Federal Reports

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

This report details the Office of Inspector General's Spring 2022 Semiannual Report to Congress. The following topics are included:• Overview of the SBA and the OIG• Pandemic Response Oversight• Small Business Access to Capital• Disaster Loan Program• Procurement Assistance• Agency Management• Other Significant OIG Activities• Statistical Highlights• Appendices

The Office of Inspector General is tasked with ensuring efficiency, accountability, and integrity in the U.S. Postal Service. We also have the distinct mission of helping to maintain confidence in the mail and postal system, as well as to improve the Postal Service's bottom line. We use audits and investigations to help protect the integrity of the Postal Service. Our Semiannual Report to Congress presents a snapshot of the work we did to fulfill our mission for the six-month period ending March 31, 2022. Our dynamic report format provides readers with easy access to facts and information, as well as succinct summaries of the work by area. Links are provided to the full reports featured in this report, as well as to the appendices.

This semiannual report summarizes the work we completed from October 1, 2021, through March 31, 2022, to deter fraud, waste, and abuse.

I am pleased to submit the Amtrak Office of Inspector General (OIG) Semiannual Report to the United States Congress for the six months ending March 31, 2022. For the past six months, Amtrak continued its recovery after its ridership plunged in 2020 due to the pandemic. In November 2021, while ridership continued to return, Congress passed the Infrastructure Investment and Jobs Act (IIJA), which provides Amtrak (the company) with access to as much as $66 billion in funding—the largest investment in passenger rail since the company’s creation more than 50 years ago. The legislation positions the company to play a major role in the nation’s transportation and economic future by providing funds to repair and rehabilitate the company’s rail assets, work with state and other partners to modernize the Northeast Corridor (NEC) and bring “world-class rail service” outside the NEC.

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 Samuel S. Stratton VA Medical Center. The inspection covered key clinical and administrative processes associated with promoting quality care. It focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; 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 inspection, the executive team had worked together in a permanent capacity for approximately six months; however, multiple leaders had served in their positions for more than two years. Employee survey data revealed that staff were satisfied with leadership and felt respected, and discrimination was not tolerated. Overall, outpatient satisfaction survey results were generally higher than VHA averages, but highlighted opportunities to improve access to specialty care appointments. Inpatient survey scores were generally lower than the VHA averages and indicated opportunities to improve experiences for both genders.The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures of adverse patient events did not identify any substantial organizational risk factors. 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 10 recommendations for improvement in three areas:(1) Quality, Safety, and Value• Surgical work group attendance• National Surgery Office quality report review(2) Care Coordination• Inter-facility transfer policy• Transfer monitoring, evaluation, and form completion• Medication list transmission• Nurse-to-nurse communication(3) High-Risk Processes• Disruptive behavior committee attendance• Risk assessment participation• Staff training

To see our report, click on the link below

The Semiannual Report to Congress summarizes the results of VA OIG oversight, provides statistical information, and lists all reports issued from October 1, 2021, to March 31, 2022. During this reporting period, VA OIG audits, evaluations, investigations, inspections, and other reviews identified nearly $4.1 billion in monetary impact for a return on investment of $41 for every dollar spent on oversight. During this reporting period, the VA OIG issued 143 reports and publications on VA programs and operations, made 397 recommendations, and conducted investigations that led to 104 arrests.

The Office of the Inspector General conducted a review of the Browns Ferry Nuclear Plant Radiation Protection (BFN RP) organization to identify factors that could impact BFN RP’s organizational effectiveness. During the course of our evaluation, we identified behavioral and operational factors that are negatively impacting BFN RP’s effectiveness and its ability to meet its responsibilities and support Nuclear’s vision and core principles. Most employees expressed having positive relationships with individuals in their own groups, and many indicated they trusted their coworkers to perform their jobs well. However, multiple negative behavioral factors were also expressed, including:• Concerns regarding interactions between BFN RP groups.• Concerns regarding management interactions.• Perceptions of (1) unethical and (2) noninclusive behaviors by certain managers.• Perceptions that BFN RP personnel cannot stop work and plant operations are placed before radiation safety.In addition, we were informed about concerns related to outdated instrumentation and equipment, inadequate supplies, the briefing room environment, and budget and staffing constraints. We also identified a risk related to the oversight and monitoring of the nuclear safety culture within BFN RP that could impact BFN as a whole.

VA has a right to recover community care treatment costs for conditions unrelated to military service from veterans’ private health insurers. The VA Office of Inspector General (OIG) audit was conducted to determine how effectively the Veterans Health Administration (VHA) billed private insurers. Prior OIG work has shown that VHA has missed opportunities to recover funds that could be used to help finance care for other veterans.VHA’s Office of Community Care (OCC) manages community care programs and bills private insurers when needed. OCC must submit reimbursement claims before insurers’ deadlines are reached, or they may be denied.The OIG found OCC did not establish an effective process to ensure staff billed veterans’ private health insurers as required. An estimated 54 percent of billable community care claims paid between April 20, 2017, and October 31, 2020, were not submitted before filing deadlines expired. As a result, OCC did not collect an estimated $217.5 million that should have been recovered, a figure that could grow to $805.2 million by September 30, 2022, if problems are not corrected.OCC’s billing and revenue collection process also was not synchronized with insurers’ filing deadlines, and claims information was not always available for billing. Also, pending workload volume and staff shortages hindered effective billing. Although OCC was broadly aware of challenges to its process to bill and collect revenue from private insurers, its responses were not sufficient to correct these issues.VHA concurred with the OIG’s recommendations to develop procedures that prioritize processing to meet insurers’ filing deadlines and strengthen its information system controls to ensure information needed to process bills for reimbursement is complete and accurate. VHA should also assess staff resources and workload to make certain they are sufficiently aligned to process the anticipated volume of claims to be billed.

To see our report, click on the link below

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.

The objective was to determine the extent to which the U.S. Immigration and Customs Enforcement (ICE) mitigates safety risks by testing migrants for COVID-19 before transport on domestic commercial flights and whether a process is in place for escorting noncitizen unaccompanied children (UCs) during transport.

We audited costs claimed and grant compliance by the U.S. Virgin Islands Department of Planning and Natural Resources under grants awarded by the FWS.

The U.S. Postal Service’s Recognition and Awards Program is intended to recognize employees who have demonstrated outstanding performance, superior competence, or had some other significant accomplishment. For fiscal years (FY) 2018 to 2021, the Postal Service presented 133,330 awards totaling over $76.8 million.Our objective was to assess the Postal Service’s effectiveness in managing its Recognition and Awards Program. We reviewed FY 2018 through FY 2021 recognition and awards data from the eAwards system.

The Office of the Inspector General (OIG) contracted with CG Strategy, Inc. to evaluate GPO’s transformation from a print-centric to a content-centric organization. The evaluation focused on the status of GPO’s transformation into a modern, world-class, and trusted source of published products and information.

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

The primary mission of the U.S. Postal Service’s enterprise risk management (ERM) program is to provide reasonable assurance that significant risks to and opportunity losses for the organization are systematically and effectively identified, evaluated, and mitigated where appropriate. The organization’s ERM Operating Charter (Charter) establishes the Executive Leadership Team in general and the Chief Financial Officer (CFO) in particular as having the responsibility for aligning the organization’s goals, defining roles, and driving progress with oversight by the Board of Governors’ Audit and Finance Committee. The ERM program is led by Finance, as directed by the CFO and the Vice President, Controller.

This report presents the results of our self-initiated audit of the efficiency of operations at the Seattle Processing and Distribution Center (P&DC) in Seattle, WA (Project Number 22-094). We conducted this audit to provide U.S. Postal Service management with timely information on operational risks at this P&DC. We judgmentally selected the Seattle P&DC based on overtime, penalty overtime, clearance times, and late and extra trips by Postal Vehicle Service (PVS) and Highway Contract Route drivers. The Seattle P&DC is in the Pacific Northwest Division of the Logistics and Processing Operations Western Region and processes letters, flats, and parcels. The Seattle P&DC services multiple 3-digit ZIP Codes in urban and rural communities.

The Udall Foundation made improper payments to contractors, did not adhere to some contract oversight duties, and improperly billed funding partners.

The Office of Inspector General (OIG) Care in the Community healthcare inspection program examines clinical and administrative processes associated with providing quality outpatient healthcare to veterans. This report provides a focused evaluation of Veterans Integrated Service Network (VISN) 23 and its oversight of the quality of care delivered in community-based outpatient clinics (CBOCs) and through its community care referrals to non-VA providers. Although it is difficult to measure the value of well-delivered and coordinated care between VA and non-VA providers, the findings in this report may help VISN leaders identify vulnerable areas of community care that, if properly addressed, should improve healthcare quality for veterans.The OIG reviewed care coordination for congestive heart failure management; primary care and mental health (diagnostic evaluations following positive screenings for depression or alcohol misuse); quality of care (home dialysis care); and women’s health (mammography care and communication of results).The OIG issued three recommendations for improvement in two areas:(1) Quality of Care• Completing initial and annual home visits for patients accepted into the VISN 23 home dialysis program• Monitoring quality of home dialysis contracted clinical services(2) Women’s Health• Receiving written results from community providers within 30 days of the procedure

We investigated allegations that former DOI Secretary David Bernhardt violated the Lobbying Disclosure Act before joining the DOI as Deputy Secretary.

In this semiannual period, our audit, evaluation, and investigative activities identified more than $9.3 million in questioned costs, funds put to better use, recoveries, waste, and opportunities for TVA to improve its programs and operations.

The Office of Enterprise Assessments implements an Independent Oversight Program to provide Department of Energy line management, Congress, and other stakeholders with an independent evaluation of the effectiveness of Department policy and line management performance in safety, security, and other critical areas. The Office of Environment, Safety and Health Assessments (EA-30), a subordinate office within the Office of Enterprise Assessments, conducts assessments to provide information on the effectiveness and performance of Department programs in protecting workers, the public, and the environment from hazards.We initiated this audit to determine whether the Department is addressing findings and deficiencies identified by EA-30. Our review found that the Department did not always fully address findings and deficiencies identified by EA-30.These issues occurred, in part, because the sites we reviewed did not always provide sufficient oversight pertaining to EA-30 findings and deficiencies, including inconsistent oversight of the issues management processes. In addition, EA-30’s processes presented opportunities for improvement, including tracking findings and deficiencies. As a result of this audit, EA-30 has begun to take steps to address these issues.Department programs may be at risk of unaddressed weaknesses in protecting workers, the public, and the environment from hazards. Effective oversight is an integral part of the Department’s responsibility to provide assurance of its safety and security posture to its leadership, its workers, and the public.To address the issues identified in this report, we have made six recommendations that, if fully implemented, should help ensure that findings and deficiencies are addressed, and effective corrective actions are implemented and documented.

Opportunities exist to enhance the Postal Service’s Collection Point Management System (CPMS) to make data management processes more efficient and improve the quality of CPMS data, according to a new white paper from the Postal Service Office of Inspector General. CPMS is a USPS data collection system that manages data pertaining to its vast network of mail collection points. The enhancements would improve the Postal Service’s ability to manage and track its collection point network, provide more accurate and timely data for internal decisionmakers, and offer better service to the public. Read the details in The Postal Service’s Collection Point Management System.

What We Looked AtWe queried and downloaded 60 single audit reports prepared by non-Federal auditors and submitted to the Federal Audit Clearinghouse between January 1, 2022, and March 31, 2022, to identify significant findings related to programs directly funded by the Department of Transportation (DOT).What We FoundWe found that reports contained a range of findings that impacted DOT programs. The auditors reported significant noncompliance with Federal guidelines related to eight grantees that require prompt action from DOT's Operating Administrations (OA). The auditors also identified questioned costs totaling $3,534,794 for three grantees. Of this amount, $3,459,757 was related to the Sangamon Mass Transit District and $24,763 related to the COVID-19 Airport Improvement Program for the Commonwealth Ports Authority of the Northern Mariana Islands.RecommendationsWe recommend that DOT coordinate with the impacted OAs to develop a corrective action plan to resolve and close the findings identified in this report. We also recommend that DOT determine the allowability of the questioned transactions and recover $3,534,794, if applicable.

Without complete oversight of the drinking water program, the public’s health is still at risk from lead in drinking water.

The Payment Integrity Information Act of 2019 requires an annual audit of the Small Business Administration’s (SBA) improper payment reporting. We contracted with the independent certified public accounting firm KPMG LLP to audit SBA’s Fiscal Year 2021 compliance with the Act.In the report, KPMG auditors found the agency was compliant with 5 of the 10 reporting requirements under the Act and Office of Management and Budget (OMB) guidance.However, SBA is not in compliance with the Act because• the agency did not conduct or update the improper payment risk assessment for each program with annual outlays greater than $10 million;• three of four reported areas did not publish an improper payment and unknown payment reduction target; • the Disaster Direct Loan Program did not publish corrective action plans, demonstrate improvement to payment integrity or develop a plan to meet the improper payment and unknown payment reduction target, and • the Disaster Direct Loan Program reported a gross improper payments and unknown payments rate exceeding 10 percent, which is the higher than the amount allowed by lawIn addition, KPMG found the agency needs to improve the accuracy and appropriateness of improper payment reporting. The agency also needs to improve controls to prevent and reduce improper payments.

MEMORANDUM FOR DEPARTMENT OF DEFENSE LEAD INSPECTOR GENERAL

National Credit Union Administration (NCUA) Office of Inspector General (OIG) Semiannual Report to the NCUA Board and the Congress highlighting our accomplishments and ongoing work for the 6-month period ending March 31, 2022.

In 2019, Congress enacted the Payment Integrity Information Act (PIIA) to update required reporting on agencies’ improper payments. PIIA requires agencies to review and identify programs and activities that may be susceptible to significant improper payments, estimate the improper payments rates in agency programs, and report on their actions to reduce and recover those payments. The Inspector General of each agency assesses compliance with these requirements annually.AmeriCorps implemented corrective actions in FY 2021 that improved its compliance with PIIA reporting requirements. The agency now meets eight of the 10 PIIA compliance requirements. Of the two remaining requirements, the agency reported improper payment rates above the ten percent compliance threshold for the AmeriCorps State and National Program , Foster Grandparent Program , Senior Companion Program , and Retired and Senior Volunteer Program and reported improper payment rates that were not accurate, reliable, or consistent with Office of Management and Budget guidance.AmeriCorps attributes the improper payment rates to the operational challenges that grantees continued to face related to the Coronavirus Disease 2019 (COVID-19) pandemic, including how to administer, and document that they appropriately administered, the temporary pay allowances that AmeriCorps allowed during the period reviewed. Additionally, AmeriCorps management does not have adequate controls over the supervision and oversight of sample selection and statistical projection procedures regarding its improper payment testing. AmeriCorps generally concurred with and agreed to implement our recommendations to (1) add additional provisions to its grant terms and conditions, (2) strengthen supervision and oversight of sample selections and statistical projection procedures to ensure that it appropriately projects estimated improper payment rates, and (3) develop and implement actions to reduce the improper payment rates below ten percent for FY 2022. AmeriCorps Management’s Response can be found in Appendix C of the report.

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 San Diego, CA, region (Project Number 22-077). These delivery units included the San Diego Downtown and Linda Vista stations in San Diego, CA; and the Ramona Main Post Office (MPO) in Ramona, CA. We issued interim reports to district management for each of these delivery units regarding the conditions we identified. In addition, we issued a report on the efficiency of operations at the Margaret L. Sellers Processing and Distribution Center (P&DC), which services these three delivery units.

DFC OIG Spring FY 2022 Semi Annual Report to Congress for the reporting period October 1, 2021 - March 31, 2022

Our objective was to evaluate how DHS determined employee status for placement into vaccine distribution priority groups; determine how DHS, in conjunction with VHA, planned to triage and distribute available vaccine inventory and vaccinate frontline, mission-critical DHS staff; and evaluate how DHS executed its plan.

Several challenges limited our ability to fulfill by audit the mandate in Section 1216 of the DRRA. For instance, FEMA’s data system does not capture Individuals and Households Program (IHP) assistance data in a manner that allows us to accurately calculate a percentage of distributions made in error in any 12-month period. In addition, the amount of data required to conduct the audit represents millions of rows of data, as well as underlying supporting documents. These efforts require considerable resources for FEMA to provide, and the Office of Inspector General to review, the IHP information. Facing these limitations, we adopted an alternate approach to estimate FEMA’s percentage of distributions made in error. Specifically, we analyzed FEMA’s IHP Recoupment Processing Executive Summary for fiscal years 2015 through 2019 and concluded that, for these fiscal years, FEMA’s percentage of distributions identified for recoupment was, on average, less than 1 percent — well below the DRRA’s 4 percent threshold.

Objective: To determine whether the Social Security Administration (SSA) had adequate controls over mail processing during the COVID-19 pandemic.

The U.S. Postal Service’s International Service Center in San Francisco, CA (SFO ISC) houses select international and military mail processing functions and a retail unit. In April 2020, the lessor notified the Postal Service that they were discontinuing the facility lease and subsequent discussions about potential on-airport facility alternatives proved unsuccessful. As a result, the Postal Service decided to permanently relocate processing operations to local and regional facilities and temporarily suspend retail services, steering customers to nearby post offices pending a final Postal Service decision on the unit. This report responds to a September 2021 congressional request regarding closure of the SFO ISC.

The tribal official profited from awarding contracts that resulted in his company receiving subcontracts, but no policy prohibited his actions.

OIG performed a review to assess whether the Peace Corps complied with the PIIA reporting requirements and provided adequate disclosure within the annual AFR and accompanying materials. In addition, we also evaluated the accuracy and completeness of the agency’s reporting. Our review determined that the Peace Corps was compliant with PIIA for Fiscal Year (FY) 2021.

The OIG conducted a healthcare inspection at the Charlie Norwood VA Medical Center in Augusta, Georgia (facility) to evaluate the adequacy of a patient’s outpatient care in the months prior to surgery and during preoperative and postoperative care. After surgery, the patient was admitted for orthostatic hypotension and physical deconditioning and placed under hospice care. The patient subsequently suffered alcohol withdrawal and declining health, and died in the intensive care unit. Prior to the patient’s surgery, primary care staff failed to provide sufficient care coordination and treatment. A provider failed to address the patient’s abnormal chest images and poor nutrition, and failed to communicate test results to the patient as required. A primary care nurse failed to respond to the patient’s secure message request for assistance two days before surgery. Additionally, a barium swallow test was not scheduled. The surgical team completed a preoperative assessment but failed to detect the patient’s overall poor health. During the patient’s hospital stay after surgery, medical-surgical nurses did not consistently assess alcohol withdrawal symptoms or administer medications as required. The OIG also found the facility’s alcohol withdrawal protocol could be discontinued prior to the onset of a patient’s withdrawal symptoms. Medical-surgical unit nursing leaders did not have adequate quality controls or training in place to ensure the provision of safe and effective alcohol withdrawal nursing care. The OIG made one recommendation to the Veterans Integrated Service Network Director to review the provider’s care of the patient. Nine recommendations were made to the Facility Director related to same-day care access, communication of test results and treatment plans, assigned surrogates, preoperative care, medical-surgical nurses’ patient care, Trendelenburg position usage and staff education, nursing competencies for alcohol withdrawal assessments and treatment, medical-surgical unit nurses’ quality control oversight, and the facility’s alcohol withdrawal treatment protocol.

The VA Office of Inspector General (OIG) conducted a healthcare inspection for 10 allegations related to the quality and management of patient care and the availability of resources within the Urgent Care Center at the Chillicothe VA Medical Center in Ohio.One allegation involved an urgent care provider sending a patient with a T12 vertebrae compression fracture to have chiropractic care at the Complementary and Alternative Medicine (CAM) clinic. The patient returned a week later with a T12 burst fracture and rib fractures.The OIG found that an urgent care provider verbally referred a patient for pain management and not for chiropractic care. However, the OIG found that the urgent care provider did not enter a CAM consult until eight days after seeing the patient. Due to this delay, the chiropractor and clinical massage therapist failed to review the consult prior to seeing the patient. Additionally, the chiropractor and massage therapist could not link documentation to the consult and had no other process to complete the documentation resulting in the failure to document care provided within the medical record.The patient returned to the Urgent Care Center eight days later where a computerized tomography scan showed an acute burst fracture and acute rib fractures. Because of the lack of documentation and provider recall, the OIG could not conclusively determine the relationship between the actions taken by the chiropractor and clinical massage therapist and the patient’s bone fractures.The OIG found the nine additional allegations to be unsupported and lacked merit.The OIG made two recommendations to the Facility Director related to education of providers, chiropractors, and clinical massage therapists on the use of consults and timely documentation, and conducting an internal review of the CAM program processes related to patient care, reviewing consults, scheduling appointments, checking-in patients, and documentation.