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Brought to you by the Council of the Inspectors General on Integrity and Efficiency
Federal Reports
Report Date
Agency Reviewed / Investigated
Report Title
Type
Location
Department of Defense
Evaluation of DoD Efforts to Assign Medical Personnel to Locations Where They Can Maintain Wartime Readiness Skills and Core Competencies
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.
Financial Audit of the Sustainable HIV Knowledge Management Project in Nicaragua, Managed by Centro para la Educacin y Prevencin del SIDA, Cooperative Agreement 72052419CA00001, January 1 to December 31, 2023
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.
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
Closeout Financial Audit of the Sustainable Management of Forest Concessions Project, Managed by Green Gold Forestry Per S.A., Cooperative Agreement 72052721CA00004, January 1, 2023, to March 21, 2024
Audit of the Schedule of Expenditures for Mercy Corps, Prosperity through Partnership Program in West Bank and Gaza, Cooperative Agreement 72029422CA00002, March 3, 2022, to December 31, 2023
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.
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.
For our evaluation of the Bureau of Industry and Security’s (BIS's) detection of and response to cyber incidents, our objective was to assess the adequacy of actions taken by BIS when detecting and responding to cyber incidents in accordance with federal and departmental requirements. We found that (1) BIS lacked effective detection and response capabilities to handle our simulated malicious activities; (2) BIS misconfigured critical security controls for its export control networks; and (3) BIS mishandled classified and other privileged credentials.
Audit of the Office of Justice Programs Victim Assistance Funds Subawarded by the California Governor's Office of Emergency Services to Building Futures with Women and Children, San Leandro, California
Financial Audit of the Consejo Nacional Anticorrupcin Program in Honduras, Managed by Consejo Nacional Anticorrupcin, Cooperative Agreement AID- 522-A-17-00001, January 1 to December 31, 2023
Closeout Financial Audit of the Forest Alliance Program in Peru, Managed by Asociacin para la Investigacin y Desarrollo integral, Cooperative Agreement 72052719CA00002, January 1, 2022, to June 4, 2024
Two Amtrak employees, Kevin Frink, 53, of Willingboro, New Jersey, and Dion Jacob, 51, of Brooklyn, New York, pleaded guilty to conspiracy to commit health care fraud on May 22, 2025, and June 11, 2025, respectively, in U.S. District Court, District of New Jersey. According to court documents, Frink and Jacob were given cash kickbacks for allowing health care providers to fraudulently bill Amtrak’s health care plan for services that were never provided and that were not medically necessary. The former employees were indicted on June 20, 2024, along with eight other employees.
We performed this review to determine the extent to which State Education Agencies (SEAs) and local educational agencies (LEAs) use digital wallets to facilitate the administration of U.S. Department of Education (Department) grant funds. Our review covered the period from October 1, 2022, through December 31, 2024. Forty-five SEAs responded to our survey regarding the use of digital wallets to facilitate the administration of Department grant funds. Twelve of those SEAs reported using digital wallets to help administer some of their Department grants during our review period, and three of these planned to continue using digital wallets in 2025. SEAs primarily relied on one digital wallet vendor to help administer their Department grant funds. That vendor, used by 11 of the 12 SEAs, was responsible for helping to administer more than 95 percent of the Department grant funds for which SEAs reported using digital wallets. SEAs used digital wallets almost exclusively for their pandemic relief Department grants, including the Governor’s Emergency Education Relief Fund, Emergency Assistance to Non-Public Schools grants, and Elementary and Secondary School Emergency Relief Fund grants. SEAs most commonly used digital wallets for automated direct deposit reimbursement or payment, built in controls for fund use, and tracking of funds; and several SEAs reported that they relied, at least partially, on their digital wallet vendors to help ensure that applicable Federal grant requirements were followed. According to the SEAs that responded to our survey, a small number of LEAs used digital wallets to help administer their Department grant funds during our review period. Only one SEA reported that its LEAs used digital wallets, and that SEA further reported that only 5 to 10 LEAs in the State used digital wallets. Although LEAs’ use of digital wallets appeared to be limited based on the survey results, the full extent of LEAs’ digital wallet usage is not known since 6 SEAs did not complete the survey and 15 of the 45 respondent SEAs reported that they did not know whether their LEAs used digital wallets to help administer Department grant funds.
Audit of the Federal Bureau of Investigation’s Participation in the Handling of Afghan Evacuees During Operation Allies Refuge and Operation Allies Welcome
OIG performed an inspection of the Office of the Chief Economist to determine the likely level of sophistication an attacker would need to compromise selected U.S. Department of Agriculture systems or data.
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 St. Louis Healthcare System in Missouri. This evaluation focused on five key content domains: • Culture • Environment of care • Patient safety • Primary care • Veteran-centered safety net The OIG issued five recommendations for improvement in two domains: 1. Environment of care • Supply storage locations and expired supplies • Video laryngoscope supplies • Safe and clean patient care areas • Preventive maintenance for biomedical equipment 2. Patient safety • Service-level workflows and processes to monitor patient test result communications
The National Credit Union Administration (NCUA) Office of Inspector General (OIG) conducted this self-initiated audit to assess how effectively the NCUA shared cyber threat information. Our objectives were to determine whether the NCUA: 1) effectively used shared cyber threat information for the supervision of credit unions; and 2) implemented effective processes to share cyber threat information to support credit union and financial system resiliency.
Our audit determined that the NCUA needs to mature its governance processes for cyber threat information sharing to support supervision of credit unions more effectively during a cybersecurity event or incident that may increase risk to the National Credit Union Share Insurance Fund (Share Insurance Fund or SIF) and financial services sector stability. Additionally, the NCUA should improve its ability to acquire, analyze, and use cyber threat information for internal analysis and external response. We made eight recommendations in our report and management agreed to all the recommendations.
The United States Coast Guard (Coast Guard) did not meet its illegal, unreported, and unregulated (IUU) fishing interdiction goals for fiscal years 2023 and 2024. For both FYs, the Coast Guard set its interdiction goal at 40 percent. This goal reflects efforts to prevent illegal foreign fishing vessels from encroaching on the U.S. Exclusive Economic Zone (EEZ). It measures the percent of detected vessels successfully interdicted by the Coast Guard.
The Federal Emergency Management Agency’s (FEMA) fiscal year 2023 Operation Stonegarden performance measure—prosecuted narcotic cases—accurately reflected Operation Stonegarden’s contributions to the President’s National Drug Control Strategy (the Strategy). Specifically, FEMA’s prosecuted narcotic cases measure reflects one of the Strategy’s key goals, namely, to reduce the supply of illicit substances in the United States.
Our objective was to determine whether the Defense Intelligence Agency (DIA) continuously applied strategies to optimize the use of funds and took timely monitoring actions to maximize the funding of mission requirements. This audit focused on DIA’s Operations & Maintenance and Family Housing single-year appropriations for fiscal years 2019-2023. We issued our results in a classified report on June 06, 2025.
This report presents the results of our audit of the Security of Electric Vehicle Charging Stations.
Our objective was to assess the security of the Postal Service’s EV charging stations. We contracted with a provider to evaluate the technical, communication, and data security controls of one charging station from each of the three vendors. We also conducted site visits to three Sorting and Delivery Centers to review physical security for safeguarding EV charging stations and evaluated policies and best practices for contingency planning.
The OIG inspection team assessed the effectiveness of GPO’s Government Publishing & Print Procurement’s (formerly Customer Services) key efforts to enhance the marketing of GPO services and increase the customer base, in accordance with the GPO Customer Services Strategic Plan FY 2023-2027.
Closeout Financial Audit of the Avancemos Bajo Cauca Program in Colombia Managed by Corporacin Interactuar Cooperative Agreement 72051419CA00007, January 01, 2023, to March 31, 2024
Financial Audit of the Community of Special Coffees Project, Managed by Central de Organizaciones Productoras de Caf y Cacao del Per, Cooperative Agreement 72052721CA00006, January 1, 2023, to December 31, 2023
An electrician based in Chicago, Illinois, was terminated from employment on June 5, 2025, following an administrative hearing. Our investigation found that the former employee violated company policy by failing to report his convictions for theft and improperly using leave granted under the Family and Medical Leave Act. The former employee is not eligible for rehire.
This PRAC fraud prevention alert focused on some of the largest pandemic relief programs: the Small Business Administration’s (SBA) COVID-19 Economic Injury Disaster Loan (COVID-19 EIDL) program and Paycheck Protection Program (PPP), and the Department of Labor’s (DOL) pandemic-related Unemployment Insurance (UI) programs. In 2023, the SBA Office of Inspector General (OIG) and the DOL OIG estimated that the total amount of fraud and improper payments for these programs is nearly $400 billion. In this alert, the PRAC estimates the amount of potential fraud across these programs stemming from the use of stolen or invalid Social Security numbers (SSNs), and illustrates how pre-award vetting using the PRAC’s data analytics tools could have mitigated this risk.
The Office of Inspector General is issuing this management advisory to present the results of our review of the U.S. Small Business Administration’s (SBA) incomplete reviews of Coronavirus Disease 2019 (COVID-19) Economic Injury Disaster Loans (EIDL) and grants disbursed to borrowers who self-disclosed their business establishment dates after January 31, 2020.
SBA asserted that the Coronavirus Aid, Relief, and Economic Security (CARES) Act requirement for a business to be in operation on or before January 31, 2020, applied only to COVID-19 EIDLs, not Emergency EIDL Advances. The Office of Inspector General disagreed and reiterated the CARES Act requirement that there be no waiver of eligibility for a business that was not in operation on or before January 31, 2020, which included Emergency EIDL Advances.
We made two recommendations for SBA to recover funds disbursed to ineligible applicants and to ensure automated controls are aligned with clearly defined disaster assistance criteria. Management’s planned action to resolve Recommendation 1 does not fully satisfy the intent of the recommendation; therefore, it will remain unresolved. Management’s planned action to resolve Recommendation 2 satisfies the intent of the recommendation; therefore, it will be closed upon issuance of this report.
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.
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 Portland Health Care System in Oregon.
This evaluation focused on five key content domains: • Culture • Environment of care • Patient safety • Primary care • Veteran-centered safety net
During our unannounced inspection of U.S. Immigration and Customs Enforcement’s (ICE) Buffalo Federal Detention Facility (Buffalo) in Batavia, New York, we found that Buffalo’s staff generally complied with Performance-Based National Detention Standards 2011, as revised in December 2016, for facility conditions, kitchen standards, legal access, medical care, recreation (general population only), and the voluntary work program. However, facility and ICE staff did not fully comply with standards related to the use of force, staff-detainee communication, detainee grievances, recreation in the Special Management Unit (SMU), classification, admission and release, and medical unit staffing. • We found one instance of an inappropriate use of force and two instances where facility staff should have used calculated rather than immediate force. • ICE did not always provide timely responses to detainee requests. Facility staff did not maintain an accurate or complete log for paper requests, nor did they always provide responses to detainee grievances within the required 5 days or capture all response dates in the grievance log. Likewise, the Grievance Appeal Board did not always conduct reviews within 5 days of each appeal. • Buffalo facility staff did not provide detainees in the SMU with exercise equipment in the outdoor space, prevent detainees of different classification levels from comingling in the same holding area, ensure detainees could hear or view captions for the orientation video, or ensure detainees’ identification wristbands were legible and always worn. • Vacant dentist and physician positions caused delays in care.
The Office of Inspector General is issuing an inspection report to determine whether the New Jersey Small Business Development Center met financial, programmatic, and performance requirements. The Small Business Administration (SBA) is authorized to make grants to states, institutions of higher education, and Women’s Business Centers to establish Small Business Development Centers (SBDCs). Since 1978, Rutgers University has been a recipient and hosts the New Jersey SBDC to administer the program.
For program year (PY) 2023, SBA awarded the New Jersey SBDC $3,620,094 in federal funds and the center contributed $4,303,349 in matching funds, for a total budget of $7,923,443. The period of performance for PY 2023 is from January 1, 2023, through December 31, 2024.
We identified operational improvements to protect program integrity and performance, such as maintaining counselors certified to assist small businesses with exporting, publicizing operating hours, informing SBDC personnel of whistleblower protections, and improving coordination with SBA so the center’s progress towards performance goals can be accurately tracked and monitored.
Financial Audit of USAID Resources Managed by Baylor College of Medicine Children's Foundation Malawi Under Cooperative Agreement 72061221CA00011, July 1, 2023, to June 30, 2024
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 Puget Sound Health Care System in Seattle, Washington.
This evaluation focused on five key content domains: • Culture • Environment of care • Patient safety • Primary care • Veteran-centered safety net
The OIG issued two recommendations for improvement in one domain: 1. Veteran-centered safety net • Staff access to government vehicles and cell phones
The U.S. Environmental Protection Agency Office of Inspector General conducted this evaluation to determine whether the EPA and its contractors followed Airborne Spectral Photometric Environmental Collection Technology flight equipment deployment procedures during the East Palestine, Ohio train derailment emergency.
Summary of Findings
During its response to the train derailment, the EPA and its contractors followed existing practices for deploying the ASPECT aircraft. Although the EPA followed existing practices for deploying ASPECT, the documented procedures that were in place remain largely unknown to all involved stakeholders and lack the clarity needed to avoid negatively affecting decision-making related to an emergency response.
Overseas Contingency Operations - Summary of Work Performed by the Department of the Treasury Related to Terrorist Financing and Anti-Money Laundering for the Second Quarter Fiscal Year 2025
Market Dominant mail classes, including First-Class Mail, Marketing Mail, and Periodicals, are some of the primary services the American public associates with the Postal Service. These classes contain well-known products like letters, postcards, advertising mail, bills, magazines, and newspapers.
While mail has been declining since 2006, mail still accounts for about half of the Postal Service’s revenue and the United States remains the world’s largest market for mail. The Postal Service plays a key role in ensuring the American public receives essential communications and products regardless of their location. However, the decline in mail volume in the last 10 years has been steep; First-Class Mail has declined 30 percent and Marketing Mail has declined 20 percent. This decline has been primarily caused by “electronic diversion,” the replacement of physical mail with electronic alternatives, including the internet, email, and text messages.
Over recent decades, the United States has seen a decline in its leadership in semiconductor chip manufacturing and research. To counter this and strengthen domestic semiconductor production and innovation, Congress passed the CHIPS Act of 2022.
The CHIPS Act provides $50 billion to the Department of Commerce to support semiconductor research, development, innovation, and manufacturing, along with authorization for up to $75 billion in direct loans and loan guarantees. The National Institute of Standards and Technology (NIST) oversees the Department’s CHIPS program.
This report provides the status of CHIPS Act programs for the period August 9, 2022, to January 31, 2025, and makes no recommendations. It describes the actions taken by the CHIPS Program Office (CPO) and the CHIPS Research and Development Office CRDO), which are the two NIST offices responsible for implementing the semiconductor incentive programs and research and development initiatives, respectively.
As of January 31, 2025, CPO has made 20 awards for up to $33.7 billion in direct funding and up to $5.5 billion in loans, and CRDO has awarded almost $8.3 billion to operate the National Semiconductor Technology Center and to fund research projects to bring new CHIPS technology to the commercial market.
Financial Closeout Audit of USAID Resources Managed by Invisible Children Inc. in Multiple Countries Under Cooperative Agreement 7260518CA00001, October 13, 2017, to March 30, 2023
This report was issued from a series of six reports taking an in-depth look at how six communities used the pandemic funding they received to address a wide range of needs. This report focused on Jicarilla Apache Nation Reservation in New Mexico with a detailed look at six of the 42 pandemic programs that provided funding to the community. This report was led by the Pandemic Relief Accountability Committee (PRAC) in coordination with HUD OIG as a project participant as well as additional Federal OIGs.
I am pleased to submit the Amtrak Office of Inspector General Semiannual Report to the United States Congress for the six months ending March 31, 2025, which summarizes our independent and objective reviews and investigations related to Amtrak’s programs and operations.
Under the Lead Safe Housing Rule (LSHR), owners of multifamily properties receiving assistance from the U.S. Department of Housing and Urban Development (HUD) must comply with specific requirements following reports that a child under the age of 6 residing in an assisted unit has a confirmed elevated blood lead level (EBLL). Some of these requirements are (1) ensuring that an environmental investigation is conducted to determine the source of the lead poisoning, (2) timely remediating or abating the source of the lead poisoning, if applicable, and (3) notifying both the Office of Multifamily Housing Programs (Multifamily) and the Office of Lead Hazard Control and Healthy Homes (OLHCHH) throughout the process. HUD requires owners to report EBLL response information to both HUD Field Offices and OLHCHH because such information must be received timely to ensure efficient and effective program administration and to monitor whether the owner has taken timely and appropriate steps to protect children who live in HUD-assisted multifamily housing.
We found that Multifamily lacks policies and processes to effectively ensure that property owners are managing reported EBLLs and are taking appropriate and timely steps to investigate and mitigate lead hazards. First, Multifamily has no internal policy specifying how staff should oversee property owners’ compliance with LSHR requirements following a potential or confirmed EBLL. Additionally, Multifamily’s property management information system, the Integrated Real Estate Management System (iREMS), is used to document digital files and interactions with property owners but was not designed to track reported EBLLs or property owners’ actions to mitigate lead hazards. HUD has received only two reports of EBLLs from multifamily property owners during fiscal years 2019 to 2024, and information on those reports in iREMS was either nonexistent or limited in nature.
To improve its oversight of owners’ responsibilities under the LSHR, Multifamily should (1) develop and implement a policy that clearly defines its staff’s roles and responsibilities for EBLL-related requirements and (2) establish a process to track reported EBLLs as well as actions required of property owners to mitigate lead hazards. Without implementing these measures, HUD will not have assurance that property owners who have children with EBLLs residing in their properties are taking timely and appropriate steps to protect residents from continued exposure to lead hazards.
We provided HUD with two recommendations to ensure HUD’s compliance with the LSHR’s specific requirements following reports that a child under the age of 6 residing in an assisted unit has a confirmed EBLL.
U.S. International Boundary and Water Commission, United States and Mexico, U.S. Section
Independent Auditor's Report on the International Boundary and Water Commission, United States and Mexico, U.S. Section, FY 2024 and FY 2023 Financial Statements
Our Semiannual Report to Congress covering the period October 1, 2024, to March 31, 2025, features highlights of the OIG’s audit and investigative accomplishments during the past 6 months.
This statutory report presents the activities and accomplishments of the OIG from October 1, 2024, through March 31, 2025. The audits, investigations, and related work highlighted in the report are products of our mission to identify and stop fraud, waste, and abuse; and promote accountability, efficiency, and effectiveness through our oversight of the Department’s programs and operations.
Under the provisions of the Inspector General Act of 1978 (Public Law 95-452), as amended, the U.S. Environmental Protection Agency Office of Inspector General reports to the Congress semiannually on its activities.
Summary
This report summarizes EPA Office of Inspector General work and accomplishments from October 1, 2024, through March 31, 2025.