Federal Reports

Coronavirus pandemic restrictions delayed work and limited on-site oversight, with disproportionate impacts to some communities.

During the fiscal year (FY) 2022 peak mailing season, U.S. Postal Service management implemented a new year-round strategy focused on a consistent build-up of employee complement, multi-year leases for facility space, and processing capacity to help ensure a successful peak mailing season. Our objective was to evaluate the Postal Service’s performance during the FY 2022 peak mailing season and implementation of its peak season preparedness plan. For this audit, we obtained supporting documentation, evaluated processing service performance, and interviewed Postal Service managers.

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, 2021, 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 17, 2021.1 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, 2021, in accordance with the audit requirements of Title 2 U.S. Code of Federal Regulations Part 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.

FEMA did not oversee and manage Hazard Mitigation Grant Program (HMGP) property acquisition projects efficiently or effectively, nor can FEMA provide assurance that projects are awarded equitably.

FEMA did not oversee and manage Hazard Mitigation Grant Program (HMGP) property acquisition projects efficiently or effectively, nor can FEMA provide assurance that projects are awarded equitably.

For our final report on fiscal year (FY) 2021 improper payment reporting, our review objective was to determine the U.S. Department of Commerce's (the Department’s) compliance with the Payment Integrity Information Act of 2019 (PIIA). To determine FY 2021 compliance, we reviewed the “Payment Integrity” section of the Department’s FY 2021 Agency Financial Report (AFR), accompanying materials to the AFR, and other improper payment-related documentation. We also assessed the Department’s efforts related to preventing and reducing improper payments and unknown payments. Based on our review, we concluded that the Department complied with the PIIA criteria for FY 2021. We did not identify any actions needed to further improve prevention and reduction measures within the Department.

We audited costs claimed by the Oklahoma Department of Wildlife Conservation under grants awarded by the U.S. Fish and Wildlife Service Wildlife and Sport Fish Restoration Program.

The DOI Interior Business Center had the necessary internal controls to prepare and submit client data, specifically related to the DATA Act.

The VA Office of Inspector General (OIG) reviews pharmaceutical proposals submitted to the VA National Acquisition Center for Federal Supply Schedule contracts valued annually at $5 million or more. The reviews are not published because they contain sensitive commercial information protected from release under the Trade Secrets Act.To promote transparency, this report summarizes the 15 preaward reviews of the pharmaceutical proposals that the OIG conducted in fiscal year 2021. The 15 proposals had a cumulative 10-year estimated contract value of about $8.3 billion and included a total of 846 offered drug items.The review team concluded, in part, that commercial disclosures were accurate, complete, and current for four of the 15 proposals reviewed. This means only those four disclosures were reliable for determining negotiation objectives and for fair and reasonable pricing. The remaining 11 proposals could not be reliably used for negotiations until the noted deficiencies were corrected.The OIG made recommendations for lower prices than offered for 10 of the 15 proposals by also examining comparable “tracking customers,” resulting in total recommended cost savings of approximately $328.8 million over the life of the contracts. Of that total, about $42.6 million in cost savings resulted from the Acquisition Center awarding contracts or modifications based on the OIG price recommendations. This report details the actions the OIG took in these reviews but does not propose any additional VA corrective actions.

Based on our audit, we determined that the Water Infrastructure Finance and Innovation Act of 2014 program’s loan award process and subsequent monitoring activities provided reasonable assurance that WIFIA loans were administered in accordance with federal and EPA requirements and that funding was used as intended to improve America’s public water infrastructure.

Since Fiscal Year (FY) 2017, AmeriCorps has not obtained an audit opinion on its financial statements. In FY 2021, independent auditors found nine material weaknesses and one significant deficiency, resulting in a total of 73 recommendations. In addition, each of AmeriCorps Office of Inspector General’s (OIG) annual Federal Information Security Modernization Act of 2014 (FISMA) evaluations since FY 2017 concluded that AmeriCorps’ cybersecurity and privacy program is ineffective. AmeriCorps has made little progress in implementing the 41 FISMA recommendations. The OIG historically conducts these evaluations in tandem with the financial statement audit because they overlap in significant respects. AmeriCorps’ challenges in financial management and accounting were the subject of December 1, 2021, hearing before the House Committee on Education and Labor. On a bipartisan basis, members articulated their expectation that AmeriCorps take decisive action to remedy the recurring problems identified in past financial statement audits. AmeriCorps, in response, described how it intends to address these serious weaknesses through a multi-year process and comprehensive corrective action plans (CAPs). To support these measures, the OIG engaged CliftonLarsonAllen, LLP (CLA), which conducted the financial statement audits and FISMA evaluations, to provide immediate feedback on AmeriCorps CAPS, approved as of January 7, 2022. While a CAP assessment should ordinarily occur during a financial statement audit and FISMA evaluation, AmeriCorps had not previously prepared meaningful CAPs. This report contains CLA’s assessment of the current CAPs. CLA rated 59 percent of the financial statement audit CAPs as “Reasonable,” 31 percent as “Required Refinement,” and 10 percent as “Inadequate.” For the FISMA evaluation CAPs, CLA determined that 66 percent were “Reasonable,” 22 percent “Required Refinement”, and 12 percent were “Inadequate.” CLA’s assessment included explanations for any CAP rated “Inadequate” and the improvements necessary to obtain a rating of “Reasonable.”Since the December 2021 hearing, AmeriCorps has made meaningful progress in creating CAPs and centralizing and elevating their supervision to the executive level. Additional expertise is needed, however, to address the most consequential of the material weaknesses. With a sustained commitment, AmeriCorps can substantially improve its financial management and cybersecurity infrastructure.

The VA Office of Inspector General (OIG) evaluated the merits of a May 2021 hotline complaint alleging that the Veterans Benefits Administration (VBA) disregarded privacy procedures so it could more quickly use a workload tracking system without receiving the appropriate security authorization. The Mission Accountability Support Tracker (MAST) helps quantify the work VBA’s support services staff perform in response to employee requests for facility, equipment, and vehicle management; reasonable accommodation; and identification card issuance and renewal. Because staff use personally identifiable information (PII) in their work, the information could be compromised in an unauthorized, unsecure application.The complaint also alleged that VBA knew that MAST did not have an approved privacy threshold analysis or privacy impact assessment, yet trained staff on using the system and knowingly “loaded” PII into the application. The privacy threshold analysis and privacy impact assessment mitigate the risk of unauthorized access and subsequent data misuse, changes, loss, or disclosure. The assessments also help ensure that systems or applications have security controls that are appropriate for the sensitivity of the information stored.The OIG found that VBA and the Office of Information and Technology (OIT) did not correctly follow privacy and security procedures. VBA’s privacy threshold analysis was inaccurate, and OIT did not conduct a privacy impact assessment. OIT’s misclassification of MAST as an asset resulted in insufficient security controls. Further, VBA lacked the authority to operate MAST before using it in regional offices.The OIG made four recommendations to ensure future information technology projects follow an approved management process and that VBA provides sufficient guidance to staff to ensure MAST is used as intended while keeping the PII of VA employees and contractors safe and secure.

This report presents a summary of the results of our self-initiated audits assessing mail delivery, customer service, and property conditions at three select delivery units in the Indianapolis, IN region (Project Number 22-091). These delivery units were the Plainfield Main Post Office (MPO) in Plainfield, the Carmel MPO in Carmel, and Linwood Station in Indianapolis. We previously issued interim reports to district management for each of these units regarding the conditions we identified. In addition, we issued a report on the efficiency of operations at the Indianapolis Processing and Distribution Center (P&DC), which services these three delivery units.All three delivery units are in the Indiana District of the Central Area and have a combined total of 66 city routes and 44 rural routes. Staffing at the delivery units during our audits included 69 full-time city carriers, 19 city carrier assistants, 45 full-time rural carriers, 23 rural replacement carriers, 24 full-time clerks, and five postal support employees (see Table 1).

Final Management Letter: Evaluation of the SEC’s FY 2021 Compliance With the Payment Integrity Information Act of 2019

A Trackman/Watchman based at Sunnyside Yard, New York, resigned on June 22, 2022, prior to his disciplinary hearing for time and attendance violations. Our investigation found that, between February 2020 and June 2021, the former employee improperly claimed and accepted payment for hours he did not work in violation of company policies. A Driver, also from Sunnyside Yard, admitted to us, however, that he clocked out for the Trackman/Watchman on approximately seven occasions and confirmed that the employee left work early on various occasions. The Driver resigned on June 21, 2022. Both employees are ineligible for rehire.

BackgroundTo meet its customers’ demands and needs, the U.S. Postal Service addressed its financial and operational challenges by developing its Ten-Year Plan — Delivering for America: Our Vision and Ten-Year Plan to Achieve Financial Sustainability and Service Excellence (the Plan). The Plan establishes strategies for achieving financial sustainability and service excellence and outlines the development of a new operating model to help improve service through strategies aligned to the changing needs of its customers. Our objective was to evaluate the Postal Service’s plan to change modes of transportation for First-Class Mail.

We inspected the DOI’s PIIA compliance and found the DOI complied with the Act, but we made two recommendations to improve its payment integrity.

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 Washington DC VA Medical Center and multiple outpatient clinics in Maryland, Virginia, and Washington, DC. The inspection covers key clinical and administrative processes that are 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.Medical center leaders had worked together for over three months at the time of the OIG virtual inspection, although several had served in their positions for more than a year. Employee satisfaction survey scores were generally better than VHA averages. Patient experience survey data were mostly lower than VHA averages, highlighting opportunities to improve both outpatient and inpatient care. The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures identified concerns with sentinel event and institutional disclosure processes. Medical center 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 six areas:(1) Leadership and Organizational Risks• Sentinel events and institutional disclosures(2) Quality, Safety, and Value• Systems redesign and improvement coordinator(3) Registered Nurse Credentialing• Primary source verification(4) Mental Health• Suicide safety plan training(5) Care Coordination• Inter-facility transfer monitoring and evaluation• Nurse-to-nurse communication(6) High-Risk Processes• Employee threat assessment team• Disruptive behavior committee meeting attendance• Staff training

This audit report shows Kearney found that EBBP funds were disbursed toproviders that met the provider eligibility requirements established by the FCC. Kearney also found deficienciesassociated with FCC’s reliance on providers to self-certify that the requirements under section904 of the Consolidated Appropriations Act of 2021 had been met.

DFC Complied with Payment Integrity Information Act of 2019 Requirements in Fiscal Year 2021

The purpose of this memorandum is to notify stakeholders of the decision to cancel the EAC OIG audit of the administration of HAVA funds by the State of Georgia.

Semiannual Report to Congress October 1, 2021 - March 31, 2022

Investigation into allegations of financial and ethical impropriety by Commission employee.

PPP documents submitted in an FWS’ employee’s name estimated income for two businesses with no evidence of reportable income related to either one.

This report presents the results of our evaluation of the U.S. Small Business Administration’s (SBA) handling of cash contributions and gifts. The objective of the evaluation was to determine the adequacy of SBA controls over the solicitation, acceptance, holding, and use of cash contributions and gifts.We found that SBA complied with the 2021 Consolidated Appropriations Act, SBA regulations and policies regarding soliciting and accepting cash contributions for National Small Business Week 2021. SBA’s Office of Communications and Public Liaison obtained proper approval from the Office of General Counsel for the 2021 National Small Business Week cosponsored activity.We recommended the agency enhance the tracking system with alerts to ensure responsible officials close out all cosponsored activities within 90 days, as required. We also recommended the agency implement quality control procedures to ensure that required fiscal agent and SBA documents for future National Small Business Week cosponsored activities are timely, complete, accurate, and can be relied on.SBA management agreed with both of our recommendations.

The Office of the Inspector General identified several instances where time was not accurately reported in the Personnel Qualification and Scheduling program (that is used to track employees’ hours to avoid a violation of the Nuclear Fatigue Rule) and the time-reporting system. However, we were unable to determine if all Nuclear Maintenance employees’ time was accurately reported because we could not account for time that employees were not badged into the protected areas (the area encompassed by physical barriers and to which access is controlled) of the plants. The inaccurate reporting resulted in a violation of the Nuclear Fatigue Rule, unnecessary paid time off for an employee, and overstated leave balances.

Our objective for this report was to assess the effectiveness of the company’s controls over payment requests.The company has a process that allows its employees to expeditiously make non-recurring and low-dollar purchases and certain high-dollar payments, subject to certain criteria. Known as “payment requests,” we found that the company’s controls over payment requests appeared to be generally effective in ensuring purchases were made for valid business purposes and that it correctly paid its vendors. We identified, however, opportunities to improve internal controls impacting its payment request process.To address the report’s findings, we recommended that the company more comprehensively and periodically analyze its payment request data to identify patterns of possible non-compliance and opportunities in which the company could do more to protect its interests and get a better value for its purchases through a contract.

Our evaluation objective was to determine whether the Department and its bureaus are managing national security systems in compliance with federal and Departmental information technology security requirements.We found the following:I. The Department mismanaged and neglected information technology security requirements for its national security systems.II. The Department wasted at least $380,000 on a national security system that it did not use.

The VA Office of Inspector General (OIG) contracted with the independent public accounting firm CliftonLarsonAllen LLP (CLA) to provide consulting services to the OIG with respect to selected financial reporting controls for the Integrated Financial and Acquisition Management System (iFAMS) at the National Cemetery Administration (NCA). VA is implementing iFAMS using an incremental approach with the first deployment having occurred at NCA in November 2020. The nature and scope of work for this consulting engagement was determined solely by agreement between the OIG and CLA and did not constitute an audit.In its consulting letter, CLA provided the OIG with observations and potential risks in such categories as obligations, reconciliations, opening balances, procurement, and intragovernmental transactions. The OIG shared this letter with management for their awareness, and CLA included management’s comments in its letter.

The attached report presents the results of the independent certified public accountants’ audit of the Western Federal Power System’s combined balance sheets, as of September 30, 2021, and 2020, and the related combined statements of revenues and expenses, changes in capitalization, and cash flows for the years then ended.To fulfill the Office of Inspector General’s audit responsibilities, we contracted with the independent public accounting firm of KPMG LLP (KPMG) to conduct the audit, subject to our review. KPMG is responsible for expressing an opinion on the Western Federal Power System’s financial statements and reporting on applicable internal controls and compliance with laws and regulations. The Office of Inspector General monitored audit progress and reviewed the audit report and related documentation. This review disclosed no instances where KPMG did not comply, in all material respects, with generally accepted government auditing standards. The Office of Inspector General did not express an independent opinion on the Western Federal Power System’s financial statements.KPMG concluded that the combined financial statements present fairly, in all material respects, the financial position of the Western Federal Power System as of September 30, 2021, and 2020, and the results of its operations and its cash flows for the years then ended in accordance with United States generally accepted accounting principles. As part of this audit, auditors also considered the Western Federal Power System’s internal controls over financial reporting and tested for compliance with certain provisions of laws, regulations, contracts, and grant agreements that could have a direct and material effect on the combined financial statements. The audit did not identify any deficiency in internal control over financial reporting that is considered a material weakness. The results of the auditors’ review of the Western Federal Power System’s compliance with provisions of laws and regulations disclosed no instances of noncompliance or other matters required to be reported under Government Auditing Standards.

NASA’s Earth Science Disasters Program uses observations from Earth-observing satellites to provide data and information products to U.S. and global entities to help predict, prepare for, respond to, and recover from natural, human-caused, and technological disasters. In this report, we assessed NASA’s management of the Program.

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 VA Maryland Health Care System, which includes the Baltimore, Loch Raven, and Perry Point VA Medical Centers, and multiple outpatient clinics in Maryland. The inspection covered key clinical and administrative processes associated with promoting quality care. This inspection 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 healthcare system’s leadership team had worked together for nearly three months, except for the interim Deputy Director, who was assigned one day prior to the inspection. Selected employee survey responses demonstrated satisfaction with leadership and maintenance of an environment where staff felt respected, and discrimination was not tolerated. Patient experience survey data implied general satisfaction with the outpatient care provided, however, leaders had opportunities to improve inpatient care satisfaction. Review of accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risks. The executive leaders were knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and factors contributing to poorly performing quality and efficiency measures.The OIG issued eight recommendations for improvement in three areas:(1) Quality, Safety, and Value• Peer review processes(2) Care Coordination• Patient transfer monitoring and evaluation• Inter-facility transfer form completion• Medication list transmission• Nurse-to-nurse communication(3) High-Risk Processes• Staff training

The VA Office of Inspector General (OIG) conducted this review to assess the oversight and stewardship of funds by the VA El Paso Healthcare System and to identify potential cost efficiencies in carrying out medical center functions. The review assessed the following financial activities and administrative processes to determine whether the healthcare system had appropriate oversight and controls in place: open obligations oversight, purchase card use, Medical/Surgical Prime Vendor-Next Generation (MSPV-NG) program use, and pharmacy operations.The team identified several opportunities for improvement:• The healthcare system did not perform required reviews for five of 10 inactive open obligations, totaling almost $3 million, risking funds not being used in the year they were appropriated, as required.• The healthcare system did not always properly oversee purchase card transactions. Twenty-two of 38 sampled transactions contained errors that resulted in $159,000 in questioned costs. This occurred because cardholders did not adhere to VA policy on document retention.• The healthcare system did not meet the goal to purchase 90 percent of formulary items from the MSPV-NG prime vendor, reaching only 14 percent on average. For 21 of 30 sampled purchase records, the review team questioned about $26,500 because the healthcare system did not submit national contract waiver requests, as required by VA policy.• The healthcare system could improve pharmacy efficiency by narrowing the gap between observed drug costs and expected drug costs, bringing the turnover rates closer to the VHA recommended level, and meeting requirements for noncontrolled drug line audits.The OIG made 12 recommendations to the VA El Paso Healthcare System director to use as a road map to improve financial operations. The recommendations address issues that, if left unattended, may eventually interfere with effective financial efficiency practices and the strong stewardship of VA resources.

This Insights Report highlights identity fraud related challenges in federal programs during the COVID-19 pandemic. By evaluating previous oversight work in this space from members of the PRAC’s Identity Fraud Reduction and Redress Working Group, this report presents best practices to reduce identity fraud before it occurs and to assist victims of identity fraud if it does occur. These best practices may be helpful for federal agencies to utilize moving forward. This report also identifies that across the federal government there is a larger focus on reducing identity fraud up front, while helping and supporting identity fraud victims has not been a concentrated focus area across the federal government. As such, the PRAC’s Identity Fraud Reduction and Redress Working Group will increase its focus on victim redress processes and claimant satisfaction.

The Federal Election Commission (FEC) Office of the Inspector General (OIG) initiated an inquiry on March 10, 2022, based on a referral from the Office of the Chief Information Officer (OCIO) that an agency employee with the Office of General Counsel (OGC) had lost her FEC laptop and may have failed to promptly report the loss in accordance with FEC policy.

We found that an energy company exceeded venting and flaring limits and that BSEE’s annual inspections are insufficient to identify similar issues.

The Office of the Inspector General conducted an evaluation to determine (1) the effectiveness of the radiation protection program in limiting employee dosage and (2) if notifications were made when required. We determined the Tennessee Valley Authority’s (TVA) radiation protection program was effective in limiting employee dosage levels during calendar years 2019 and 2020. Additionally, we determined the Nuclear Regulatory Commission and TVA personnel were notified, as required, when personnel dosage met regulatory milestones. However, we identified an opportunity for improvement related to performing dosimetry investigation reports.

The Department of Homeland Security did not comply with the Payment Integrity Information Act of 2019 (PIIA) in fiscal year 2021.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Renton Main Post Office (MPO) in Renton, WA (Project Number 22-097). The Renton MPO is in the Washington District of the WestPac Area and services ZIP Codes 98055 and 98058, which serves about 68,271 people and is considered to be an urban community. We judgmentally selected the Renton MPO based on the number of customer inquiries per route the unit received. From December 1, 2021, through February 28, 2022, the unit received 23.73 inquiries per route, which was more than the average of 13.52 inquiries per route for all sites serviced from the Seattle Processing and Distribution Center (P&DC) and the South Delivery Distribution Center (DDC).

NASA awarded a $383 million contract in 2019 to Bechtel National, Inc. to design and build a second mobile launcher—the ground structure that will assemble, process, transport, and launch a larger variant of the SLS rocket and Orion capsule to the Moon beginning with the Artemis IV mission. In this report, we examined whether NASA is meeting cost, schedule, and performance goals for the contract.

This flash report presents our finding concerning duplicate Higher Education Emergency Relief Fund (HEERF) grant awards to institutions of higher education.1 This report includes a recommendation to enhance the U.S. Department of Education’s (Department) ability to prevent, identify, and correct duplicate HEERF grant awards.We identified 25 duplicate HEERF grant awards that OPE made to 24 schools, totaling about $73 million, which had not been corrected and documented in G5 as of August 2021. OPE officials stated that their processes for reviewing and approving HEERF applications and awards, which evolved over time, resulted in OPE identifying and correcting many duplicate HEERF grant awards. However, we found that OPE’s processes did not always prevent or timely identify and correct duplicate HEERF grant awards, and that OPE did not consistently document activities taken to correct duplicate awards.

External peer review of the Farm Credit Administration Office of Inspector General's audit organization, conducted by the Federal Trade Commission Office of Inspector General.

This follow-up evaluation was conducted to assess whether inspection rates of treatment, storage, and disposal facilities have changed since our earlier 2016 report on the same topic: OIG Report No. 16-P-0104, EPA Has Not Met Statutory Requirements for Hazardous Waste Treatment, Storage and Disposal Facility Inspections, but Inspection Rates Are High, issued March 11, 2016.

International mail is primarily processed through the U.S. Postal Service’s International Service Centers (ISC). ISC operations focus on the timely and secure movement of international mail and packages. ISC staff use equipment to perform processing scans for events such as mail arrival and departure and customs clearance. Scan data is recorded in the Product Tracking and Reporting (PTR) system and converted to message scripts for customers tracking packages on USPS.com. Our objective was to assess the Postal Service’s international mail operations and performance data. We reviewed key international operations and data, including analyzing 543 packages judgmentally selected at ISCs from May-December 2021.

Given the importance of medical exams to disability claims and the high cost of VA’s contracts with exam vendors, the VA Office of Inspector General (OIG) set out to determine whether the Veterans Benefits Administration (VBA) oversaw contract medical disability exams to ensure they met quality standards and contractual requirements, established procedures for correcting errors, and gave feedback to vendors to improve exam quality.VBA’s governance of and accountability for the exam program needs to improve. The identified deficiencies appear to have persisted, at least in part, because of limitations with VBA’s management and oversight of the program at the time of the review. The OIG found VBA’s program was deficient because it hindered the ability to hold vendors accountable for correcting errors and improving exam accuracy. VBA should improve the program to help ensure vendors produce accurate exams to support correct decisions for veterans’ claims.Contract exams are a significant investment, and VA has spent nearly $6.8 billion since fiscal year 2017. Some of the exams produced by vendors have not met contractual accuracy requirements. As a result, claims processors may have used inaccurate or insufficient medical evidence to decide veterans’ claims. Therefore, it is vital for VBA to improve the governance and accountability of the program.The OIG made four recommendations to the acting under secretary for benefits, including ensuring vendors can be held contractually accountable for unsatisfactory performance and establishing procedures for vendors to correct errors. The OIG also recommended requiring the Medical Disability Examination Office to communicate vendor exam errors to the Office of Field Operations and the regional offices and demonstrate progress in correcting them, and analyze all available data to identify systemic errors and provide systemic exam issues and error trends to vendors.

The PRAC works with dozens of IGs across the federal government to oversee pandemic relief funds. These collaborative efforts have led thus far to ten lessons learned across the pandemic response, which we outline here in our Lessons Learned Report. This report is intended as a living document that we’ll update as we continue our mission.