Federal Reports

Pursuant to the VA Choice and Quality Employment Act of 2017 (VCQEA), the OIG conducted a review to identify clinical and non-clinical occupations experiencing staffing shortages within Veterans Health Administration (VHA). This is the ninth iteration of the staffing report, and the fifth evaluating facility-level data. The OIG evaluated staffing shortages by surveying VHA facilities, and compared this information to the previous four years. The OIG found that all 139 VHA facilities reported at least one severe occupational staffing shortage. The total number of reported severe shortages was 2,622. Twenty-two occupations were identified as a severe occupational staffing shortage by at least one in five facilities. Every year since 2014, the Medical Officer and Nurse occupations were reported as severe shortages. Practical Nurse was the most frequently identified clinical severe occupational staffing shortage in FY 2022, with 62 percent of facilities reporting this occupation. Custodial Worker was the most frequently reported non-clinical severe occupational shortage in FY 2022, with 69 percent of facilities reported the occupation. Medical Support Assistance was the most frequently reported Hybrid Title 38 severe occupational shortage. In FY 2022, VHA reported twenty-two percent more severe occupational staffing shortages as compared to FY 2021. FY 2022 is the first year since implementation of VCQEA reporting requirements in which the OIG did not observe a yearly decrease in the overall number of severe occupational staffing shortages; it was also the first time that facilities identified more than 90 occupations as severe shortages. The OIG again determined the ongoing need for Custodial Worker and Medical Support Assistance, noting an increase in the number of facilities identifying these occupations as severe shortages. The OIG emphasizes the importance of VHA’s continued assessment of severe occupational staffing shortages given the increases from FY 2021 to FY 2022.

The Office of Inspector General (OIG) initiated an inspection to assess allegations of deficient practices within the Sterile Processing Service (SPS) at the Edward Hines, Jr. VA Hospital (facility) in Hines, Illinois, as well as the alleged failure of SPS leaders to provide adequate oversight, quality control, education, and training to SPS staff. The OIG did not substantiate that dirty instruments were sent to the operating room, that endoscopes were not being cleaned properly, that loaner trays were not reprocessed appropriately, or that SPS standard operating procedures were chaotic and incomplete. The OIG found no reported deficiencies in reprocessing of reusable medical equipment for operating room use during the period of the inspection. The OIG also assessed the status of facility action plans from April 2021, which addressed prior SPS deficiencies, and found that the facility had implemented and sustained process improvement actions. The OIG did not substantiate that SPS leaders failed to provide adequate oversight, quality control, education, and training to SPS staff or that SPS leaders and education and training staff lacked appropriate knowledge to provide staff training. SPS leaders and education and training staff implemented relevant training plans and assessed staff competencies in accordance with VHA policy. SPS leaders conducted oversight of staff competencies per VHA policy.Although the OIG noted instability within SPS leadership positions, facility leaders worked with Veterans Integrated Service Network (VISN) subject matter experts to ensure continuity of leadership when vacancies existed. The OIG learned of challenges related to workplace culture within SPS, which may have factored into unsubstantiated negative perceptions of service leadership.The OIG determined that both the VISN and facility leaders maintained adequate oversight, identifying and taking actions in response to concerns, and providing support for quality improvement efforts within SPS at the facility.

Our objective was to determine to what extent CBP adheres to its policies and procedures for resolving facial biometric discrepancies when confirming travelers’ identities at airports.

The objective was to determine the extent to which DHS is positioned to prevent and reduce domestic terrorism in the United States. We determined that DHS has taken steps to help the United States counter terrorism, but those efforts have not always been consistent.

Our objective was to assess the Postal Service’s justification for and use of funds received under the CARES Act, as amended by the Consolidated Appropriations Act of 2021, and associated disclosure requirements.

For our final report on our audit of the U.S. Department of Commerce’s (the Department’s) Business Applications Solution program (the Program), our objective was to assess the Department’s management and implementation of the Program. To meet our objective, we determined the extent to which the Program implemented four selected best practice areas—business process reengineering, requirements management, program monitoring, and risk management—and identified opportunities for improvement. We found the following: I. the Program continues to lack a sound business process reengineering plan; II. the Program should address weaknesses in its requirements management plans and processes; and III. the Program should enhance its risk management practices.

This letter advises of the closure of the audit of the U.S. Department of Education’s enforcement of entities’ compliance with the Family Educational Rights and Privacy Act of 1974.

The Office of the Inspector General audited TVA’s information technology (IT) equipment inventory to determine if TVA had controls and processes in place to maintain an accurate and complete inventory of IT equipment. Due to the inventory inaccuracies and control weaknesses, we did not test for inventory completeness. Although we found access controls to IT inventory data were effective, we found TVA’s controls and processes in place to maintain an accurate and complete inventory of IT equipment were ineffective. Specifically, we found IT inventory (1) records were not accurate, (2) lacked reconciliation processes, (3) lacked a deployment and tracking policy, and (4) policies and procedures were not reviewed and updated timely. TVA management agreed with our recommendations.

The objective was to determine the extent to which the Office of Intelligence and Analysis (I&A) has an effective process for collecting, managing, and protecting open source intelligence (OSINT) for operational and intelligence purposes.

In the course of its work, the OIG learned that survey records for VA educational programs submitted remotely during the pandemic lacked sufficient protection for students’ personally identifiable information. This management advisory memorandum conveyed information needed for the Veterans Benefits Administration (VBA) to determine the need for corrective actions.Both VBA and state approving agencies use education compliance survey specialists to conduct in-person surveys meant to ensure VA payments to each school and the students enrolled there are based on proper and correct enrollment information, and applicable legal requirements are met. But on March 16, 2020, VBA required surveys to be conducted remotely and documents submitted electronically to the survey specialists as COVID-19 precautions. About 4,570 surveys were conducted through March 16, 2022. The OIG estimates almost 37,800 students had their records requested in the process.The OIG reviewed documents for 30 of those compliance surveys and found 26 contained personally identifiable information of 323 students, including full names, dates of birth, social security numbers, and addresses.VBA’s guidance for remote compliance surveys says under circumstances including a travel ban schools should submit requested documents by mail or email (with no mention of encryption). The memorandum issued to suspend in-person compliance surveys did not provide any indication of how documentation should be collected electronically. VBA and state approving agency staff asked school certifying officials to send the documents electronically, instead of requiring they be sent by mail with a tracking number.The lack of standard procedures and oversight has resulted in personally identifiable information not being consistently safeguarded as required. The OIG did not assess whether any information had been inappropriately disclosed but requested that VBA provide follow-up information. VBA agreed to review, research, and evaluate the OIG findings and take corrective action as needed.

The U.S. Postal Service and the Board of Governors released their 10-year strategic plan, called Delivering for America: Our Vision and Ten-Year Plan to Achieve Financial Sustainability and Service Excellence (the Plan), on March 23, 2021. The Plan outlines steps to achieve a positive net income within three years and break-even operating performance over the next 10 years. To achieve these objectives, the Postal Service identified 13 strategic focus areas, which are supported by 175 initiatives designed to eliminate a 10-year projected loss through additional revenue and cost savings opportunities, totaling $160 billion.Our objective was to evaluate the Plan to determine if the underlying assumptions and projections were supported and whether metrics were established and reasonable. We reviewed 58 key initiatives, their risks and interdependencies, as well as methods of communication for internal and external stakeholders.

We inspected the U.S. Small Business Administration’s (SBA) award and payment practices used to administer the Shuttered Venue Operators Grant (SVOG) program.Even after determining multiple disbursements would better protect grant funds from fraud or misuse, SBA switched to a riskier single advance payment for all grantees. This payment method may have hastened award disbursement, but the agency removed internal controls that would have better protected taxpayer funds. Multiple disbursements enable program officials to verify that grant recipients used award funds for allowable activities before disbursing additional funds.We selected 10 awards, totaling $33.2 million, to use as a sample to test SBA’s disbursement and budget approval practices. None of the 10 awards reviewed had the proper documentation signed by an authorized government official. The authorizing agency signature on the notice of award demonstrates that the proper procedure has been followed and the obligation has been officially recorded. Without the proper official documentation, all 10 awards we reviewed, totaling $33.2 million, are unauthorized commitments.Program officials did not ensure it had adequate support for the grant amounts in 3 of the 10 awards we reviewed. SBA awarded these three recipients $2.6 million above amounts that were requested. The higher grant award amounts did not correspond to their budgets, nor was there supporting documentation to show why SBA awarded the higher amounts. In addition, SBA did not consistently ensure the recipient’s budget accurately summarized the financial plan for the award amount. Awards made to 1,849 recipients, totaling $1.49 billion, did not have a budget that reconciled to the award amount.We made six recommendations for SBA management to ensure SBA properly safeguards program funds and improves disbursement and award procedures while administering the SVOG program. SBA management agreed or partially agreed with four recommendations and disagreed with two. Management’s planned actions resolve all six recommendations.

The objective was to conduct an unannounced inspection of Folkston Processing Center and Folkston Annex to monitor compliance with select ICE detention standards.

The USPP failed to record all its radio communications in the WMA for more than 2 years, but now has a functioning recorder.

SIGPR Quarterly Report to Congress

Without additional internal controls, the EPA cannot ensure that it effectively screens regulated entities’ self-disclosures of environmental violations to identify and mitigate significant concerns, such as criminal conduct and potential imminent hazards. If not mitigated, these significant concerns could pose threats to human health and the environment.

The Transportation Cost System (TRACS) is a statistical sampling and data collection system the U.S. Postal Service uses to estimate transportation costs and distribute those costs to mail categories, set prices, create new products and services, and provide operational information to management. There are two types of TRACS tests: Air and Surface. The Postal Service uses TRACS – Surface to estimate and distribute transportation costs for highway, railroad, and water transportation accounts.

The VA Office of Inspector General (OIG) assessed allegations at the New Mexico VA Health Care System (facility) regarding the policy and practices related to the provision of buprenorphine treatment for patients with opioid use disorder.The OIG substantiated that pharmacists declined early refills of buprenorphine despite prescribing providers’ documented clinical rationales, which increased patients’ risk for adverse clinical outcomes associated with interruption of buprenorphine treatment. The OIG substantiated that justification for declining early refills was incorrectly based on a facility policy that was not applicable to the use of buprenorphine for treatment of opioid use disorder.The OIG substantiated that the Opioid Safety Committee pharmacist placed standing orders for urine drug screening without coordinating with patients’ prescribing providers. However, the pharmacist acted within the scope of practice.The OIG did not substantiate that the facility’s Opioid Safety Committee Chairperson interfered with prescribing providers’ practices regarding buprenorphine orders for patients with opioid use disorder, the facility’s standing operating procedure (SOP) on buprenorphine treatment for patients with opioid use disorder was inconsistent with VHA guidance or that facility practices varied from VHA guidance on increasing access to buprenorphine.The OIG did not substantiate that facility leaders failed to respond to a provider’s report of patient safety concerns. However, actions taken by leaders did not fully address the reported concerns.The OIG identified a related concern regarding staffing challenges that affected the Substance Use Disorder program and plans for expanding buprenorphine treatment.The OIG made five recommendations to the Facility Director to align facility practices with policy applicable to early refills for buprenorphine; ensure communication between providers, pharmacists, and patients for early medication refills; clarify and educate staff on the Opioid Safety Committee’s role in buprenorphine treatment; revise the facility’s buprenorphine SOP; and review Substance Use Disorder provider staffing.

Refrigerated pharmaceuticals must be stored within manufacturer-recommended temperature ranges to maintain their potency. Exposure to excessive heat, cold, or light can cause these pharmaceuticals to lose potency, risking significant waste of medical and financial resources.In January 2019, VA reported a loss of about $1.1 million because medical facilities failed to maintain appropriate storage temperatures for refrigerated pharmaceuticals. These losses prompted Veterans Health Administration’s (VHA) Pharmacy Benefits Management Services (PBM) to issue three notices between January 2020 and August 2021 to clarify responsibilities, processes, and procedures for safeguarding refrigerated pharmaceuticals.The VA Office of Inspector General (OIG) conducted this audit to determine if VA medical facilities met requirements to safeguard the potency and value of refrigerated pharmaceuticals and found that VA medical facilities generally did so. For example, most medical facilities reported using electronic monitoring systems with software alerts for temperature excursions, and most medical facilities reported using, or being in the process of acquiring, pharmaceutical-grade purpose-built refrigerators and freezers.Some refrigerated pharmaceutical loss is expected, and VA medical facilities reported about $1.7 million in such losses for fiscal year 2021 out of about $1.4 billion spent on these kinds of drugs, a figure the OIG acknowledges is comparatively minimal. PBM officials agreed that medical facility officials need to strengthen and reinforce safeguards to further reduce their risk of refrigerated pharmaceutical loss and risk to veterans who could receive compromised medications or vaccines.The OIG recommended the under secretary for health reinforce requirements for storing refrigerated pharmaceuticals and establish a procedure to ensure medical facilities comply with VHA Notice 2021-16. Guidance should also be updated to clarify that medical facilities must report all refrigerated pharmaceutical loss.

We audited the expenditures made by the Mississippi Department of Wildlife, Fisheries, and Parks under grants awarded by the FWS.

Our objective was to evaluate DIA's efforts to assess, standardize, and coordinate open source intelligence tools and data sets across the Department of Defense Components. We issued our results in a classified report on June 30, 2022.

We found that a former employee embezzled funds and she pleaded guilty and was sentenced.

We substantiated allegations that a former employee misapplied BIE grant funds. He pleaded guilty and was sentenced.

The Office of Inspector General (OIG) assessed allegations at Tuscaloosa VA Medical Center (facility) that facility and community living center (CLC) leaders failed to address CLC safety and security issues, and that facility leaders failed to fill key positions, utilize unused space, and ensure environment of care and grounds provided a safe setting.Facility leaders failed to address CLC safety and security issues resulting in a resident’s elopement. The OIG found a 2018 quality improvement recommendation to install an alarm system was not implemented until November 2021. The OIG identified concerns regarding operability of CLC cameras, CLC outdoor security, and use of elopement risk alerts in residents’ electronic health records and determined these concerns likely contributed to, or failed to mitigate, resident elopements.Facility leaders failed to fill several key positions. Difficulty in recruiting candidates, lower salary levels, and challenging human resource processes were contributing factors.The OIG did not substantiate facility leaders failed to use available space. Although the facility had unused space, the OIG found the lack of use did not limit patient care.The OIG did not substantiate facility leaders failed to ensure the environment of care and grounds provided a safe setting. The OIG determined facility leaders did not inspect patient care areas and grounds per policy and due to multiple findings during the on-site visit and determined the facility’s environmental care rounds were ineffective. However, the OIG found the facility’s grounds were generally maintained and did not observe safety concerns that impacted patient care.The OIG made one recommendation to the Veterans Integrated Service Network (VISN) Director to ensure completion of VISN site visit recommendations. Nine recommendations were made to the Facility Director to assess CLC security; develop a plan for coverage recruitment, and retention of difficult to fill positions; and improve environmental care rounds.

This report contains information about recommendations from the OIG's audits, evaluations, reviews, and other reports that the OIG had not closed as of the specified date because it had not determined that the Department of Justice (DOJ) or a non-DOJ federal agency had fully implemented them. The list omits information that DOJ determined to be limited official use or classified, and therefore unsuitable for public release.The status of each recommendation was accurate as of the specified date and is subject to change. Specifically, a recommendation identified as not closed as of the specified date may subsequently have been closed.

This audit examined whether NASA complied with the requirements of the Payment Integrity Information Act of 2019 (PIIA) for FY 2021.

The VA Office of Inspector General (OIG) conducted this review to determine whether VA complied with the requirements of the Payment Integrity Information Act of 2019 (PIIA) for fiscal year (FY) 2021. The PIIA, enacted in March 2020, requires federal agencies to identify and review all programs and activities they administer that may be susceptible to significant improper payments based on Office of Management and Budget (OMB) guidance. In addition, PIIA requires inspectors general to review each of their agency’s improper payment reporting and issue an annual report.Agencies found to be noncompliant with PIIA and OMB guidance are required to perform additional reporting to OMB, Congress, and the Comptroller General depending on the number of years the OIG found them noncompliant. FY 2021 is considered the first year for any program considered noncompliant when applying those additional reporting requirements.In FY 2021, VA reported improper and unknown payment estimates totaling $5.12 billion for seven programs and activities. Of that amount, about $1.97 billion (around 39 percent) represented a monetary loss, and the remaining approximately $3.14 billion (about 61 percent) was considered either a nonmonetary loss or unknown payment that cannot be recovered. Though VA had an overall decrease in total improper payments and unknown payments, the overall monetary loss more than doubled from $892 million in FY 2020 to $1.97 billion.VA satisfied nine of the 10 requirements under the PIIA; however, it is not considered to be compliant because it failed to report an improper and unknown payment rate of less than 10 percent for four VA programs and activities that had estimates in the accompanying materials to their financial statements.The OIG recommended the under secretary for health reduce improper and unknown payments to below 10 percent for the noncompliant programs.

OIG reviewed USDA’s compliance with improper payment and high-dollar overpayment requirements for FY 2021.

The Office of Inspector General (OIG) conducted a healthcare inspection to assess concerns regarding facility providers’ failures to communicate, act on, and document a patient’s abnormal test results. The OIG also evaluated the facility’s quality management processes in response to identified deficiencies in the patient’s care.The OIG identified multiple providers’ failures to communicate, act on, and document abnormal test results from July 2019 until April 2021, when the patient was diagnosed with metastatic prostate cancer. In July 2019, a vascular surgeon failed to communicate and act on an abnormal CT scan, which noted a potentially malignant lesion in the prostate gland. In September 2020, a nurse practitioner failed to adequately address the patient’s urologic complaints during telephone triage call. In fall 2020, a primary care provider failed to communicate test results to the patient and to act on an abnormal PSA test result by not performing follow-up tests or consulting a urologist. In March 2021, the primary care provider failed to correctly enter bone scan orders in the electronic health record. A technologist attempted to correct this error; however, a facility registered nurse with no knowledge of the patient was entered as the ordering provider. Consequently, the results, which showed possible metastatic bone disease, were not sent to a provider. In April 2021, the patient’s new primary care provider became aware of the bone scan findings and communicated the results to the patient.The OIG concluded that the failures contributed to a delay in the diagnosis of prostate cancer. Additionally, the OIG found that facility leaders did not initiate peer reviews within three days and facility staff did not submit patient safety reports as required.The OIG made seven recommendations to the facility director related to communication of abnormal test results, entering imaging orders, urology consults, and quality reviews.

This audit report shows Kearney noted two of the 10 FCC programs,the Universal Service Fund (USF) Lifeline (LL) program and the USF High Cost (HC) program,were not compliant with at least one PIIA criteria. Overall, Kearney’s audit report includes six findings along with 17 recommendations.

The EPA needs to implement appropriate control measures to better identify and reduce the risk of its improper payments.

Audit of case handling efforts to reduce charge filing to disposition time for FY 2019 and FY 2020 as compared to FY 2018.

What We Looked AtThe Payment Integrity Information Act of 2019 (PIIA) requires agencies to identify, report, and reduce improper payments in programs susceptible to significant improper payments. For fiscal year 2021, the Department of Transportation (DOT) tested three programs with total expenditures over $49 billion and estimated that about 1.41 percent were improper payments. PIIA also requires inspectors general to report annually on their agencies' compliance. Accordingly, our audit objective was to determine whether DOT complied in 2021 with PIIA's requirements.What We FoundDOT is in compliance with PIIA requirements. For fiscal year 2021, DOT reported improper payment estimates for three susceptible programs. The payment integrity information in DOT's 2021 Agency Financial Report and data posted to the Payment Accuracy website were accurate and complete. A clerical error related to payment recapture data for two programs occurred but did not impact DOT's compliance with PIIA. DOT conducted four risk assessments for programs and reported one program, the Federal Transit Administration's (FTA) Coronavirus Aid, Relief, and Economic Security Act program, susceptible to significant improper payments. DOT published improper and unknown payment amounts and estimated future rates on the Payment Accuracy website. However, we found issues with the universe population identification procedures for the Federal Aviation Administration's and FTA's Bipartisan Budget Act of 2018 activities. The Federal Highway Administration's (FHWA) Highway Planning and Construction Program did not meet its reduction target of .80 percent and reported estimated improper payments about $697 million. The total estimate did not impact FHWA's compliance with PIIA. For fiscal year 2021, DOT reported an improper and unknown payment estimate of less than 10 percent. FHWA improved its corrective action plan by focusing on root causes of improper and unknown payments and prioritized these actions.RecommendationsDOT concurred with our three recommendations to help improve its reporting processes for improper payments. We consider these recommendations resolved but open pending completion of planned actions.

The objective of our audit was to determine whether the U.S. Department of Education complied with the Payment Integrity Information Act of 2019 (PIIA) for fiscal year (FY) 2021.The Department did not comply with the PIIA because it did not meet one of the six compliance requirements. The Department published unreliable improper payment estimates for three programs that required an estimate for FY 2021: Title I, Part A; Pell; and Direct Loan. We reviewed the corrective action plans and found the Department’s Title I, Part A proposed corrective actions to be inadequate and ineffective in addressing the true root cause of the reported improper payments.

We audited the U.S. Department of Housing and Urban Development’s (HUD) fiscal year 2021 compliance with the Payment Integrity Information Act of 2019 (PIIA) and implementation of Office of Management and Budget (OMB) guidance.  PIIA was enacted to prevent and reduce improper payments and require each agency’s inspector general to perform an annual review of the agency’s compliance with PIIA.  Our objectives were to assess (1) whether HUD had met all requirements of PIIA and OMB Circular A-123, Appendix C-Requirements for Payment Integrity Improvement and (2) HUD’s efforts to prevent and reduce improper and unknown payments.We found that HUD was noncompliant with PIIA in fiscal year 2021.  Specifically, HUD’s improper and unknown payment estimates were noncompliant and unreliable because HUD was unable to test the full payment cycle for the Office of Public and Indian Housing’s Tenant Based Rental Assistance (PIH-TBRA) and Office of Multifamily Housing’s Rental Subsidy (MF-Rental Subsidy) programs, representing 63 percent of HUD’s total expenditures. This was due to logistical and security challenges, as documentation was not readily available, and HUD could not properly secure the data.  Without completing its testing, HUD reported a 100 percent payment accuracy rate, instead of classifying the rate as unknown in accordance with OMB criteria.  This put HUD at risk of not implementing corrective actions and other compliance requirements.  In addition, in the PIH-TBRA program, two of the primary monitoring and verification controls for improper payment detection and prevention were suspended due to COVID-19 related issues, increasing the risk of improper payments.  HUD also missed opportunities to detect improper and unknown payments in its Office of Community Planning and Development (CPD) programs.  Finally, there were some errors in HUD’s information on PaymentAccuracy.gov due to new government-wide processes.  While HUD made some progress in fiscal year 2021, significant efforts are needed to bring PIH-TBRA and MF-Rental Subsidy programs into compliance.For HUD’s noncompliant programs, we recommend that HUD (1) develop and implement a sampling methodology that allows for the timely testing of the full payment cycle and (2) consult with OMB on the appropriate reporting for untested portions of the payment cycle.  Next, we recommend that HUD develop and implement a plan that ensures adequate internal controls over the PIH-TBRA program to detect and prevent improper payments, which can be implemented in a virtual environment.  We also recommend that HUD work with grantees to better identify the risks of improper and unknown payments throughout the payment cycle in its CPD programs and ensure that its risk assessments and improper and unknown payment estimates fully consider these risks.  Finally, we recommend that HUD coordinate with OMB to ensure that its data on PaymentAccuracy.gov are accurate.

The Smithsonian Office of the Inspector General contracted with Castro & Company, LLC to evaluate the effectiveness of the Smithsonian's information security program in fiscal year 2021.

Our ongoing inspection is reviewing P‑EBT—this report provides the results on Objectives 1, 3, and 4 for P‑EBT funding and outreach activities, and the procedures and criteria FNS used to approve State plans.

We assessed how AMS designed the Farmers to Families Food Box Program solicitation, whether AMS awarded the contracts in accordance withrequirements, and what methodology AMS used to allocate funding.