Federal Reports

A Negotiated Service Agreement (NSA) is a customized and mutually beneficial contractual agreement between the U.S. Postal Service and a specific mailer, customer, or organization to retain price-sensitive customers and encourage additional mail volume and revenue. An NSA provides for customized classifications and pricing under the terms and conditions established in the NSA and may include modifications to current mailing standards and other Postal Service requirements. Our objective was to assess processes, methodologies, accuracy of data, and internal controls for pricing competitive outbound international NSAs. We reviewed NSA data related to cost coverage, inflation, and contingency factors for fiscal years (FY) 2018 through 2021. We also reviewed Postal Service policies and procedures for minimum revenue commitments of NSAs, and FY 2021 through FY 2022, Quarter 2, data to determine the number of customers not meeting minimum revenue commitments.

A Negotiated Service Agreement (NSA) is a customized and mutually beneficial contractual agreement between the U.S. Postal Service and a specific mailer, customer, or organization to retain price-sensitive customers and encourage additional mail volume and revenue. An NSA provides for customized classifications and pricing under the terms and conditions established in the NSA and may include modifications to current mailing standards and other Postal Service requirements. Our objective was to assess processes, methodologies, accuracy of data, and internal controls for pricing competitive outbound international NSAs. We reviewed NSA data related to cost coverage, inflation, and contingency factors for fiscal years (FY) 2018 through 2021. We also reviewed Postal Service policies and procedures for minimum revenue commitments of NSAs, and FY 2021 through FY 2022, Quarter 2, data to determine the number of customers not meeting minimum revenue commitments.

For our final report on our audit of the National Oceanic and Atmospheric Administration’s (NOAA's) next-generation satellite system architecture, our objective was to assess NOAA's progress planning and implementing this architecture. We found the following: I. NOAA requirements management practices need improvement; and II. NOAA should improve tools in support of observing system portfolio management.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Kent Main Post Office (MPO) in Kent, WA (Project Number 22-096). The Kent MPO is in the Washington District of the WestPac Area and services ZIP Codes 98030, 98031, and 98032, which serves about 105,501 people and is considered to be an urban community. We judgmentally selected the Kent MPO based on the number of stop-the-clock3 (STC) scans occurring at the delivery unit, rather than at the customer’s point of delivery.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Lacey Branch in Lacey, WA (Project Number 22-098). The Lacey Branch is in the Washington District of the WestPac Area and services ZIP Codes 98513 and 98516, which serves about 51,113 people and is considered an urban community. We judgmentally selected the Lacey Branch based on the number of customer inquiries the unit received related to package tracking and mail delivery delays. From December 1, 2021, through February 28, 2022, the unit received 25.65 inquiries per route, which was more than the average of 12.28 inquiries per route for all sites serviced by the Seattle Processing and Distribution Center (P&DC).

Under the Infrastructure Law, the Department of Energy’s Office of Fossil Energy and Carbon Management is to receive $2.1 billion to implement the new Carbon Dioxide Transportation Infrastructure Finance and Innovation Program, which can be distributed through loans, loan guarantees, or grants. To carry out this new program, the Department entered into a Memorandum of Understanding with the Loan Programs Office (LPO) to administer the funding based on its experience in evaluating financing for large-scale energy infrastructure projects and issuing Government loans and loan guarantees. In addition to the impending Infrastructure Law funding, the LPO currently administers three distinct loan programs with more than $40 billion in loan and loan guarantee authority, as well as manages a portfolio comprising of more than $30 billion of loans, loan guarantees, and conditional commitments.The Office of Inspector General has identified prior reports from six audits, two inspections, and numerous investigations regarding the LPO. Additionally, we identified several Government Accountability Office reports related to the LPO. Based on our review of this body of work, we identified four major risk areas that warrant immediate attention and consideration from Department leadership to prevent similar problems from recurring. Specifically, this includes: insufficient federal staffing; inadequate policies, procedures, and internal controls; lack of accountability and transparency; and potential conflicts of interest and undue influence.As part of this effort, we discussed the risk areas highlighted above with LPO officials. According to LPO officials, actions have been taken or were underway to address the risk areas. For example, officials asserted that the number of staff has significantly increased in recent years and additional positions are being actively pursued to ensure sufficient staffing exists to meet program needs. In addition, officials indicated that enhanced policies and procedures are in place that address previously identified weaknesses. These policies include more stringent documentation requirements and require the LPO to conduct an annual assessment of internal controls to validate their effectiveness. Further, LPO officials noted that administrative remedies would be considered and pursued as necessary as the program moves forward with new loans and loan guarantees.While LPO officials asserted that actions have been taken or were underway to address the risk areas, we did not perform test work to determine whether the actions will be fully effective to correct previously identified weaknesses. As such, we have identified several prospective considerations to help prevent fraud, waste, and abuse as the Department moves forward with financing projects funded through the Infrastructure Law and existing loan authorities. As a top priority, we suggest that the LPO undertake proper staffing, and develop comprehensive policies, procedures, and internal controls to ensure the Government and taxpayers are adequately protected.

As part of the Veterans Health Administration’s (VHA) suicide prevention strategy, suicide prevention coordinators at VA medical facilities are required to reach out to veterans referred from the Veterans Crisis Line. Coordinators provide access to assessment, intervention, and effective care; encourage veterans to seek care, benefits, or services with the VA system or in the community; and follow up to connect veterans with appropriate care and services after the call. VHA’s Office of Mental Health and Suicide Prevention is responsible for issuing policy and guidance for managing crisis line referrals. The VA Office of Inspector General (OIG) conducted this review to evaluate whether coordinators properly managed crisis line referrals to ensure at-risk veterans were reached.The OIG found that coordinators mistakenly closed some veteran referrals because coordinators lacked the proper training, guidance, and oversight necessary to maximize chances of reaching at-risk veterans referred by the crisis line. VHA lacked comprehensive performance metrics to assess coordinators’ management of crisis line referrals, and coordinators lacked clear guidance on how to manage crisis line referrals. Until VHA provides appropriate training, issues adequate guidance, and improves performance metrics, coordinators could miss opportunities to reach and assist at-risk veterans.The OIG made five recommendations to the under secretary for health that include improving data integrity, training coordinators on using patient outcome codes, developing additional guidance, monitoring compliance with requirements to space calls over three days, and evaluating program data for additional opportunities to improve services for referred veterans.

The Federal Information Security Modernization Act of 2014 requires the Office of Inspector General to conduct an annual independent evaluation to determine whether the Department of Energy’s unclassified cybersecurity program adequately protected its data and information systems during the fiscal year. As part of that evaluation, the Office of Inspector General is required to assess the Department’s cybersecurity program according to Federal Information Security Modernization Act of 2014 security metrics issued by the Department of Homeland Security, the Office of Management and Budget, and the Council of the Inspectors General on Integrity and Efficiency.We conducted this evaluation to determine whether the Department’s unclassified cybersecurity program adequately protects data and information systems.Our fiscal year 2021 evaluation determined that the Department, including the National Nuclear Security Administration, had taken actions to address many previously identified weaknesses related to its unclassified cybersecurity program. Weaknesses included areas related to: risk management, supply chain risk management, configuration management, identity and access management, data protection and privacy, security training, information security continuous monitoring, incident response, and contingency planning. Many of the deficiencies were similar in type to those identified in our prior evaluations.The identified weaknesses in the Department’s unclassified cybersecurity program occurred for a variety of reasons. For instance, weaknesses related to configuration management, information security continuous monitoring, and contingency planning generally occurred because of deficiencies in related processes and procedures. In addition, some of the identity and access management issues we identified occurred because officials were unaware of current account management requirements. To correct the cybersecurity weaknesses identified throughout the Department, we made 61 recommendations to programs and sites during fiscal year 2021 including those identified during this evaluation and in other issued reports. Corrective actions to address each of the recommendations, if fully implemented, should help to enhance the Department’s unclassified cybersecurity program. Management concurred with the recommendations issued to programs and sites related to improving the Department’s overall cybersecurity program.

The U.S. Postal Service enters into customer agreements to provide customers with customized shipping solutions and mailing incentives. These agreements provide mutual benefits for the Postal Service and its customers. One type of customer agreement is a Negotiated Service Agreement (NSA), which is a contractual agreement between the Postal Service and a specific mailer that gives the mailer customized pricing in exchange for meeting volume and mail preparation requirements. During fiscal years (FY) 2019 to 2021, the number of domestic competitive NSAs decreased from 977 to 801 (18 percent), revenue increased from [redacted], and volume increased from [redacted] (105 percent each). Our objective was to summarize the results of our recent audits of customer compliance with five NSAs.

The former counselor did not appropriately notify the Ethics Office of employment negotiations and misused their position regarding former associates.

As part of our annual audit plan, we audited costs billed to the Tennessee Valley Authority (TVA) by Williams Plant Services, LLC (Williams) under Contract No. 10728 for managed task construction and modification work at TVA's nuclear facilities. The contract provided for TVA to compensate Williams for these services on either a time and materials or fixed price basis. Our objective was to determine if costs billed to TVA were in accordance with the contract's terms. Our audit scope included approximately $34.1 million in costs billed to TVA from January 1, 2019, through September 18, 2020.In summary, we determined Williams overbilled TVA $549,911, including (1) $359,753 in unapproved subcontractor costs, (2) $30,802 in excessive and ineligible fee applied to subcontractor costs, (3) $107,080 in ineligible temporary living allowance and travel costs, (4) $29,840 in unsupported and ineligible labor costs, (5) $14,209 in ineligible material costs, and (6) $8,227 in credits not received by TVA (which have since been recovered by TVA).In addition, we noted several opportunities to improve contract administration by TVA. Specifically, (1) TVA approved and implemented a contract rate attachment that contained incorrect craft labor rates, (2) TVA paid invoices under an incorrect contract, and (3) the contract contained inconsistent compensation terms for nonmanual labor.(Summary Only)

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 Hershel “Woody” Williams VA Medical Center and multiple outpatient clinics in Kentucky, Ohio, and West Virginia. The inspection covers key clinical and administrative processes that are 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 inspection, all leadership positions were permanently assigned and the executive team had worked together for over one year. The Director and Chief of Staff were assigned in February 2014 and June 2020, respectively. Employee survey data revealed an opportunity for the Director to decrease staff feelings of moral distress at work. Patient experience survey scores generally reflected similar or higher care ratings than the VHA averages, although leaders appeared to have an opportunity to improve female patients’ primary care access. The OIG’s review of the medical center’s accreditation findings did not identify any substantial organizational risk factors. However, the OIG identified concerns with conducting institutional disclosures for sentinel events. Executive leaders were knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue efforts to sustain and improve performance.The OIG issued six recommendations for improvement in four areas:(1) Leadership and Organizational Risks• Institutional disclosures(2) Quality, Safety, and Value• Systems Redesign Coordinator meeting participation• Surgical work group meetings(3) Care Coordination• Inter-facility transfer form completion(4) High-Risk Processes• Disruptive behavior committee meeting attendance

The post office lobby is the principal business office of the U.S. Postal Service. There are over 30,000 leased and owned Postal Service retail facilities nationwide. For most customers, the lobby is their only close-up view of Postal Service operations; therefore, its appearance directly affects the Postal Service’s public image. The Postal Service must maintain a safe environment for both employees and customers, including adherence to federal safety laws enforced by the Occupational Safety and Health Administration (OSHA) and internal policies and procedures regarding the appearance of lobbies and facilities, safety, and security of its facilities.Our objective was to summarize the results of prior property condition reviews of Postal Service retail facilities, identify systemic issues, and assess the effectiveness of management’s corrective actions.

By disclosing nonpublic information, the employees violated regulations that prohibit providing preferential treatment to any private organization.

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 Beckley VA Medical Center and two outpatient clinics in West Virginia. The inspection covered key clinical and administrative processes that are 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 inspection, the medical center’s executive leadership team had worked together for over one year. Employee survey data revealed general satisfaction with leaders. However, opportunities appeared to exist for the Chief of Staff to improve employees’ perceptions toward leaders and the workplace, and for the Chief of Staff, Associate Director/Patient Care Services, and Associate Director to reduce staff feelings of moral distress at work. Patient experience survey scores implied satisfaction with the care provided, but highlighted opportunities for leaders to improve female patients’ experiences with specialty care providers. The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Executive leaders were generally knowledgeable within their scope of responsibility about selected Strategic Analytics for Improvement and Learning model measures and should continue to take actions to sustain and improve performance. The OIG issued four recommendations for improvement in four areas: (1) Quality, Safety, and Value • Surgical workgroup meetings (2) Mental Health • Suicide safety plan training (3) Care Coordination • Medication list transmission (4) High-Risk Processes • Prevention and management of disruptive behavior training

The VA Office of Inspector General (OIG) conducted this inspection to determine whether the Tucson Consolidated Mail Outpatient Pharmacy (CMOP) was meeting federal security guidance. The inspection team selected the Tucson CMOP because it is home to the CMOP Local Area Network, which establishes an interface for electronically transferring information between all Veterans Health Administration medical centers and the CMOP host systems located at each of the seven CMOPs, which form an integrated and highly automated outpatient prescription dispensing system.The OIG team found deficiencies in configuration management, contingency planning, and access controls. Specifically, the Tucson CMOP had inaccurate component inventories, ineffective vulnerability management, and inadequate flaw remediation and had not implemented the configuration management plan; lacked a disaster recovery plan; and had not changed the default username and password for the security camera system and did not consistently generate or forward audit records to the Cybersecurity Operations Center. Without these controls, VA may be placing critical systems at unnecessary risk of unauthorized access, alteration, or destruction. The OIG made six recommendations to the Tucson CMOP director: implement effective inventory management tools, an effective vulnerability and flaw remediation program, and a disaster recovery plan; ensure CMOP staff understand their assigned roles and responsibilities; task the facility manager to change the default username and password for the security camera system; and request the Office of Information and Technology to configure audit logging on the misconfigured devices in accordance with established baselines, policy, and procedures.

As part of our annual audit plan, we performed an audit of Tennessee Valley Authority’s (TVA) non-power dam control system cybersecurity. Our objective was to determine if the cybersecurity controls of TVA’s non-power dam control system were operating effectively.In summary, we found (1) no clear ownership of the non-power dam control system, (2) vulnerable versions of operating systems and control system software, (3) inappropriate logical and physical access, and (4) internal information technology controls were not operating effectively or had not been designed and implemented. Prior to completion of our audit, TVA clarified the ownership of the control system and took actions to address the inappropriate logical and physical access. We recommend the Senior Vice President, Resource Management and Operations Services, update the non power dam control system to address the identified vulnerabilities and information technology control weaknesses. TVA management agreed with our recommendation and provided information on planned actions.

The objective of the audit was to determine whether the Office of Postsecondary Education (OPE) has an adequate process in place to ensure that institutions of higher education (schools) use Higher Education Emergency Relief Fund (HEERF) grant funds appropriately and that performance goals are met. OPE needs to strengthen its oversight processes to ensure that schools use HEERF grant funds appropriately and that performance goals are met. OPE established and implemented several controls to promote transparency and accountability in program administration, including providing guidance and other technical assistance to schools on the appropriate uses of HEERF grant funds, requiring that schools post to their websites or submit to OPE various reports on their uses of funds as well as other information (HEERF reports), and taking steps to expand independent audit coverage for schools. However, OPE did not perform or document several key activities that are essential to effective program oversight.

The Veterans Data Integration and Federation Enterprise Platform (VDIF) allows VA to share sensitive health information with the Department of Defense and community care providers. VA is required by law to ensure the safe sharing of veterans’ sensitive personal information. Linking information across an extremely diverse and highly fragmented healthcare system can create technical challenges and increase vulnerabilities. Therefore, establishing the appropriate security categorization for VDIF is essential. Moreover, veterans who do not trust VA to protect their information may be more reluctant to seek treatment.The Office of Inspector General (OIG) audited whether VA’s Office of Information and Technology (OIT) developed and implemented sufficient security controls for VDIF to ensure confidentiality, data integrity, and the safeguarding of veterans’ sensitive health information in accordance with federal standards.The OIG found OIT allowed VDIF to become operational without effectively executing all the risk management framework steps developed by the National Institute of Standards and Technology (NIST). While OIT followed the steps, it inappropriately categorized the confidentiality and availability security objectives. This resulted in 22 important security controls not being applied, increasing the risk to personal health information within more than 10 million veteran records. Furthermore, OIT did not adequately determine whether the implemented controls were executed correctly and produced the desired security outcome. OIT did not properly follow NIST and VA policy requirements because of ineffective oversight. Consequently, VDIF became operational with inadequate security controls.The assistant secretary for information and technology did not concur with two OIG recommendations to ensure VDIF’s security objectives are set at high and to reestablish VDIF, instead proposing a privacy overlay as sufficient. The OIG disagrees and also recommended OIT develop appropriate oversight for following proper program management processes and protocols when establishing and monitoring security controls. VA concurred with this recommendation.

The Office of Inspector General (OIG) evaluated the availability and utilization of metrics more than a year after the Mann-Grandstaff VA Medical Center became the first facility to implement the new Electronic Health Record (EHR) system. The OIG determined that, one year after go-live, gaps existed between required and available metrics using new EHR data.The OIG learned that many quality, patient safety, and organizational performance metrics were unavailable, including metrics needed for hospital accreditation. Additionally, the OIG found that access metrics were largely unavailable. The OIG remains concerned that deficits in new EHR metrics may negatively affect organizational performance, quality and patient safety, and access to care.Challenges with the new EHR’s metrics included the following: Cerner failed to deliver metrics reports, new EHR’s metrics could not be assessed prior to go-live, utility was impaired, and training was deficient. VHA-generated metrics using new EHR data also created challenges. VHA resources were insufficient for generating new EHR metrics, VHA metrics using new EHR data were not validated and unavailable, and VHA changed the metrics required from the facility.The OIG determined that deficiencies related to the new EHR’s metrics and challenges with VHA-generated metrics using new EHR data impaired the facility’s access to and utilization of metrics.The OIG is concerned that further deployment of the new EHR in VHA without addressing the gap in metrics available to the facility will affect the facility and future sites’ ability to utilize metrics effectively. Accordingly, to address the gaps in metrics available to the facility and future sites, VA must resolve the factors identified by the OIG that affect the availability of metrics.The OIG made two recommendations to the Deputy Secretary regarding evaluating gaps in new EHR metrics and the factors affecting the availability of metrics and taking action as warranted.

This report summarizes the oversight work performed by EAC OIG during the 6-month period ended March 31, 2022.

(May 2022) The Office of the Inspector General of the Intelligence Community (IC IG) recently released its Semiannual Report to the Director of National Intelligence (DNI) and Congress for the period of October 1, 2021, through March 31, 2022. The National Security Act of 1947 (as amended) requires the IC IG to prepare and submit to the DNI a classified and, as appropriate, unclassified report summarizing the work of the IC IG for the preceding six-month period.

The VA Office of Inspector General (OIG) conducts information technology (IT) inspections to assess whether VA facilities are meeting federal security requirements. They are typically conducted at selected facilities that have not been assessed in the sample for the annual audit required by the Federal Information Security Modernization Act of 2014 (FISMA) or at facilities that previously performed poorly. The OIG selected the Dallas Consolidated Mail Outpatient Pharmacy (CMOP) because it had not been previously visited as part of the annual FISMA audit.The OIG inspections are focused on four security control areas that apply to local facilities and have been selected based on their level of risk: configuration management controls, contingency planning controls, security management controls, and access controls. The OIG found deficiencies in configuration management and access controls at the Dallas CMOP, but none in contingency planning or security management controls.Without effective configuration management, users do not have adequate assurance that the system and network will perform as intended and to the extent needed to support the CMOP’s missions. The access control deficiencies create risks of unauthorized access to critical network resources, inability to respond effectively to incidents, loss of personally identifiable information, or loss of life.The OIG made 10 recommendations to the Dallas CMOP director aimed at fixing the control deficiencies. The assistant secretary for information and technology provided comments for the Dallas CMOP. The assistant secretary concurred with nine recommendations and did not concur with one recommendation. The OIG disagrees with the nonconcurrence.

In accordance with our Annual Performance Plan Fiscal Year 2022. dated November 2021, the Office of Inspector General (OIG) conducted a review of the United States Capitol Police (USCP or the Department) Communications Section's Dispatch and Call Taking Process. The scope of the review included existing policies and procedures related to the Communications Section for Fiscal Year 2021 through December 31. 2021.  OIG objectives were to determine if the Department (1) established adequate internal controls and processes for ensuring compliance with select Department policies and (2) complied with select policies and procedures, laws, regulations, and best practices.

The Office of the Inspector General for the Nuclear Regulatory Commission and the Defense Nuclear Facilities Safety Board presents its Semiannual Report to Congress. This report highlights the work the OIG has completed from October 1, 2021, to March 31, 2022.

The VA Office of Inspector General (OIG) conducted an inspection to review the care of an unresponsive patient by Emergency Department staff and the subsequent response of leaders at the Malcom Randall VA Medical Center (facility), after the patient’s death at the University of Florida Health Shands Hospital (Shands).The OIG determined that facility Emergency Department nurses failed to provide emergency care to an unresponsive patient who arrived by ambulance. Despite emergency medical services (EMS) personnel having relayed, while en route to the facility, the criticality of the patient’s condition and the limited patient identifying information available, Emergency Department nurses and an Administrative Officer of the Day wasted critical time concentrating efforts on whether the patient was a veteran (which the patient was, but not so identified by the nurses) versus patient care. As a result, EMS personnel reloaded the patient into the ambulance for transport to Shands.The Emergency Department nurses disregarded EMS personnel’s patient status report, failed to recognize the patient’s emergency medical condition, and inaccurately assessed the patient’s condition. The OIG identified deficiencies in nursing competencies and concerns regarding the replication of competency assessments.The OIG learned that the facility had prior instances of Veterans Health Administration Emergency Medical Treatment and Labor Act (EMTALA)-related policy violations in 2019, resulting in Emergency Department staff being required to complete EMTALA-related training. The OIG found the actions implemented by facility leaders to address concerns were not effective in preventing the occurrence of additional patient incidents, and delays in the provision of emergency care to patients continued.The OIG made one recommendation to the Veterans Integrated Service Network Director regarding consideration of administrative action and reporting to state licensing board(s). The OIG made four recommendations to the Facility Director related to the prioritization of emergency patient care and nursing competencies.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the leadership performance and oversight by Veterans Integrated Service Network (VISN) 2: New York/New Jersey VA Health Care Network in Bronx, New York, covering leadership and organizational risks and key processes associated with promoting quality care. This inspection also focused on COVID-19: Pandemic Readiness and Response; Quality, Safety, and Value; Medical Staff Credentialing; Environment of Care; Mental Health: Suicide Prevention; Care Coordination: Inter-facility Transfers; and Women’s Health: Comprehensive Care.The VISN had a stable leadership team, with the Quality Management Officer and Chief, Human Resources Officer permanently assigned prior to the integration of VISNs 2 and 3 in 2015. Selected employee satisfaction survey scores indicated that some VISN leaders had opportunities to improve employee perceptions of servant leadership, respect, discrimination, and psychological safety. Inpatient experience survey scores were lower than VHA national averages but outpatient ratings were higher. The OIG’s review of access metrics and clinical vacancies identified potential organizational risks, with wait times over 20 days at one medical center and clinical vacancies in certain specialties. Opportunities existed to improve executive leadership oversight of facility-level oversight of quality, safety, and value; care coordination; and high-risk processes.The OIG issued four recommendations for improvement in three areas:(1) Medical Staff Credentialing• Physician credentials review process(2) Environment of Care• Annual reviews(3) Women’s Health• Lead women veterans program manager appointment• Annual site visits

This interim report presents the results of our self-initiatedaudit of the efficiency of selected processes at the WyliePost Office in Wylie, TX (Project Number 22-066). This auditwas designed to provide U.S. Postal Service managementwith timely information on potential financial control risksat Postal Service locations. The Wylie Post Office is in theTexas 1 District of the Southern Area. We judgmentallyselected the Wylie Post Office for our audit.Our objective was to review cash and stamp inventories,daily reporting activities, clock ring errors, and employeeseparations processing at the Wylie, TX Post Office.To accomplish our objective, we reviewed data regardinginventories, daily reporting activities, clock ring errors,and employee separations to identify at risk transactions.1We conducted physical counts of all cash, stamp, andmoney order inventories, reviewed stamp transfers, andevaluated selected internal controls. We also observeddaily closing procedures, traced selected transactions tosource documentation, and interviewed unit personnel. Wedetermined the cause of clock ring errors and the stepstaken to resolve them. We also reviewed compliance withprocedures for separated employees, including timelysuspending system access and collecting and protectingaccountable property. We discussed our observations andconclusions with management on May 9, 2022, and includedtheir comments where appropriate.1

An Amtrak operation supervisor based in Miami resigned from the company on May 31, 2022, after he failed to respond to company letters advising him to report as available for duty. Prior to his resignation, we conducted an investigation and found that he violated company policies by engaging in self-employment as an independent realtor while on a medical leave of absence and while receiving short-term disability benefits. The company issued the employee a Notice of Investigation following the issuance of our investigative report and he failed to report to work.

This interim report presents the results of our self-initiatedaudit of the efficiency of selected processes at the MesquitePost Office in Mesquite, TX (Project Number 22-067).This audit was designed to provide U.S. Postal Servicemanagement with timely information on potential financialcontrol risks at Postal Service locations. The Mesquite PostOffice is in the Texas 1 District of the Southern Area. Wejudgmentally selected the Mesquite Post Office for our audit.

The Pandemic Response Accountability Committee’s (PRAC) Semiannual Report to Congress, covering the period from October 1, 2021 through March 31, 2022.

The U.S. General Services Administration Office of Inspector General's Semiannual Report to the Congress covering the period from October 2021 through March 2022.

The Inspector General Act of 1978 requires the Inspector General to prepare semiannual reports summarizing the activities of the Office of Inspector General for the preceding six-month period. The semiannual reports are intended to keep the Secretary and Congress fully informed of significant findings, progress the Agency has made, and recommendations for improvement.

EDOIG SAR 84 Final 508

Looking forward: Semiannual Report to Congress for October 1, 2021 – March 31, 2022.

See the additional details link below for the full report, report summary, multimedia or any agency follow-up.

See the additional details link below for the full report, report summary, multimedia or any agency follow-up.

The U.S. Postal Service uses Corporate Succession Planning to identify and develop top-performing employees to become future executives. In addition, a variety of leadership development programs align with competency models to develop upcoming leaders, including Managerial Leadership, Advanced Leadership, Executive Leadership, and Executive Foundations. The overarching program of employee knowledge development is referred to as the learning continuum. During fall 2020, the Postal Service initiated a series of phased organizational changes to improve its ability to implement strategies and drive success.

The U.S. Postal Service contracts for professional, technical, and information technology related services to supplement its workforce and support its operations. For service contracts, the contracting officer (CO) assigns key contract personnel to labor categories that are designated as essential, and which have qualification requirements. The supplier is required to submit a proposal identifying key personnel and their qualifications. Substitutions of key personnel can be made if approved by the CO in writing and should be documented in the contract file.Our objective was to determine whether the Postal Service has effective controls to ensure supplier compliance with contract requirements for key personnel qualifications and substitutions. For this audit, we chose a judgmental sample of 19 suppliers with a spend of about $411.7 million that were not recently audited by the Postal Service Office of Inspector General (OIG) and had invoices in both fiscal years.

Semiannual Report to Congress: October 1, 2021 through March 31, 2022

Objective: To determine whether overpayments resulting from incorrect Old-Age, Survivors and Disability Insurance benefit payment computations were avoidable.

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 New York Harbor Healthcare System. The inspection covered key clinical and administrative processes associated with promoting quality care, focusing 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 inspection, the system’s three permanently assigned leaders had worked together for over four years. However, the leadership team also had two vacant positions and one position that was detailed after a two-and-a-half-year vacancy. Employee satisfaction survey scores for leaders were generally similar to or better than VHA averages. Outpatients appeared satisfied with their care, although overall and gender-specific inpatient survey results were lower than VHA averages. The OIG found deficiencies with identifying sentinel events and conducting institutional disclosures. Additionally, there were repeat findings from the June 2017 comprehensive healthcare inspection related to inter-facility transfers. Executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue taking actions to sustain and improve performance.The OIG issued eight recommendations for improvement in five areas:(1) Leadership and Organizational Risks• Sentinel events and institutional disclosures(2) Quality, Safety, and Value • Peer reviews(3) Mental Health• Staff suicide safety plan training(4) Care Coordination• Inter-facility transfer forms(5) High-Risk Processes• Disruptive behavior committee attendance• Orders of Behavior Restriction• Staff training

The results of the Federal Election Commission (FEC) Office of Inspector General’s (OIG) Special Review of the Contracting Officers Representative (COR) Program.

The Office of Inspector General (OIG) found that the Small Business Administration (SBA) did not have an organizational structure with clearly defined roles, responsibilities, and processes to manage and handle potentially fraudulent Paycheck Protection Program (PPP) loans across the program. In addition, the agency did not establish a centralized entity to design, lead, and manage fraud risk. This problem occurred because the agency did not establish a sufficient fraud risk framework at the start of and throughout PPP implementation. Management stated this was partly due to the speed of the delivery of PPP and the continuous and rapid discovery of different kinds of fraud schemes. Lenders also were not always clear on how to handle PPP fraud or recover funds obtained fraudulently from the PPP that remained in the borrower’s account. SBA did not provide lenders sufficient specific guidance to effectively identify, track, address, and resolve potentially fraudulent PPP loans. During our review, SBA established a Fraud Risk Management Board.To better mitigate fraud, we recommend SBA establish clearly defined and detailed roles, responsibilities, and processes and provide lenders formal guidance for managing and handling potentially fraudulent loans.SBA management generally agreed with the findings and agreed with both recommendations. Management plans to document the roles, responsibilities, and processes for all SBA offices responsible for managing and handling potentially fraudulent PPP loans. Management also plans to consolidate its existing guidance to lenders regarding fraud and provide new guidance as appropriate.

The audit found the agency had significant issues implementing the Coronavirus Aid, Relief, and Economic Security (CARES) Act. The agency did not sufficiently review CARES invoices due to changing guidelines, reduced contract oversight staffing during the pandemic, overreliance on contractor-provided information, and the lack of clear and comprehensive Contracting Officer Representative (COR) oversight procedures for CARES invoices. As a result, the OIG questioned more than $16.4 million, or 40 percent of the sampled CARES invoice charges. As of June 8, 2021, NSA reported $917 million in CARES invoices.

An Amtrak conductor based in Miami, Florida, resigned from his position on April 12, 2022, prior to his administrative hearing. Our investigation found that the former employee violated company policies by stealing supplies from a contractor doing business with Amtrak. The former employee was captured on video entering the contractor’s building, which is co-located at the Amtrak yard, and stealing the supplies and loading them into the trunk of his personally-owned car.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Carmel Main Post Office in Carmel, IN (Project Number 22-086). The Carmel Main Post Office is in the Indiana District of the Central Area and services ZIP Codes 46032 and 46033, which serves about 76,498 people and is considered an urban community. We judgmentally selected the Carmel Main Post Office based on the number of stop-the-clock (STC) scans occurring at the delivery unit, rather than at the customer’s delivery address.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Plainfield Main Post Office (MPO) in Plainfield, IN (Project Number 22-085). The Plainfield MPO is in the Indiana District of the Central Area and services ZIP Code 46168, which serves about 29,744 people and is considered an urban community. We judgmentally selected the Plainfield MPO based on the number of stop-the-clock (STC) scans occurring at the delivery unit, rather than at the customer’s delivery address.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Linwood Station in Indianapolis, IN (Project Number 22-087). The Linwood Station is in the Indiana District of the Central Area and services ZIP Code 46201, which serves about 30,926 people and is considered an urban community. We judgmentally selected the Linwood Station based on the number of customer inquiries per route the unit received. From November 1, 2021, through January 31, 2022, the unit received 22 inquiries per route, which was more than the average of 7.36 inquiries per route for all sites serviced by the Indianapolis Processing and Distribution Center (P&DC).

This letter to Congress reports on NCUA OIG's assessment of the NCUA's 2021 compliance under the requirements of the Payment Integrity Information Act of 2019 (PIIA).