Federal Reports

KPMG made 60 recommendations intended to strengthen the DOI’s information security program as well as the programs of DOI bureaus and offices.

An Amtrak train attendant based in New Orleans, Louisiana, was terminated from employment on April 4, 2022, following his administrative hearing. The employee was terminated after our investigation resulted in criminal charges for making false statements and theft of government funds. He pleaded guilty to these charges on April 27, 2022.Our investigation found the former employee fraudulently received unemployment benefits provided under the Coronavirus Aid, Relief, and Economic Security Act. The employee was not eligible to receive the funds as he was employed by Amtrak during this time and the loan application form he submitted contained false information. The employee received an $89,583 Paycheck Protection Program (PPP) loan by falsifying information in the loan application. He will be sentenced at a future date.

In September 2021, the Atlanta Journal Constitution reported on large quantities of unopened mail being stored in the warehouse basement of the VA medical facility in Atlanta. The OIG conducted a review that found the Atlanta VA Health Care System (HCS) had formed a task force to open, sort, and process stacks of mail reportedly piled as high as 10 feet and dating back at least 10 months. When opened, the 17,660 pieces of mail contained medical records, claims, nearly $207,000 in checks, and correspondence from veterans.The mail backlog began accruing after a November 2020 verbal agreement between Atlanta VA HCS officials and VHA’s Payment Operations and Management (POM) personnel. The agreement called for POM staff to vacate space in a building leased by the medical facility where POM was processing mail if Atlanta VA HCS personnel took over the responsibility for processing that mail.The OIG determined that VA should have established a formal agreement clearly detailing each office’s responsibilities. VA HCS leaders did not include responsible managers in decision making discussions and lacked a clear understanding of the volume of mail processing work they were accepting. Atlanta VA HCS did not ensure mailroom staff were adequately prepared or trained to handle or sort the influx of mail, and POM officials were later reluctant to help, citing the verbal agreement.Given the mail mismanagement in Atlanta, VHA should ascertain the effects the mail processing delays had on veterans and community care providers and take corrective action. Because POM is implementing similar transitions at sites across the country, POM and medical facilities need to ensure there is adequate staff with sufficient training to handle the mail processing workload. VA concurred with the OIG’s five recommendations.

We conducted a performance audit of three National Endowment for the Arts (NEA) awards issued to the Arizona Commission on the Arts (Commission) – Awards No. 17-6100-2062 (2017award), 180989-61-18 (2018 award), and 1855979-61-19 (2019 award). Based on our review, wedetermined that the Commission generally met the financial and compliance requirementsestablished in the award documents. However, we also determined the following areas requireimprovement. Specifically, the Commission:1. Reported $36,483 in costs incurred outside the award period on its FFRs - $4,272 for the2018 award and $32,211 for the 2019 award;2. Did not report a subaward that met the Federal Financial Accountability andTransparency Act reporting requirement; and3. Did not verify potential contractors were eligible to participate in Federal awards.Based on our review, we are questioning $36,483 in reported costs. As a result, we determinedthe Commission did not meet the cost share/match requirement for the 2018 award, resulting in apotential refund due to the NEA totaling $2,136. The report includes three recommendations tothe Commission and two to the NEA to address these findings. The Commission concurred withthese findings and recommendations.

The owner of Corrosion Monitoring Services (CMS), a TVA contractor, pleaded guilty to one felony count of Misprision of a Felony, one felony count of Obstruction of Justice and one felony count of Witness Tampering. The charges were related to an allegation that CMS purposefully damaged metal tubes used in an air heating and exchange system at TVA’s former Paradise Fossil Plant in order to repair those tubes under the CMS contract with TVA.

What We Looked AtWhile track-caused rail accident numbers and rates have declined over the past 2 decades, defective track conditions are still among the most frequent causes of train derailments. The Federal Railroad Administration’s (FRA) Track Division deploys track inspectors and its Automated Track Inspection Program (ATIP) to determine whether railroads are complying with minimum safety requirements for railroad track. Given the impact of track conditions on railroad safety, we initiated this audit to evaluate FRA’s use of automated inspections to aid track safety oversight. What We FoundFRA deploys eight ATIP inspection vehicles to monitor track conditions nationally and recently took actions to improve the program’s operation and oversight. However, the Agency’s formal program metric for ATIP vehicle utilization is outdated. Specifically, FRA contracts out operation of these vehicles to two contractors but only established a single utilization goal to run the ATIP vehicles 150 survey days a year. While some ATIP vehicles came close to the goal individually, collectively the ATIP fleet fell short, with an average 80-percent utilization between fiscal years 2016 and 2021. FRA officials offered several reasons, including weather events, to explain the missed goal. In addition, over half of the 539 ATIP-related inspection reports we reviewed contain inaccurate data—in part because FRA does not have sufficient guidance on recording ATIP-related inspection activities. FRA also relies on inspectors to respond promptly to changing conditions and use their territory knowledge in planning their work but does not have any national or formal district-level track inspection planning processes in place. However, FRA does use ATIP vehicles and survey data to perform data-driven evaluations of railroad track testing programs and improve its data inventories. Until FRA improves ATIP utilization goals and ATIP-related track inspection reporting, it cannot ensure its resources are optimally targeted to support the Agency’s track oversight. Our RecommendationsFRA concurred with all six of our recommendations to improve its use of automated inspections to aid track safety oversight and provided appropriate actions and completion dates. We consider these recommendations resolved but open, pending completion of planned actions.

This report was submitted to the Comptroller General in accordance with Section 5 of the Government Accountability Office Act of 2008. The report summarizes the activities of the Office of Inspector General (OIG) for the six-month reporting period ending March 31, 2022. During the reporting period, the OIG issued two audit reports and began one performance audit. In addition, the OIG closed five investigations including a self-initiated inquiry and opened seven new investigations including two self-initiated inquiries. The OIG processed 63 hotline complaints, many of which were referred to other OIGs for action because the matters involved were within their jurisdictions.The OIG remained active in the GAO and OIG communities by briefing new GAO employees on its audit and investigative missions and participating in committees and working groups of the Council of Inspectors General on Integrity and Efficiency, including those related to the Pandemic Response Accountability Committee. Details of these activities and other accomplishments are provided in the report.

What We Looked AtRecognizing that Unmanned Aircraft System (UAS) is the fastest growing segment of the aviation industry and in response to a Presidential Memorandum, the Federal Aviation Administration (FAA) initiated the 3-year UAS Integration Pilot Program (IPP) in 2017. Through the IPP, FAA worked with selected State, local, and tribal governments, who partnered with private sector entities (e.g., UAS operators) to accelerate safe integration and help develop new rules to enable more complex UAS operations in the National Airspace System (NAS). After ending the IPP as planned in October 2020, FAA launched a follow-on program called BEYOND to address remaining UAS-related challenges, including operations beyond visual line of sight. Citing the importance of the IPP's efforts, the Ranking Members of the House Committee on Transportation and Infrastructure and its Subcommittee on Aviation requested that we assess FAA's IPP, including next steps. Accordingly, our audit objectives were to assess (1) the results of FAA's IPP and (2) FAA's plans for using those results, including how the Agency will incorporate them into its new program BEYOND.What We FoundWhile FAA made progress advancing UAS operations through the IPP, results did not fully meet industry and participant expectations and integration challenges remain. Further, challenges with planning, data requirements, and the Agency's organization hindered the IPP's overall success. FAA also faced challenges balancing the need to ensure aviation safety with UAS innovation, especially given the complexity of proposed operations. In addition, issues coordinating across multiple FAA lines of business and Agency turnover contributed to participant frustration and program challenges. Finally, while FAA incorporated lessons learned and best practices into BEYOND, challenges that limited the IPP's success remain. As a result, it is uncertain when FAA and industry will be positioned to enable operations beyond visual line of sight that are economically viable throughout the NAS.Our RecommendationsWe made six recommendations to improve FAA's use of UAS IPP results, including in its current program, BEYOND. FAA concurred with all six of our recommendations and provided appropriate actions and planned completion dates.

Management Report: Improper Payment Determination for Fiscal Year 2021

The objective was to conduct an unannounced inspection of South Texas ICE Processing Center to monitor compliance with select ICE detention standards.

The report summarizes the FTC OIG’s activities and accomplishments during the first half of the FY 2022 reporting period.

Between 2014 and 2016, a former executive director of an Alaska Native organization embezzled $174,290.67 through unauthorized use of accounts.

John Flores, a former Amtrak reservation sales agent based in Riverside, California, was sentenced on April 25, 2022, in U.S. District Court, for the Central District of California, to 3 years of probation and $25,137 in restitution to the company. He pleaded guilty to Theft from Programs Receiving Federal Funds on September 29, 2021. Our investigation found that Flores stole hundreds of eVouchers valued at over $25,000 from customers’ accounts by exploiting the company’s computer system. He then resold the stolen eVouchers for his own personal gain. Flores resigned from the company on May 2, 2017.

VA is replacing its aging electronic health record system with a new one intended to be interoperable with the Defense Department to give healthcare providers a continuous and comprehensive medical history for veterans. The Electronic Health Record Modernization (EHRM) program is expected to take about 10 years to implement across VA facilities, with projected completion in fiscal year 2028.The Office of Inspector General (OIG) audited the EHRM program’s master schedule as part of its continued oversight of this costly and complex effort and identified reliability weaknesses. The audit team found VA lacked a reliable integrated master schedule consistent with scheduling standards, which increases the risk of missing milestones and delaying the delivery of a system to support prompt quality care to veterans. Schedule delays that extend the program are also likely to result in about $1.95 billion in cost overruns per year and may undermine VA’s other modernization efforts on supply chain and financial management systems.Additional deficiencies included known tasks not being reflected on schedules, no risk analysis, lack of longer-term actions scheduled, and no complete baseline schedule or overall schedule that fully integrated individual project schedules. VA also did not comply with federal regulations when it paid its contractor for deliverables before accepting them (reviewing for compliance with contract requirements).VA concurred with the OIG recommendations for the EHRM program office to comply with internal guidance and develop an integrated master schedule that meets standards, improve stakeholder coordination to ensure activities from all relevant VA entities are included, implement procedures for performing schedule risk analyses, make contract language and program office plans or other guidance consistent, evaluate and modify contract requirements for schedule management to clarify roles for further schedule development and maintenance, and issue guidance to accept deliverables not separately priced before invoice payment.

As part of our annual audit plan, we performed an audit of costs billed to the Tennessee Valley Authority (TVA) by Voith Hydro, Inc. (Voith) under Contract No. 9000, for hydro modernization, unit rehabilitation, and functional support services in support of TVA's hydro facilities, including Raccoon Mountain Pumped Storage Plant. The contract provided for TVA to compensate Voith for these services on either a fixed price, time and material, and/or target price estimate basis. Our audit objectives were to determine if (1) costs were billed in accordance with the terms and conditions of the contract and (2) tasks were issued using the most cost efficient pricing methodology. Our audit scope included about $119.6 million in costs TVA paid to Voith from August 20, 2014, through December 31, 2020. This included $118.2 million for fixed price projects and $1.4 million for time and material projects. In summary, we determined Voith billed TVA (1) at least $2,435,353 for labor classifications that did not have a corresponding labor rate in the contract and (2) $12,606 in excessive labor rates due to ineligible rate adjustments. In addition, based on the limited fixed price information we reviewed, it did not appear TVA was paying excessive prices by compensating Voith on primarily a fixed price basis. (Summary Only)

In planning and performing our audit of the financial statements of the United States Capitol Police (USCP or the Department) as of and for the year ended September 30, 2021, in accordance with auditing standards generally accepted in the United States of America, we considered USCP's internal control over financial reporting as a basis for designing audit procedures that are appropriate in the circumstances for the purpose of expressing our opinions on the financial statements and on internal control over financial reporting.

In accordance with our annual plan, the United States Capitol Police (USCP or the Department) Office of Inspector General (OIG) conducted an audit of the Department's financial statements for the years ended September 30, 2021 and 2020. Our objective was to express an opinion on the fairness of the financial statements in all material respects and render an opinion on controls over financial reporting and report on compliance with laws, regulations, and contracts. Our audit was conducted in accordance with Government Auditing Standards.

The Veterans Benefits Administration (VBA) provides a variety of benefits to eligible veterans, including monthly disability compensation or pension payments. VBA primarily relies on death notifications from the Social Security Administration (SSA) in an automated process called the death match to ensure that payments will properly stop when there is a record of a veteran’s death.The VA Office of Inspector General (OIG) conducted a limited evaluation of VBA’s processes for discontinuing compensation and pension benefit payments to deceased veterans to help improve VBA’s efficiency as well as prevent or redress fraud and waste. The OIG team reviewed three samples and determined that, in one sample, VBA was unaware its systems failed to complete one automated weekly death match in December 2020. The failed weekly death match resulted in payments continuing to 43 veterans after their deaths. Of those, 29 payments were made for seven months until those veterans’ deaths were discovered by the OIG.In a second sample, the review team determined the death match mechanism was limited because VBA’s electronic systems contained incorrect social security numbers, which may result in VBA continuing to pay compensation or pension benefits to veterans after their deaths. The team reviewed a judgmental sample of 140 veterans and found that 87 of the records had incorrect social security numbers in VBA’s electronic systems. In a third sample, the team reviewed a random sample of 121 veterans with dates of death between January 2017 and February 2021 and determined that VBA could have minimized improper compensation or pension payments to deceased veterans if it had obtained death notification data from the Veterans Health Administration. The OIG made three recommendations to improve oversight of and communication for VBA’s death match process that can help prevent improper benefit payments from being made to deceased veterans.

Nestor Rojas, a resident of Miami, pleaded guilty in U.S. District Court, Middle District of Florida, to one count of conspiracy to commit health care fraud and wire fraud on April 21, 2022. Our investigation found that Rojas conspired with others to unlawfully bill for approximately $1.4 billion of laboratory testing services which were medically unnecessary and fraudulently used rural hospitals as billing shells to submit claims for services that mostly were performed at outside laboratories. As a result of this scheme, Amtrak’s health care plans paid out more than $610,000 to three rural hospitals and associated laboratories. Rojas will be sentenced at a future date. Criminal judicial proceedings for additional co-conspirators are pending.

Dominique Henley, a former Amtrak baggageman based in Chicago, pleaded guilty to identity theft and was sentenced in the Circuit Court of Cook County, Illinois, on April 20, 2022, to 24 months’ probation. Our investigation found that Henley was in possession of 21 Social Security cards and 13 state and government-issued identification cards belonging to 21 different individuals. We found that of the 21 individuals’ identification documents in his possession, 19 were previously located in the Chicago Union Station lost and found or were reported lost on Amtrak trains. Henley was terminated from employment on November 3, 2020.

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 Syracuse 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.At the time of the inspection, the medical center’s executive leadership team appeared stable, with all positions permanently assigned. Leaders had worked together almost five months, although some had served in their positions for more than five years. Employee survey data revealed opportunities for leaders to improve servant leadership and decrease employees’ feelings of moral distress. Patients generally appeared satisfied with the care provided. The OIG’s review of the accreditation findings did not identify any organizational risk factors. However, the OIG noted concerns related to patient safety and risk management. Executive 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 seven recommendations for improvement in three areas:(1) Leadership and Organizational Risks• Sentinel events and institutional disclosures(2) Quality, Safety, and Value• Systems redesign and improvement coordinator meeting participation• Surgical work group administration and data analysis(3) High-Risk Processes• Disruptive behavior committee meeting attendance• Staff training

In FY 2021, the U.S. Postal Service’s delivery network consisted of 163.1 million possible addresses, with more addresses – or delivery points – added every day. Delivering to every address is part of the Postal Service’s Universal Service Obligation (USO). In this white paper, the OIG sought to identify trends in delivery points and review the process for adding, maintaining, and removing delivery points from the network.Delivery point growth did not occur evenly across the country. The south and west experienced more growth than other parts of the U.S., with some states adding delivery points at more than double the national average. Delivery point growth on rural routes far exceeded growth on city routes, and cluster box units (CBUs) were the fastest-growing mode of delivery. Since FY 2011, more than four million delivery points were removed from the network.We identified several areas of opportunity for the Postal Service to improve delivery point management processes, including clarifying CBU maintenance responsibility and establishing permanent growth manager positions across the agency. Continuing to promote centralized delivery in new developments can help the Postal Service control delivery costs. However, growing parcel volumes and packages that are too large to fit CBUs may require door delivery and erode some of the cost savings.

We audited costs claimed by the North Dakota Game and Fish Department under grants awarded by the U.S. Fish and Wildlife Service Wildlife and Sport Fish Restoration Program.

ICE did not adequately justify the need for the sole source contract to house migrant families and spent approximately $17 million for hotel space and services at six hotels that went largely unused between April and June 2021.

Our objective was to determine whether U.S. Customs and Border Protection (CBP) complied with the National Standards on Transport, Escort, Detention, and Search (TEDS).

We are issuing this management alert to advise the Federal Emergency Management Agency (FEMA) that its Coronavirus disease 2019 (COVID-19) Funeral Assistance Program operating procedures contradict FEMA’s previous interpretation of long-standing regulations for ineligible funeral expenses established in FEMA’s Individual Assistance Program and Policy Guide (IAPPG). This interpretation of regulations for ineligible funeral expenses remains unchanged in FEMA Policy 104-21-0001 (COVID-19-specific policy).

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 Columbus, OH, region (Project Number 22-052). These delivery units include the Lewis Center Main Post Office (MPO) in Lewis Center, OH, and the South Columbus Station and East City Annex in Columbus, OH. We previously 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 Columbus, OH, Processing and Distribution Center (P&DC), which services these three delivery units.All three delivery units are in the Ohio 2 District of the Central Area. The three delivery units have a combined total of 74 city routes and 20 rural routes. Staffing at the delivery units during our audit included 82 full-time city carriers, 12 part-time city carriers, 17 full-time rural carriers, 14 part-time rural carriers, 12 full-time clerks, and 11 part-time clerks (see Table 1).

The Office of Inspector General (OIG) evaluated the U.S. Small Business Administration’s (SBA) procedures to award a contract for data analysis and loan recommendation services for Economic Injury Disaster Loan (EIDL) applications and Targeted EIDL Advance applications related to the Coronavirus Disease 2019 (COVID-19) pandemic.To increase loan processing capabilities and quickly disburse loans during the pandemic, SBA used an existing contract awarded to RER Solutions and its subcontractor Rocket Loans set aside for small businesses. SBA initially set a contract ceiling of $100 million and then used emergency contracting authority to increase the contract ceiling to $850 million. This increase was done in a noncompetitive process to quickly administer the COVID-19 EIDL program.To quickly award loans during the COVID-19 economic crisis, SBA relied on an earlier 2018 contract but did not follow the proper procedures to ensure that contract provided the best value to the government. SBA awarded the contract for data analysis and loan recommendation services without adequately ensuring the contract prices were fair and reasonable in accordance with Federal Acquisition Regulation and agency policy.SBA’s needs had changed significantly from the 2018 disaster loan contract to the requirements for processing COVID-19 EIDLs, and those changes were not fully taken into consideration when awarding following contracts. As a result, there is no assurance that the rates SBA paid for services under the data analysis and loan recommendation contract were fair and reasonable.SBA also did not ensure the contractor complied with established size standards to be eligible for a small business set-aside award. In addition, SBA did not ensure the contractor complied with subcontracting limitations, exceeding the limit by $13 million. These awards are intended to help small businesses compete and win government contracts. Instead, the COVID-19 contract was noncompetitively awarded and largely performed by an affiliate of one of the nation’s largest mortgage lenders.We made six recommendations to strengthen SBA’s procurement policies and enhance controls to ensure compliance with SBA’s contracting program requirements. SBA agreed or partially agreed with all six recommendations.

The Office of the Inspector General conducted a review of the Allen Integrated Site (Allen) to identify factors that could impact Allen’s organizational effectiveness. During the course of our evaluation, we identified positive behavioral factors, including relationships with team members and business units outside Allen; however, we also identified behavioral concerns with two managers. In addition, we identified operational factors needing improvement related to (1) perceptions of ineffective work management, (2) fire alarm system repairs, and (3) site security and access concerns. Management is addressing some of these concerns by implementing a Gas Operations’ initiative to address work management, overseeing fire alarm system repairs, and submitting documentation to upgrade site security.

This report presents the results of our self-initiated audit of the U.S. Postal Service’s Mail Transport Equipment (MTE) Program (Project Number 21-229). Our objective was to assess Postal Service management of the MTE program. See Appendix A for additional information about this audit.MTE consists of containers (including sacks, pouches, trays, wheeled containers, pallets, etc.) used to contain mail during processing and while transporting it between postal facilities, delivery units, and mailers.The Postal Service purchases and distributes MTE to transport mail. The use of MTE is provided as a courtesy to convey mail to and from facilities and mailers and it may not be retained or used for unauthorized purposes. Additionally, to reduce processing costs, all MTE must be properly containerized or finalized as Postal Prepared Finished Goods (PPFG) and must have a Mail Transport Equipment Labeler (MTEL) placard affixed prior to it being returned to the Mail Transport Equipment Service Center (MTESC).The Postal Service’s MTESC network is comprised of 14 contractor-operated centers that are responsible for processing, repairing, storing, and distributing MTE in a timely and efficient manner. The Mail Transport Equipment Support System (MTESS) supports MTESCs and processes orders for facilities and large mailers.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations related to a primary care provider’s delivery of hypertension treatment and post-stroke care, nursing staff communication and documentation, and facility telephone communication processes at the Amarillo VA Healthcare System (system) in Texas. The OIG was unable to determine whether delays in treatment for hypertension and headaches caused the patient’s stroke and did not find primary care-related treatment failures in the weeks leading up to the stroke. However, when the patient presented to the clinic with stroke-like symptoms in early 2021, the provider and clinic nurse failed to ensure the patient received urgent medical attention. The delay in evaluation and treatment may have resulted in a more difficult recovery for the patient.The OIG did not substantiate allegations regarding a failure to order cardiology and neurology consults, that a licensed vocational nurse diagnosed the cause of the patient’s headaches, or that secure messaging was the only way the patient could communicate with the primary care team. The OIG was unable to determine whether nurses’ communications were dismissive and condescending.The OIG identified multiple system leaders’ failure to assess and follow through on the provider’s ongoing quality of care deficits. These failures allowed the provider to continue practicing substandard medicine, and as a result, patients experienced adverse outcomes. The provider has been functioning in an administrative capacity without direct patient care duties since spring 2021.The OIG made one recommendation to the Veterans Integrated Service Network Director to assess system leaders’ actions related to professional practice evaluations, institutional disclosure, and staff training.The OIG made five recommendations to the System Director related to vital sign protocols, clinical practice evaluation of a nurse, respectful communications, critical view alerts and other quality of care reviews, and communication and documentation requirements.

This management alert presents issues identified during our Review of National Change of Address and Moversguide Applications audit (Project Number: 21 146). Our objective is to notify U.S. Postal Service management of risks associated with ineffective identify verification controls on the Moversguide application. See Appendix A for additional information about this alert.

This investigation was initiated based on a Highway Contract Route driver for the Postal Service who alleged he transported completed mail-in ballots across state lines from Bethpage, NY, to Lancaster, PA, on October 21, 2020.

We identified poor data management practices in the Bureau of Land Management’s Compensatory Mitigation program.

At the request of the Tennessee Valley Authority's (TVA) Supply Chain, we examined the cost proposal submitted by a company for coal combustion residual (CCR) program management services. Our examination objective was to determine if the company's cost proposal was fairly stated for a planned 20-year contract.In our opinion, the company's proposed markup rates for recovery of indirect costs were fairly stated. However, the company's proposed costs for a $248.2 million CCR project were overstated by a net $1.6 million due to inaccuracies in craft pay and benefits. Subsequently, the company submitted a revised estimate of $246.6 million to correct the inaccuracies.(Summary Only)

We substantiated allegations related to missing National Park Service equipment, including power tools, at the San Juan National Historic Site.

This report presents the results of our self-initiated audit of Efficiency of Operations at the Margaret L. Sellers (MLS) Processing and Distribution Center (P&DC) in San Diego, CA (Project Number 22-061). 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 MLS P&DC based on overtime, penalty overtime, late and extra trips, and low clearance time percentage for package processing. The MLS P&DC is in the Southern California Division; processes letters, flats, and parcels; and services multiple 3-digit ZIP Codes in urban and rural communities.

This audit examined the Agency’s processes for estimating, tracking, and reporting life-cycle costs and questioned whether current practices support transparency and accountability.

In June 2021, a complainant alleged that the then acting principal deputy under secretary for health had been informed in the fall of 2019 that VHA’s patient wait times reporting may be misleading but that no action was taken in response. After an initial examination, the OIG determined that there was no basis to proceed with a misconduct investigation of the then acting principal deputy under secretary for health, as the OIG found no evidence of intent or efforts to mislead. This management advisory memo, however, details how VHA has presented wait times to the public without clearly and consistently disclosing the basis for their calculations. Since 2014, VHA has employed several different methodologies (particularly using different start dates) for calculating wait times reported online, as well as for determining whether wait time criteria are met for community care program eligibility. The methodologies deviated in some instances from VHA’s scheduling directive and its stated wait time measures announced in the Federal Register in 2014. As a result, VHA has presented wait times with different methodologies, using inconsistent start dates that affect the overall calculations without clearly and accurately presenting that information to the public. The OIG found that efforts to improve wait time disclosures had been under consideration but had been deferred by urgent priorities, including the COVID-19 pandemic. VHA’s efforts to improve the accuracy in its reporting of the timeliness of veterans’ access to care are dependent on the consistency of its calculations of wait times and its transparency regarding which methodologies and data sources have been used, together with any limitations. This memo serves to alert VA of the problems identified regarding wait time calculations and reporting, and requests that VA inform the OIG what action is taken to address the identified issues.

The VA Office of Inspector General (OIG) conducted an inspection to assess VA medical facilities’ compliance and processes regarding Veterans Health Administration (VHA) policies for reporting healthcare professionals to state licensing boards (SLBs) and the National Practitioner Data Bank (NPDB).The OIG found widespread noncompliance with SLB and NPDB reporting processes applied by facilities to healthcare professionals whose conduct or competence led to separation from employment. Failure to comply with reporting policies leaves SLBs and recipients of NPDB information unaware of a healthcare professional’s practice deficiencies and ultimately violates an important VA commitment to protect the health of veterans and the public. Moreover, the OIG found a lack of programmatic oversight of compliance with SLB and NPDB reporting processes.For a majority of cases involving separated healthcare professionals, facility directors failed to follow mandatory processes for reporting healthcare professionals to SLBs. The OIG identified SLB reporting noncompliance was related to staff misunderstanding policy and poor facility processes.In 15 of 35 physician or dentist cases appealing a separation from employment, facility directors failed to submit NPDB reports as required by federal regulation and VHA policy. Conflicting language in VHA policies, misunderstanding of policies, and poor facility processes contributed to the failures.VHA SLB and NPDB reporting policies did not assign programmatic oversight to ensure facility leaders’ compliance with SLB and NPDB reporting processes. The lack of programmatic oversight contributed to the failure of VHA leaders to detect and intervene upon facility noncompliance.The OIG made four recommendations to the Under Secretary for Health regarding ensuring SLB and NPDB reporting compliance and programmatic oversight as well as aligning NPDB policy with federal regulation.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of Veterans Integrated Service Networks (VISNs) 2, 5, and 6 facilities’ COVID-19 pandemic readiness and response. This evaluation focused on emergency preparedness; supplies, equipment, and infrastructure; staffing; access to care; community living center patient care and operations; facility staff feedback; and VA and VISNs 2, 5, and 6 vaccination efforts.The OIG has aggregated findings on COVID-19 preparedness and responsiveness from routine inspections to ensure information is provided in a comprehensive manner, given the changing landscape as infection rates and demands on facilities continue to shift. Findings of inspected medical facilities are grouped by VISN, which are regional systems that provide oversight of medical centers in their area.This report, the fourth in a series, describes findings on COVID-19 practices from healthcare inspections performed within VISNs 2, 5, and 6 during the third and fourth quarters of fiscal year 2021 (April 1 through September 30, 2021). It provides a more recent snapshot of the pandemic’s demands on these facilities’ operations based on data compiled as of September 2021. Additionally, it includes information on COVID-19 vaccination efforts, based on a review of VA’s vaccination statistics as of September 29, 2021. Interviews and survey results provide additional context on lessons learned and perceptions of readiness and response.This report aims to provide the nation’s largest integrated healthcare system with relevant information to use in its efforts toward innovation and transformation to meet the healthcare needs of our nation’s veterans.

Prior to landing humans on the Moon as part of the Artemis program, NASA is developing new science instruments to explore the lunar surface including VIPER, a rover that will survey the Moon’s water ice to see if people can “live off the land.” In this report, we assessed NASA’s management of the VIPER project.

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 Western New York Healthcare System. 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.The healthcare system’s executive leadership team appeared stable, with all positions permanently assigned. Leaders had worked together for about five months, although some had served in their positions for multiple years. Employee survey data revealed opportunities for leaders to improve workplace satisfaction and reduce feelings of moral distress. Patients generally appeared satisfied with their care. The inspection team reviewed accreditation agency findings and disclosures of adverse patient events and did not identify substantial organizational risk factors. However, the OIG identified concerns related to sentinel event identification and reporting. Executive 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 seven recommendations for improvement in four areas:(1) Leadership and Organizational Risks• Identification and reporting of sentinel events(2) Quality, Safety, and Value• Peer review committee recommendation of improvement actions• Surgical work group attendance(3) Care Coordination• Monitoring and evaluation of inter-facility transfers(4) High-Risk Processes• Disruptive behavior committee meeting attendance• Staff training

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Linda Vista Station, San Diego, CA (Project Number 22-059). The Linda Vista Station is in the California District of the WestPac Area and services ZIP Codes 92108 and 92111. These ZIP Codes serve about 65,493 people and are considered to be urban communities. We judgmentally selected the Linda Vista Station 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 Ramona Main Post Office (MPO) in Ramona, CA (Project Number 22-062). The Ramona Main Post Office is in the California 6 District of the WestPac Area and services ZIP Code 92065, which serves about 35,349 people and is considered to be an urban community. We judgmentally selected the Ramona 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 Downtown San Diego Station in San Diego, CA (Project Number 22-060). The Downtown San Diego Station is in the California District of the WestPac Area. The station services ZIP Code 92101, which serves about 36,785 people and is considered an urban community. We judgmentally selected the Downtown San Diego Station based on the number of stop-the-clock (STC)3 scans occurring at the delivery unit, rather than at the customer’s delivery address.

As required by the Inspector General Act of 1978 (as amended), this Semiannual Report summarizes the activities of the Department of Transportation Office of Inspector General for the preceding 6-month period.