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Brought to you by the Council of the Inspectors General on Integrity and Efficiency
Federal Reports
Report Date
Agency Reviewed / Investigated
Report Title
Type
Location
Social Security Administration
The Social Security Administration’s Compliance with the Payment Integrity Information Act of 2019 in Fiscal Year 2021
Objective: To determine whether the Social Security Administration (SSA) met all requirements of the Payment Integrity Information Act of 2019 (PIIA) in the Fiscal Year (FY) 2021 Agency Financial Report (AFR) and accompanying materials.
Our objective for this report was to assess the extent to which the company planned effectively for the Unified Operations Center (UOC) program, including developing a business case that demonstrated the expected financial and operational benefits compared to the estimated costs.The company began planning for the UOC program in December 2018. It is a multi-year effort to relocate several vital customer care functions—including train-dispatching personnel who are currently spread across five cities—into a centralized location. Mitigating flooding risks at the current Consolidated National Operations Center, located on the Christina River in Wilmington, Delaware, was another reason the company planned to move personnel to the new building. In May 2020, the company purchased a building in Wilmington for $41.1 million to house the UOC program.We found that the company experienced challenges associated with its building purchase, which have led to questions about how the company will use the property. Specifically, the purchase was largely premised on two significant yet faulty assumptions: (1) that the company could centralize and collocate its train control and dispatch personnel, a specialized Amtrak Police Unit, social media staff, and relocate IT personnel from leased office space; and (2) that the program would yield cost savings. Neither assumption materialized because the company did not effectively verify the feasibility of centralizing these personnel and functions—including retrofitting the building to accommodate significant IT requirements—before purchasing the building in May 2020. The company is in the early stages of design work to retrofit the building to accommodate the UOC program at an estimated cost of $37 million, and it is updating its business case for the program’s future.To help the company make more informed decisions about the future of the UOC program, the building it purchased, and the best use of resources, we recommended that it verify the assumptions in its revised business case about the UOC program’s functions and staff relocations, as well as develop the most accurate estimates possible of the associated costs and benefits so that decisionmakers can determine whether and how to proceed. The company agreed with our recommendation and plans on taking corrective action.
This report presents the results of our self-initiated audit of the Efficiency of Operations at the Indianapolis Processing and Distribution Center (P&DC) in Indianapolis, IN (Project Number 22-080). 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 Indianapolis P&DC based on a review of overtime, penalty overtime, late, extra, and cancelled trips by Postal Vehicle Service (PVS) and Highway Contract Route (HCR) drivers, and overall scanning performance. The Indianapolis P&DC is in the Westshores Division and processes letters and flats; and it services multiple 3-digit ZIP Codes in urban and rural communities.
Audit of Community Service and Other Grants Awarded to South Florida PBS, Inc. (SFPBS), Boynton Beach, Florida, for the Period July 1, 2019 through June 30, 2021, Report No. AST2204-2205
Management Advisory: Tracking of Follow-On Production Other Transaction Agreements and Tracking and Awarding of Experimental Purpose Other Transactions
Financial Audit of Costs Incurred in Afghanistan by Blumont Global Development, Inc. Under the Conflict Mitigation Assistance for Civilians Program, Cooperative Agreement No. 72030618CA00005, June 1 to October 31, 2020
Closeout Audit of the Schedule of Expenditures of Engicon Company, Management Engineering Services Non-Revenue Water Program in Jordan, Contract AID-278-C-15-00005, January 1, 2019, to March 14, 2020
Financial Audit of USAID Resources Managed by University of Nairobi Enterprises and Services Limited in Kenya Under Cooperative Agreement AID-615-A-16-00013, July 1, 2020, to June 30, 2021
The Veterans Health Administration (VHA) Office of Emergency Management issued the initial COVID-19 Response Plan on March 23, 2020, and then an updated version on August 7, 2020. The National Center for Organization Development created a COVID-19 rapid response consultation process for VHA leaders in a supervisory role. The Organizational Health Council developed a team that coordinated with multiple VHA program offices to create a COVID-19 Employee Support Toolkit and other resources. Additionally, several program offices independently created and disseminated employee well-being resources specific to the COVID-19 pandemic, including National Center for Organization Development, Patient Centered Care & Cultural Transformation, Chaplain Service, and the Office of Mental Health and Suicide Prevention.The VA Office of Inspector General (OIG) identified a generally diminishing awareness of employee emotional well-being supports in relation to organizational hierarchy, low utilization of support resources by leadership and frontline employees, as well as employee perception of inadequate support and responsiveness from leadership.The OIG conducted a review to assess how the VHA addressed the emotional well-being of employees during the COVID-19 pandemic. The OIG also conducted an overview of VHA programs, including what specialized programs were developed and deployed in response to the unique psychological challenges created by the COVID-19 pandemic for VHA’s staff. The OIG interviewed VA and VHA leaders in multiple offices. The OIG developed and deployed a survey about VHA guidance regarding employees’ emotional well-being during the pandemic, available resources, monitoring of available support programs, and employee engagement with available support programs.The OIG made one recommendation to the Under Secretary for Health related to increasing leadership and staff awareness of COVID-19 emotional well-being resources for VHA employees and awareness of resources about potential risks and signs of burnout.
Financial Audit of The Producer-Owned Women Enterprises Project in India Managed by Indus Tree Crafts Foundation Under Cooperative Agreement 72038619CA00003, April 01, 2020 to March 31, 2021
Department of Health and Human Services Met Many Requirements, but It Did Not Fully Comply With the Payment Integrity Information Act of 2019 and Applicable Improper Payment Guidance for Fiscal Year 2021
Our evaluation was conducted as part of a series of reviews to determine whether the Bureau’s planning and execution of 2020 Census peak operations successfully reduced the risk to decennial census data quality and costs. Overall, we found that the Bureau continues to face longstanding challenges in providing sufficient governance for its personnel suitability program, which is necessary to ensure that background investigation requirements are met at its facilities. Specifically, we found the following:I. The Bureau continues to have a significant backlog of post-employment cases requiring adjudication and the actual number of cases requiring adjudication is questionable.II. Inadequate documentation and oversight have allowed quality problems regarding post-employment background investigations to persist.III. Census Investigative Services did not properly adjudicate results for an estimated 7 percent of temporary 2020 Census pre-employment, fingerprint-only investigations.IV. The Census Hiring and Employment Check system data is incomplete and, insome instances, inaccurate.
In this semiannual report, we discuss both the major accomplishments and activities of OIG from October 1, 2021 through March 31, 2022, as well as its goals and future plans.
The Department of Energy’s Los Alamos National Laboratory (LANL) is part of the National Nuclear Security Administration nuclear security enterprise. LANL’s primary mission is to ensure the safety, security, and reliability of the Nation’s nuclear stockpile. Department orders and guidance reflect the Department’s commitment to operating its nuclear facilities and conducting work activities in a manner that ensures compliance with environmental, safety, and health requirements.We conducted this followup audit to determine whether: (1) LANL took corrective actions related to the recommendations in our prior report on Issues Management at the Los Alamos National Laboratory (DOE-OIG-16-07, February 2016), and (2) actions taken to correct the deficiencies in our prior report resulted in an issues management program compliant with Federal requirements.We found that LANL took corrective actions related to Recommendations 1 through 3 in our prior report. Specifically, our current review did not reveal significant issues with LANL’s Issues Management program’s compliance with Federal requirements However, we found that LANL’s corrective actions related to Recommendation 4 did not always ensure all applicable subcontracts contained the Differing Professional Opinion requirement. By not including Exhibit F documents and the mandatory Differing Professional Opinion language into subcontracts for offsite work that LANL categorized as medium- and low-hazard, subcontractor employees may not know a process exists to report differing professional opinions involving technical issues that have a potentially adverse environmental, safety, or health impact.The issues we identified occurred, in part, because LANL’s process to include Differing Professional Opinion requirements in subcontracts did not always ensure all applicable subcontracts contained this mandatory requirement. Management agreed with our finding and recommendation, and its proposed corrective action is consistent with our recommendation.
The Department of Energy’s Los Alamos National Laboratory (LANL) is part of the National Nuclear Security Administration nuclear security enterprise. LANL’s primary mission is to ensure the safety, security, and reliability of the Nation’s nuclear stockpile. Department orders and guidance reflect the Department’s commitment to operating its nuclear facilities and conducting work activities in a manner that ensures compliance with environmental, safety, and health requirements.We conducted this followup audit to determine whether: (1) LANL took corrective actions related to the recommendations in our prior report on Issues Management at the Los Alamos National Laboratory (DOE-OIG-16-07, February 2016), and (2) actions taken to correct the deficiencies in our prior report resulted in an issues management program compliant with Federal requirements.We found that LANL took corrective actions related to Recommendations 1 through 3 in our prior report. Specifically, our current review did not reveal significant issues with LANL’s Issues Management program’s compliance with Federal requirements However, we found that LANL’s corrective actions related to Recommendation 4 did not always ensure all applicable subcontracts contained the Differing Professional Opinion requirement. By not including Exhibit F documents and the mandatory Differing Professional Opinion language into subcontracts for offsite work that LANL categorized as medium- and low-hazard, subcontractor employees may not know a process exists to report differing professional opinions involving technical issues that have a potentially adverse environmental, safety, or health impact.The issues we identified occurred, in part, because LANL’s process to include Differing Professional Opinion requirements in subcontracts did not always ensure all applicable subcontracts contained this mandatory requirement. Management agreed with our finding and recommendation, and its proposed corrective action is consistent with our recommendation.
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 Northport VA Medical Center and multiple outpatient clinics in New York. The inspection covered 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 almost five months at the time of the virtual inspection. Employee satisfaction survey scores for the medical center were lower than VHA averages, but scores for the Director were consistently higher than those for VHA and the medical center. Outpatient satisfaction survey results were generally higher than VHA averages but revealed opportunities to improve specialty care experiences for female veterans. The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. 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 five recommendations for improvement in four areas:(1) Quality, Safety, and Value• Peer review of deaths within 24 hours(2) Registered Nurse Credentialing• Primary source verification(3) Care Coordination• Nurse-to-nurse communication(4) High-Risk Processes• Disruptive behavior committee meeting attendance• Staff training
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 Jersey Health Care System in East Orange. 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; 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 inspection, the Director had served in the role since 2017 and some other leaders had been in their positions for over a year. Employee satisfaction survey data revealed opportunities for the Associate Director for Patient Care Services and Associate Director to improve perceptions of leadership and the workplace. Patient experience survey results indicated that males were generally satisfied with their primary care compared to VHA averages. Outpatient survey scores for females were lower than VHA averages. The OIG’s review of the system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Leaders were knowledgeable within their scope of responsibilities about VHA data and factors contributing to poor performance on specific Strategic Analytics for Improvement and Learning measures.The OIG issued eight recommendations for improvement in four areas:(1) Quality, Safety, and Value• Systems redesign and improvement coordinator meeting participation• Peer review processes• Surgical work group meetings(2) Registered Nurse Credentialing• Primary source verification(3) Care Coordination• Patient transfer monitoring and evaluation(4) High-Risk Processes• Disruptive behavior committee meeting attendance
The U.S. Postal Service developed an overarching Continuity of Operations (COOP) plan that allows essential business functions to continue when there is a disruption of normal operations. In support of that plan, the Postal Service developed the Retail Systems COOP (Plan) to provide a methodology for continuing retail operations in the event of a complete Retail Systems Software (RSS) system failure or power or network outage. The Plan ensures that field retail operations provides a limited scope of products and services with minimal customer service impact if retail systems automated functions become unavailable. In fiscal year (FY) 2021 post office retail revenue was over $13 billion.
This management alert presents issues the U.S. Postal Service Office of Inspector General (OIG) identified during the State of Cybersecurity audit (Project Number 21-205). Our objective is to notify Postal Service management of risks associated with security control deficiencies identified during the Assessment & Authorization (A&A) process that have not been mitigated.
This joint audit led by the DoD OIG examined actions taken by the DoD and VA regarding the Cerner Millennium electronic health record (EHR) system being deployed throughout VA and DoD. The audit assessed internal controls and compliance with legal requirements, as well as actions by DoD, VA, and their joint Federal Electronic Health Record Modernization (FEHRM) Program Office to help ensure that health care providers serving veterans can access a patient’s complete EHR. The audit focused on whether those actions would achieve interoperability between DoD, VA, and external health care providers. The joint audit found that DoD and VA took some actions to achieve system interoperability, but there are remaining challenges. DoD and VA did not consistently migrate information from legacy systems into Cerner Millennium to create a single, complete patient EHR; develop interfaces from all medical devices to the system; or ensure users were granted access to Cerner Millennium only for information needed for their duties. A contributing factor for these deficiencies was that the FEHRM Program Office did not develop a clear plan to achieve full interoperability or actively manage the program’s success. The audit report recommends that DoD and VA review FEHRM’s actions and direct the program office to comply with its charter and applicable laws. The FEHRM should also coordinate with DoD and VA on implementing recommendations that include (1) determining the type of health care information that constitutes a complete EHR; (2) implementing a plan for accurately migrating legacy health care information; (3) create medical device interfaces to directly transfer health care information to Cerner Millennium; and (4) implementing a plan to modify system user roles to ensure their access is restricted to only information needed to perform their duties.
The COVID-19 pandemic accelerated efforts by the Veterans Health Administration (VHA) to expand veteran access to telehealth. Accordingly, VHA’s Connected Care Office created a new digital divide consult to issue iPhones to veterans experiencing homelessness who were enrolled in the Department of Housing and Urban Development VA Supportive Housing (HUD-VASH) Program. VHA was already loaning iPads to other veterans who lacked telehealth capable devices through the digital divide consult process. The VA Office of Inspector General (OIG) initiated this review to evaluate whether purchases of iPads and iPhones for veterans met mission needs while minimizing waste during fiscal year (FY) 2020 and through the first two quarters of FY 2021.In July 2020, Connect Care officials purchased 10,000 iPhones with unlimited prepaid data plans for the homeless veterans enrolled in the HUD-VASH program. However, 8,544 of the 10,000 iPhones remained in storage as of July 2021, as demand for the iPhones was much lower than anticipated. The OIG found that this resulted in an estimated $1.8 million in wasted data plan costs. The OIG also identified opportunities for improvement regarding data plans for nearly 81,000 iPads purchased. Because Connected Care did not have strong enough oversight procedures for reducing or eliminating data plan waste, it incurred approximately $571,000 in additional wasted data plan costs.The OIG made two recommendations to the under secretary for health. The first was to establish a realistic goal for days in storage and a process for monitoring days in storage. The second was to determine the viability of initiating data plan charges only when a device is issued to the veteran.
The VA Office of Inspector General (OIG) evaluated allegations that Portland VA Medical Center (facility) staff “inappropriately discharged” a patient with “severe cognitive impairment,” then “turned away” the patient, and failed to provide the patient’s records to Adult Protective Services (APS). The OIG identified a concern regarding discharge coordination with family.In 2021, the patient, with a history of alcohol use and cognitive impairment, presented to the facility’s Emergency Department with gangrene and homelessness. Throughout the patient’s 33-day admission, staff evaluated the patient’s cognitive functioning, communicated with the patient’s family and APS staff, and pursued placements.Approximately an hour after discharge, the patient presented to the facility’s Emergency Department. A social worker provided the patient with a bus ticket “to return to the shelter.” Within an hour, the patient returned and the social worker reprinted the instructions and advised the patient to board the bus.The OIG substantiated that the patient was discharged to a non-VA homeless shelter by cab but did not substantiate the patient was “inappropriately discharged.” Staff determined that direct transport was preferable to the more complicated bus route.The OIG was unable to determine whether staff discussed the patient’s final discharge plan with family due to an absence of documentation and conflicting reports.The OIG substantiated that staff did not establish a safe transportation plan after the patient returned to the Emergency Department after discharge.The OIG did not substantiate that staff failed to provide the patient’s records to APS. However, staff returned requests without providing information regarding specific missing elements.The OIG made three recommendations related to consideration of requiring staff to document family contacts, a review of the Emergency Department social worker’s care coordination of the patient, and consideration of Privacy Office staff communicating the missing element(s) when returning a release of information request.
Our office, through a partnership with the Pandemic Response Accountability Committee, obtained data from the United States Small Business Administration (SBA) related to their Economic Injury Disaster Loans (EIDL) and Paycheck Protection Program (PPP) loans. We scheduled this audit after identifying potential matches between the SBA data and TVA employees. Our audit objective was to determine if TVA’s policies and procedures are effective in assuring outside employment of TVA employees is properly approved. Our audit scope was limited to TVA employees identified as having potential outside employment or business ownership through review of EIDL and PPP loan data received from the SBA. We found TVA’s policies and procedures are not effective in assuring outside employment of TVA employees is properly approved. Specifically, we found TVA employees are not consistently submitting their outside employment or business ownership on TVA Form 15570 prior to accepting outside employment or opening a business. In addition, we found TVA’s (1) review for potential conflicts of interest and (2) application of 5 CFR § 7901 requirements could be improved. We also found (1) the TVA Forms 15570 on file were not updated as required and (2) roles and responsibilities in the outside employment approval process could be clarified.
As of March 31, 2022, there are 71 open recommendations, 7 of which were reported as implemented by management but remain open per third-party (CLA/other Independent Public Accounting firm (IPA)/OIG) determination; and none of the remaining 64 were considered “Overdue.”
The U.S. AbilityOne Commission’s (Commission) charge card programs for fiscal years (FY) 2020 and 2021, as required by the Government Charge Card Abuse Prevention Act of 2012 (Charge Card Act) conducted by RMA Associates, LLC (RMA), an independent public accountant firm.
To report internal control weaknesses, noncompliance issues, and unallowable costs identified in the single audit to the Social Security Administration (SSA) for resolution action.
In April 2021, the U.S. Postal Service announced that, due to declining mail volume, it would relocate or remove unnecessary letter and flat sorting equipment as appropriate from 18 selected facilities to make space for package processing.Our objective was to review the Postal Service’s plan to transfer processing operations from 18 mail processing facilities to analyze adherence to established policy and identify any associated risks and opportunities. For this audit, we obtained implementation plans, reviewed Postal Service handbooks, interviewed Postal Service managers, and performed site observations.
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 Finger Lakes Healthcare System, which includes two medical center campuses—Bath and Canandaigua—and multiple outpatient clinics in New York and Pennsylvania. 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 inspection, system leaders had worked together for approximately three months. The OIG reviewed employee satisfaction survey results and concluded that averages from selected leadership questions were similar to or lower than VHA averages. Patient experience survey data showed that patients were generally satisfied with their outpatient care but less happy with their inpatient care than VHA patients nationally. The OIG’s review of the healthcare system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. However, the OIG identified a vulnerability in staffing challenges at the Canandaigua VA Medical Center. System leaders were knowledgeable within their scope of responsibilities about selected VHA data used in Strategic Analytics for Improvement and Learning models, and should continue taking actions to sustain and improve performance.The OIG issued six recommendations for improvement in three areas:(1) Mental Health• Suicide safety plan training(2) Care Coordination• Patient transfer monitoring and evaluation• Advance directive sent to receiving facility• Nurse-to-nurse communication(3) High-Risk Processes• Disruptive behavior committee meeting attendance• Staff training
Objective: to evaluate the effectiveness of the Social Security Administration’s controls over the recording of death information on the Numident database for deceased beneficiaries.
At the request of the Tennessee Valley Authority's (TVA) Supply Chain, we examined the cost proposal submitted by a company for transmission construction services. Our examination objective was to determine if the cost proposal was fairly stated for a planned 5-year, $50 million contract.In our opinion, the company's cost proposal was overstated. Specifically, we found the proposed general liability insurance markup rate was overstated compared to recent actual costs. We estimated TVA could avoid about $118,000 over the planned $50 million contract by negotiating a reduction to the general liability insurance markup rates to more accurately reflect the company's recent actual costs. (Summary Only)
EAC OIG performed this review to determine whether EAC complied with the Payment Integrity Information Act of 2019 reporting requirements for fiscal year 2021.
A Crew Management Representative based in Wilmington, Delaware, was terminated from the company on May 3, 2022, after a disciplinary hearing. Our investigation found that the employee violated company policies by engaging in outside employment while on a medical leave of absence and receiving short-term disability benefits. The employee is not eligible for rehire.
Deficiencies in a Behavioral Health Provider’s Documentation and Assessments, and Oversight of Nurse Practitioners at the VA Pittsburgh Healthcare System in Pennsylvania
The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate OIG identified concerns related to the assessment and documentation practices of a behavioral health certified registered nurse practitioner (BHNP) and leaders’ completion of BHNPs’ ongoing professional practice evaluations (OPPEs) at the VA Pittsburgh Healthcare System (facility) in Pennsylvania. During the inspection, the OIG found that the BHNP did not perform thorough suicide risk assessments for a patient who died by suicide.The OIG identified multiple deficiencies in a BHNP’s assessment and documentation practices including absence of comprehensive suicide risk assessments, failure to complete abnormal involuntary movement and metabolic assessments for patients prescribed certain antipsychotic medication, missing informed consent or a risk-benefit discussion when prescribing off-label medications, failure to resolve rule-out diagnoses, and substantial copy and paste use. The OIG found adverse clinical outcomes for one of eight patients for whom the BHNP did not document a comprehensive suicide risk assessment, as required by The Joint Commission.The OIG concluded that the Nurse Manager evaluated BHNPs as satisfactory in the OPPE elements of copy and paste use for fiscal year 2018 through the first half of fiscal year 2021, and safety plan completion for high risk for suicide patients for February 2020 through the first half of fiscal year 2021, without these elements being evaluated.The OIG made five recommendations to the Facility Director related to a comprehensive review of the BHNP’s assessment practices regarding the patient who died by suicide, a review of the BHNP’s overall assessment and documentation practices, alignment of facility policy and leaders’ expectations related to the assessment and documentation of abnormal involuntary movements and metabolic problems for patients prescribed antipsychotic medications, Behavioral Health managers’ verification of BHNPs’ OPPEs review, and a review of managers’ oversight of BHNPs’ OPPEs.
The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate leaders’ response to the knowledge of inappropriate provider-patient relationships (inappropriate relationships) in the Mental Health Service Line at the VA Illiana Health Care System (facility) in Danville, Illinois.The OIG determined that while facility leaders took initial actions to address three inappropriate relationships between mental health providers (Providers A, B, and C) and mental health patients (Patients A, B, and C), multiple factors affected the effectiveness of those actions. The OIG found that effective facility leader actions to investigate and address the inappropriate relationships of Provider A and Provider B occurred only after an Office of Accountability and Whistleblower Protection complaint. Facility leaders ineffectively addressed Provider C’s inappropriate relationship before Patient C died by overdose.Facility leaders implemented action plans to prevent future occurrences of inappropriate relationships. Given the egregious nature of the providers’ behaviors, facility leaders failed to report Providers B and C to their state licensing boards in a timely manner and failed to report Provider A to the appropriate professional certification board.The OIG also determined that facility leaders did not take actions to address the circumstances that contributed to the death of Patient C who was involved in an inappropriate romantic relationship with Provider C.The OIG made one recommendation to the Veterans Integrated Service Network 12 Director related to evaluating processes that affected facility supervisors’ identification and actions to address inappropriate relationships. The OIG made two recommendations to the Facility Director related to timely reporting of providers to state licensing or certification boards, and reviewing Patient C’s care to determine if there was an adverse event and if so, whether institutional disclosure is warranted.
The VA Office of Inspector General (OIG) audited Post-9/11 GI Bill student enrollments that included vacation breaks because of the risk they were not being accurately processed and veterans were not getting the correct benefits.The OIG found the Veterans Benefits Administration (VBA) did not always accurately process these enrollments. An estimated 2,500 of 10,000 enrollments from August 1, 2020, through April 1, 2021, should have been adjusted for vacation breaks but were not.Insufficient training and guidance meant school certifying officials frequently made mistakes. About 790 of the estimated errors involved officials either not reporting or underreporting vacation breaks. VBA claims examiners often mishandled enrollments even when the correct information was submitted. The OIG estimated claims examiners incorrectly processed accurately reported vacation breaks for about 1,700 of 2,500 enrollments with errors.The OIG determined that the estimated 2,500 enrollments with vacation break errors resulted in about 14,400 days of undercharges to students’ entitlement and about $624,000 in underpayments for monthly housing allowance and college fund.VBA officials plan to replace manual reporting and processing of enrollments with an automated system. However, VBA still needs to ensure school certifying officials are entering accurate information.The OIG recommended VBA update guidance and training for certifying officials to ensure a clear understanding of how to calculate and report vacation breaks. Other recommendations included creating procedures for claims examiners to verify information in enrollments flagged for manual processing. Amended enrollments for identified reporting errors should be submitted to VBA for remedial action. Data analysis and record matching can be used to identify enrollments likely to have vacation breaks that have not been properly reported or processed as part of VBA’s quality review process. Finally, VBA should include fields for vacation breaks in automated systems to minimize errors caused by manual data entry.
Starting in May 2021 and ending in March 2022, the GPO OIG sent joint teams of auditors, inspectors, and investigators to better understand the purpose, functioning, and management of the U.S. Government Publishing Office’s (GPO) regional offices.
U.S. Fish and Wildlife Service Grants Awarded to the State of Missouri, Department of Conservation, From July 1, 2018, Through June 30, 2020, Under the Wildlife and Sport Fish Restoration Program
U.S. Fish and Wildlife Service Grants Awarded to the Commonwealth of Virginia, Department of Wildlife Resources, From July 1, 2018, Through June 30, 2020, Under the Wildlife and Sport Fish Restoration Program
DOJ Press Release: South Bay Man Pleads Guilty to Participating in a Multimillion-Dollar Real Estate Scam Involving Fake Open Houses at Not-for-Sale Homes
U.S. Customs and Border Protection (CBP) and the Department of Homeland Security’s Countering Weapons of Mass Destruction Office (CWMD) co-manage the Radiation Portal Monitor (RPM) program but do not monitor and maintain RPM systems to ensure they continue to meet needed capabilities.
This report was issued in conjunction with the Office of Inspector General for the Railroad Retirement Board's Semiannual Report to the Congress. It was incorporated by reference in the corresponding Semiannual Report which is available at the link below.
The U.S. Postal Service uses overtime to provide flexibility and meet its operational requirements. To aid in efficiently managing overtime, the Postal Service implemented the Overtime Administration System (OT Admin) – a web-based application intended to assist managers and supervisors in administering and tracking overtime for craft employees while ensuring consistency with appropriate collective bargaining agreements.
The United States Capitol Police (USCP or the Department) Training Services Bureau (TSB) is one of eleven organizational units reporting to the Chief Administrative Officer (CAO).TSB is responsible for preparing Department employees to act decisively and correctly in a broad spectrum of situations, for improving overall productivity and effectiveness, and for fostering cooperation and unity of purpose.
In accordance with our Annual Performance Plan Fiscal Year 2022, the Office of Inspector General (OIG) conducted a review of TSB.Our objective was to determine if (1) the Department’s organizational structure and processes for its training program were the most efficient and effective and (2) the department complied with selected policies, procedures, applicable laws, regulations, guidance, and best practices.Our scope included the TSB organizational structure, processes, and operations.
The Federal Information Security Management Act requires the information security program of every agency to be evaluated each year. In FY 2021, SBA faced new information security challenges under the weight of lending huge amounts during the pandemic. In 2021, the agency had to deal with months of continued issues caused by the unprecedented volume of loan and grant applications spurred by the Coronavirus Aid, Relief, and Economic Security Act and other pandemic relief laws. We tested a subset of systems in nine areas, called “domains,” and evaluated them using guidance for FISMA metrics. Inspectors General are required to assess the effectiveness of information security programs on a maturity model spectrum.We rated SBA’s overall program of information security as ”not effective” because SBA only achieved a maturity level rating of “managed and measurable” in one of the nine domains.Based on tests of the eight information systems, we determined the results of each domain as follows:1. Risk Management — Defined2. Supply Chain Risk Management — Ad Hoc3. Configuration Management—Defined4. Identity and Access Management — Consistently Implemented5. Data Protection and Privacy — Consistently Implemented6. Security Training — Defined7. Information Security Continuous Monitoring — Defined8. Incident Response — Managed and Measurable9. Contingency Planning — Consistently Implemented.We made 10 recommendations in five of the domains: three recommendations in risk management, three recommendations for configuration management, two for identity and access management, one recommendation for security training, and one for information security continuous monitoring. SBA management agreed with the recommendations in this report.
A new white paper from the U.S. Postal Service Office of Inspector General (OIG) assessed changes in the geographic distribution of collection points and retail sites, and the extent to which these changes display patterns that may have disproportionately affected populations in locations with specific racial, ethnic, and income characteristics. The OIG also identified demographic trends in service performance scores and the volume of negative customer feedback across the U.S. USPS is not required to consider a community’s demographic characteristics — such as race, ethnicity, and income — when implementing changes to mail access or evaluating service quality. However, if the Postal Service considered demographic data, management would be better informed about the potential unintended consequences of their decisions.