIG determined that the VHA medication recall process generally met VHA requirements. However, the OIG identified potential vulnerabilities related to the monitoring and reporting of medication recall adverse drug events and variations in the software used to record medication lot numbers in two VHA medical facilities named in the allegations—the VA Oklahoma City Healthcare System and VA North Texas Health Care System.The OIG found that during the medication recall, the VHA National Center for Patient Safety (NCPS) monitored communications and responded according to VHA policy requirements. NCPS emailed designated VHA leaders and staff providing known details, required actions, and instructions. VHA Pharmacy Benefits Management followed VHA requirements to distribute medication recall safety information throughout VHA medical center facilities and ensured notification of patients affected by the recalled medications. The OIG found that VHA medical facility staff were responsible for notifying all affected patients.Adverse drug events resulting from recalled medications are not identified specifically as a category nor required to be reported in the VA Adverse Drug Event Reporting System. Therefore, the OIG could not determine if VHA monitored all adverse drug events from recalled medications.The OIG made two recommendations to the Under Secretary for Health related to the monitoring and reporting of medication recall adverse drug events and vulnerabilities in the medication recall process due to variances in VHA medical facility processes.

We audited costs claimed and grant compliance by the Nevada Department of Wildlife under grants awarded by the FWS.

An Amtrak lead service/train attendant based in New Orleans, Louisiana, resigned from her position on July 18, 2022, prior to her administrative hearing. Our investigation found that the former employee violated company policies by engaging in outside employment while on a medical leave of absence. During an interview with our agents, the former employee admitted she had been employed as a full-time contract driver for a trucking company while on medical leave from the company.

The objective of our audit was to determine whether the California Department of Education (California) appropriately allocated Immediate Aid to Restart School Operations (Restart) program funds and ensured that local educational agencies (LEA) and nonpublic schools used Restart program funds for allowable and intended purposes.We found that California appropriately allocated 2018 and 2019 Restart program funds to LEAs and nonpublic schools. Although we did not identify any unallowable costs at the two LEAs whose uses of Restart program funds we reviewed, we found that California needs to improve its processes for ensuring that LEAs use Restart program funds for allowable and intended purposes. Specifically, California did not always adhere to its established procedures for reimbursement of expenditures for the 2018 Restart program, including not obtaining supporting documentation for $103,124 in expenditures for two LEAs; did not timely monitor the Restart program; and did not ensure remittance of interest earned on Restart program funds that were advanced to LEAs.

The objectives of the audit were to determine whether the State of Oklahoma (Oklahoma) designed and implemented awarding processes that ensured that the Governor's Emergency Education Relief Fund (GEER grant) was used to support local educational agencies (LEA) and institutions of higher education (IHE) that were most significantly impacted by the coronavirus or LEAs, IHEs, or other education-related entities within the State that were deemed essential for carrying out emergency educational services; and monitoring processes to ensure that subgrantees used GEER grant funds in accordance with the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) and other applicable Federal requirements.Oklahoma did not award all of its GEER grant funds in accordance with the CARES Act, Federal regulations, Department guidance, and GEER grant conditions.

What We Looked AtThe Coronavirus Aid, Relief, and Economic Security (CARES) Act provided the Federal Aviation Administration (FAA) with $10 billion to help airports deal with the public health emergency caused by Coronavirus 2019 (COVID-19). FAA awarded $9.1 billion in grants to airports nationwide, using its existing Airport Improvement Program (AIP) to distribute the funds. Our objective for this self-initiated audit was to assess whether FAA’s policies and procedures for awarding and overseeing CARES Act grants are sufficient to protect taxpayer interests. What We FoundLeveraging the AIP allowed FAA to announce CARES Act awards for more than 3,000 airports in just 2 weeks. However, changes in the Agency’s oversight process regarding supporting documentation requirements affected its ability to monitor program performance, and we determined at the time of our review that it contributed to more than $271 million in unsupported costs, $85 million in questioned costs, and $3 million of improper payments. FAA also did not establish procedures for deobligating CARES Act grants that become inactive, exceed the period of performance, or provide airport sponsors with adequate guidance on documenting workforce retention data. These internal control weaknesses hindered FAA’s ability to ensure that it is operating the program as Congress intended, administering projects in a fiscally responsible manner, and achieving reporting and compliance objectives. Our RecommendationsWe are making seven recommendations to improve FAA’s oversight of COVID relief funds. FAA concurred with recommendations 5–7 and provided completion dates. The Agency partially concurred with recommendations 1–4. Based on documentation FAA provided after our review was completed, we consider recommendation 1 resolved but open pending completion of planned actions, recommendations 2 and 3 resolved and closed, and recommendation 4 unresolved. We are asking FAA to reconsider its position and provide us with a revised response within 30 days of the date of this report.

The objective was to determine the extent to which the Department of Homeland Security and U.S. Customs and Border Protection (CBP) manage and enforce the priority trade issue related to intellectual property rights (IPR).

The Office of the Inspector General conducted a review of the Communications and Public Relations (C&PR) organization to identify factors that could impact C&PR’s organizational effectiveness. During the course of our evaluation, we identified behavioral and operational risks, some of which were recurring, that stemmed from alignment issues, which could negatively affect sustainable execution within C&PR. Specifically, these risks included (1) perceived lack of organizational direction, (2) perceived lack of empowerment in C&PR leadership, (3) concerns with the development of the organizational structure, (4) staffing and prioritization concerns, (5) role clarity concerns, (6) concerns with relationships within and outside of C&PR, and (7) organizational placement concerns.

From March to July 2022, The AmeriCorps Office of Inspector General (OIG) conducted a modified peer review of the AbilityOne OIG’s Office of Audit (OA). The team from AmeriCorps OIG reviewed (1) the OA’s established audit policies and procedures in effect for the year ended September 30, 2021, and (2) the OA’s monitoring of Government Audit Standards (GAS) engagements performed by Independent Public Accountants (IPAs).

An Amtrak conductor based in Sanford, Florida, was suspended from his position without pay, in lieu of termination, on July 15, 2022, following his administrative hearing. The employee was held out of service without pay for a total of 68 days from May 26, 2022, through August 1, 2022. Our investigation found that the employee violated company policies by attempting to sell high-security switch keys and other assorted railroad keys on Facebook Marketplace, including keys used by Amtrak.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the leadership performance and oversight by Veterans Integrated Service Network (VISN) 5: VA Capitol Health Care Network in Linthicum, Maryland, covering leadership and organizational risks and key processes associated with promoting quality care. This inspection also focused on COVID-19: Pandemic Readiness and Response; Quality, Safety, and Value; Medical Staff Credentialing; Environment of Care; Mental Health: Suicide Prevention; Care Coordination: Inter-facility Transfers; and Women’s Health: Comprehensive Care.The executive leaders, who had worked together since August 2020, had spent much of their time and efforts on improving care and leadership at the Louis A. Johnson VA Medical Center following an OIG criminal investigation of a VA nursing assistant who was convicted and sentenced for the murder of seven veterans. Leaders reported taking actions such as ensuring staff completed Morbidity and Mortality reviews, evaluating quality of care through an Administrative Investigation Board, and monitoring hiring and background check processes.Selected survey scores related to employee satisfaction with VISN leaders generally exceeded VHA averages; however, the Deputy Network Director’s servant leadership score was lower than the VHA average. VISN patient experience survey scores were similar to VHA averages, except for inpatient care satisfaction at selected VISN 5 facilities. The OIG identified potential risk factors including mental health wait times at selected facilities over 20 days, higher rates of clinical vacancies, and challenges with facility hiring support and retention of human resources staff. The Network Director, Chief Medical Officer, and Quality Management Officer/Chief Nursing Officer had opportunities to improve oversight of facilities’ quality, safety, and value; care coordination; and high-risk processes.The OIG issued one recommendation for improvement:(1) Medical Staff Credentialing• Physician credentials review process

The Office of Inspector General (OIG) conducted an inspection to assess a safety concern with the new electronic health record (EHR) that resulted in patient harm. The OIG found that the new EHR sent thousands of orders for medical care to an undetectable location, or unknown queue, instead of to the intended location. Veterans Health Administration (VHA) identified and ranked safety concerns with the new EHR. In December 2021, VHA assessed the risk of the unknown queue as “major severity,” “frequently occurring,” and “very difficult to detect.” As such VHA recognized immediate mitigation was needed. Oracle Cerner failed to inform VA end-users of the existence of the unknown queue and put the burden on VHA to mitigate the problem.Beginning in June 2021, VHA staff spent substantial hours to complete clinical reviews to assess patient risk and harm related to the unknown queue and found that the new EHR’s delivery of orders to the unknown queue caused 149 patient harm events.In late 2021,VHA staff provided the Deputy Secretary and the Executive Director for VA’s EHR modernization effort with information on the unknown queue safety concern and identified patient harm. Each facility that goes live with the new EHR will require an ongoing commitment from facility staff to monitor and address the new EHR’s unknown queue. Cerner and VHA took actions to minimize orders being routed to the unknown queue. However, after finding over 200 orders in the unknown queue in May 2022, the OIG has concerns with the effectiveness of Cerner’s plan to mitigate the safety risk.

The objective was to determine the extent to which the Public Assistance Alternative Procedures (PAAP) met the goals set forth in Section 428 of the Stafford Act and did so in accordance with legislation and FEMA guidelines since the alternate procedures were made available in 2013.

We determined whether FSIS’ actions taken in response to complaints of sexual misconduct and harassment in the workplace, received October 1, 2019, through May 31, 2021, were in accordance with Departmental and agency policy.

The USPP supervisor used his GOV to drive to and from his approved outside employment on 10 occasions in 2021, in violation of law and USPP policy.

The unclassified version of the SAR covers the period from 1 October 2021 – 31 March 2022, and reflects what the NSA OIG could release publicly about its work for that SAR Report Cover reporting period. The OIG made 171 recommendations that we believe will be impactful in improving the economy, efficiency, and effectiveness of this critical Agency's operations.

This administrative investigation addressed concerns of possible misconduct by two leaders responsible for overseeing medical facility staff training on implementing VA’s new multibillion-dollar patient electronic health record system. The investigation stemmed from a prior OIG review at the initial operating site (the Mann-Grandstaff VA Medical Center in Spokane, Washington), during which OIG healthcare inspectors experienced significant challenges in receiving timely, complete, and accurate information from the then VA Office of Electronic Health Record Modernization’s (OEHRM’s) Change Management group.The investigation revealed that while the Change Management leaders did not intentionally seek to mislead the OIG, their lack of diligence resulted in delays and misinformation being submitted that impeded oversight efforts. Failures included (1) submitting a training evaluation plan without disclosing to the OIG that it was in its “infancy” and had not been fully implemented or even approved; (2) delaying production of requested proficiency check datasets that should have been available under the submitted evaluation plan; (3) instead providing three summary statistics with errors that doubled the training proficiency test pass rate from initial findings of 44 to 89 percent, without the requested methodology; (4) overlooking red flags indicating that all failing scores had in fact been removed from reported rates (with the total number of proficiency tests dropping by more than 3,000 in submitted recalculations); and (5) failing to disclose concerns regarding data reliability and that data were excluded.VA concurred with the OIG’s two recommendations for providing guidance to staff in the since-reorganized Electronic Health Record Modernization and Integration Office on providing timely, complete, and accurate responses to OIG staff and ensuring direct staff-level communications with OIG personnel are not impeded. VA also agreed to consider whether administrative action is appropriate given the conduct and performance of the two Change Management leaders.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Chouteau Station in St. Louis, MO (Project Number 22-115-3). The Chouteau Station is in the Kansas-Missouri District of the Central Area and services ZIP Code 63110, which serves about 17,235 people and is considered to be urban. We judgmentally selected the Chouteau Station based on the number of Stop-the-Clock (STC) scans occurring at the delivery unit rather than at the customer’s point of delivery.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Maryville Gardens Station in St. Louis, MO (Project Number 22-115-2). The Maryville Gardens Station is in the Kansas-Missouri District of the Central Area and services ZIP Codes 63104, 63111, and 631181 which serve about 65,703 people and are all considered urban communities. We judgmentally selected the Maryville Gardens Station based on the number of Stop-the-Clock (STC) scans occurring at the delivery unit rather than at the customer’s delivery address.

This report presents the results of our self-initiated audit of the efficiency of operations at the St. Louis Processing and Distribution Center (P&DC) in St. Louis, MO (Project Number 22-112). We conducted this audit to provide U.S. Postal Service management with timely information on operational risks at this P&DC. We judgmentally selected the St. Louis P&DC based on a review of overtime; penalty overtime; late, extra, and cancelled trips by Postal Vehicle Service (PVS) and Highway Contract Route (HCR) drivers; and overall scanning performance. The St. Louis P&DC is in the Midwest Division, it processes letters and flats, and it services multiple 3-digit ZIP Codes in urban and rural communities (see Table 1).

We reviewed the EEOC’s payment integrity section of its FY 2021 AFR to assess the agency’s compliance with the requirements of PIIA, OMB guidance, and information on PaymentAccuracy.gov. We found that EEOC was not compliant with PIIA for FY 2021. The agency included a payment integrity section in the FY 2021 AFR in accordance with IPERIA. EEOC completed a risk assessment in FY 2020 and was not required to conduct a risk assessment in FY 2021. However, the agency did not conduct its annual OMB payment integrity review and data call resulting in our finding of non-compliance with PIIA.

Results of the Inspector General’s Fiscal Year 2021 Purchase and Travel CardProgram Risk Assessment

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Martinsburg VA Medical Center. The inspection covered key clinical and administrative processes associated with promoting quality care. It focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.At the time of the OIG’s virtual inspection, the medical center’s executive leadership team had worked together for just over one month. Employee survey data revealed opportunities for the Director; Chief of Staff; and Associate Director, Patient Care Services to reduce staff feelings of moral distress at work. Patient experience survey data indicated that leaders had an opportunity to improve female respondents’ inpatient and specialty care experiences. The OIG’s review of the medical center’s accreditation findings did not identify any substantial organizational risk factors. However, the OIG identified concerns related to sentinel events and institutional disclosures. Executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance.The OIG issued nine recommendations for improvement in four areas:(1) Leadership and Organizational Risks• Sentinel events and institutional disclosures(2) Quality, Safety, and Value• Systems Resign and Improvement Program• Surgical work group attendance(3) Care Coordination• Patient transfer monitoring and evaluations• Inter-facility transfer forms• Medication list transmission(4) High-Risk Processes• Disruptive behavior committee attendance• Staff training

The Veterans Health Administration (VHA) has three regional procurement offices (RPOs) that acquire supplies and services to support the medical facilities within their regions (Central, East, and West). In FY 2020, the VA Office of Inspector General (OIG) published a report on contract closeout compliance at RPO East. Because of problems identified there, the OIG conducted this review to determine whether RPO Central and RPO West contracting officers adequately performed and documented contract closeout requirements. When contracting officers do not follow the necessary steps to close out contracts, they increase future financial and legal risk to the government and may prevent it from obtaining the maximum benefit of any unused funds. Therefore, to protect veterans and taxpayer dollars, contracting officers must maintain the necessary evidence to demonstrate contractor compliance with contract terms and conditions.The team reviewed a random sample of 55 RPO Central contracts and 40 RPO West contracts, each valued at over $500,000, that were closed between June 1 and December 31, 2020. Based on the team’s review, the OIG found that RPOs Central and West contracting officers did not perform required contract closeout duties. Reasons included unclear policies and systems, as well as ineffective oversight of the closeout process. Contracting officers also informed the team that a heavy workload and the prioritization of awarding contracts affected their ability to comply with contract administration requirements.The OIG recommended the executive directors for RPO Central and RPO West establish consistent quality assurance reviews, balance contracting officer workload, update guidance on the use of simplified acquisition procedures, consider additional strategies to ensure contract closeout compliance, and verify that the contract files for the 81 sampled contracts have complete closeout documentation.

The Tennessee Valley Authority (TVA) operates three nuclear plants capable of generating 7,800 megawatts of electricity. Groundwater contamination can result from routine nuclear plant activities such as wet storage of spent fuel, leaks from liquid waste pipelines and tanks, and leaks of contaminated cooling water. TVA Nuclear Power Group, Standard Programs and Processes 05.15, Fleet Groundwater Protection Program, establishes a long-term groundwater-monitoring program with the purpose of minimizing the potential for inadvertent releases to the environment from plant activities. Due to risks associated with potential groundwater contamination, we performed an evaluation to determine if TVA Nuclear has taken actions to address issues related to groundwater at nuclear plants, identified during fiscal years 2017 through 2021, in internal assessments, external assessments, consultant reports, and condition reports. We determined TVA Nuclear has taken actions, or no further actions were needed, to address the majority of issues and/or recommendations made. However, two recommendations from 2015 have not been addressed and likely affected TVA’s corporate insurance premiums.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Marian Oldham Station in St. Louis, MO (Project Number 22-115-4). The Marian Oldham Station is in the Kansas-Missouri District of the Central Area and services ZIP Codes 63106 and 63108,1 which serve about 32,922 people and are considered to be urban. We judgmentally selected the Marian Oldham Station based on the number of customer inquiries per route that the unit received. From December 1, 2021 through February 28, 2022, the unit received 13.03 inquiries per route, which was more than the average of 7.02 inquiries per route for all sites serviced by the St. Louis Processing and Distribution Center (P&DC).

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Saint Peters Main Post Office (MPO) in Saint Peters, MO (Project Number 22-115-1). The Saint Peters MPO is in the Kansas-Missouri District of the Central Area and services ZIP Code 63376, which serves about 71,535 people and is considered to be urban. We judgmentally selected the Saint Peters MPO based on the number of customer inquiries per route the unit received. From December 1, 2021 through February 28, 2022, the unit received 12.54 inquiries per route, which was more than the average of 7.02 inquiries per route for all sites serviced by the St. Louis Processing and Distribution Center (P&DC).

Our objective for this report was to assess the company’s efforts to address challenges in recruiting and retaining skilled engineering managers as it recovers from the pandemic and builds for the future.We found that the company is fully aware of the difficulties of recruiting and retaining skilled engineering managers in today’s labor market and has taken steps to address them. These steps include establishing meaningful pay differences between managers and subordinates, benchmarking management compensation with market rates, increasing salaries for field engineers, and offering one-time bonuses to entice agreement employees to move into management positions. In addition, the company recently commissioned a compensation analysis that will benchmark its salaries and determine appropriate rates for management positions company-wide. The analysis, scheduled to be completed this summer, is the first such review since 2014. We also found that the company has additional opportunities to build on these efforts, to include codifying existing policies on compensation and using workforce data to assess the effectiveness of its recruitment and retention effort for engineering managers.To address the report’s findings, we recommended that the company 1) establish formal compensation policies that define a schedule for regularly conducting analyses to identify whether the company is offering market-competitive salaries and communicate the policy to all relevant parties, 2) routinely analyze common workforce metrics such as employee turnover and share the metrics with relevant departments through existing workforce management tools, and 3) Use the common workforce metrics to assess the effectiveness of recent efforts to address compensation or work-life balance issues and determine whether further adjustments are needed.

The Office of Inspector General (OIG) is initiating an audit of Third-Party Service Provider Agreements. Our overall objective is to determine the extent to which the services provided by third-party organizations align with the terms of existing service agreements.

The Office of Inspector General (OIG) is initiating an audit of the Commission’s Contract Administration Process. Our overall objectives is to determine whether and to what extent the staffing shortfalls in the Office of Contracting Policy impacted the ability to manage and administer the contract administration process.

The objectives of our audit were to determine whether the Puerto Rico Department of Education (Puerto Rico DOE) provided accurate and complete displaced student count data to the U.S. Department of Education (Department) and appropriately accounted for Temporary Emergency Impact Aid for Displaced Students (Emergency Impact Aid) program funds in accordance with Federal guidelines.In our displaced student count testing, we determined that the Puerto Rico DOE reported inaccurate and unsupported displaced student count data to the Department for school year 2017–2018.We also determined that the Puerto Rico DOE generally accounted for Emergency Impact Aid program funds in accordance with Federal guidelines.

External peer review of the Farm Credit Administration Office of Inspector General's inspection and evaluation organization, conducted by the U.S. Securities and Exchange Commission Office of Inspector General.

Review to determine the Commission’s compliance with Fiscal Year (FY) 2021reporting on improper payments.

Because the EPA did not follow docketing procedures, the public was not notified of the changes to the final Long-Chain Perfluoroalkyl Carboxylate and Perfluoroalkyl Sulfonate Chemical Substances Significant New Use Rule.

The VA Office of Inspector General (OIG) assessed the VA Boston Healthcare System’s stewardship and oversight of funds in fiscal year (FY) 2021 and identified potential cost efficiencies in carrying out medical center functions. The review team looked at open obligation oversight, purchase card use, inventory and supply management, and pharmacy operations.From the healthcare system’s 421 open obligations, the team selected 20 totaling $20.6 million and found half were at least 90 days past their end date, most without being reviewed to see if they were still valid and necessary, and two had residual funds totaling approximately $4,439 that should have been released from obligation and used elsewhere to support veterans.Of 36 purchase card transactions totaling $441,000, the team found 28 lacked evidence to show they were properly approved and that payments were accurate, and 25 were processed by cardholders and approving officials whose duties were not segregated as required. The team also identified 10 purchases that should have been procured through contracting but were intentionally split into multiple transactions to stay below the cardholder’s single purchase limit.The team found inaccurate entries in the inventory system that caused it to show insufficient amounts of stock on hand in more than 70 percent of tested cases. The inaccuracies result in inefficient purchasing and receiving and could adversely affect patient care.The healthcare system had a low pharmacy turnover rate, an efficiency measure. In FY 2021, the healthcare system reported a rate of 8.2 compared to the recommended 12. Low inventory turnover rates could indicate an inability to properly forecast needed drug inventories, which could adversely affect patient care.The OIG made eight recommendations to improve the stewardship of VA resources and address issues that could adversely affect patient care.