Federal Reports

The VA Office of Inspector General (OIG) reviewed Veterans Health Administration (VHA) assertions required by the Office of National Drug Control Policy (ONDCP) in its fiscal year 2021 detailed accounting report and budget formulation compliance report.The OIG’s review was conducted in accordance with generally accepted government auditing standards, which incorporate the attestation standards established by the American Institute of Certified Public Accountants. Those standards require that the OIG plan and perform the review to obtain limited assurance about whether any material modifications should be made to management’s assertions for them to be fairly stated. The OIG believes this review provides a reasonable basis for its conclusion.In the detailed accounting report, VHA reported three material weaknesses, two significant deficiencies, and five matters concerning noncompliance with laws and regulations, as identified in the OIG report, Audit of VA’s Financial Statements for Fiscal Years 2021 and 2020. A material weakness is a deficiency, or combination of deficiencies, such that there is a reasonable possibility that a material misstatement of the entity’s financial statements will not be prevented or detected and corrected on a timely basis. A significant deficiency is a control deficiency, or a combination of control deficiencies, that is less severe than a material weakness, yet important enough to merit attention by those charged with governance.Based on the OIG’s review, except for the effects, if any, of the matters described in the preceding paragraph, the OIG is not aware of any material modifications that should be made to VHA management’s assertions for them to be fairly stated.

In November 2021, Congress passed the VA Transparency & Trust Act of 2021 to oversee VA’s spending of emergency relief funding related to the COVID-19 pandemic. The law requires VA to report to Congress how it will spend the funding and provide biweekly updates thereafter.The law also requires the VA OIG to report within 120 days on whether VA is spending the funds according to its plan and must address waste, fraud, and abuse. This inaugural report focuses on whether the spend plans VA provided to Congress on December 22, 2021, satisfy the requirements of the Transparency Act.VA’s spend plans generally outlined how it intended to use the supplemental funds. The OIG found, however, that the National Cemetery Administration’s planned use of funds included a shrine project to raise and realign over 17,000 headstones, replace irrigation, and repair turf in the historical sections of a cemetery. The $3.6 million used for the Beaufort National Shrine project may have violated the law because the work did not appear to be directly related to COVID-19. Further, the team identified a planned use of funds that did not include a projected cost related to maintaining information technology projects. As a result, it is unclear if all planned uses are captured in VA’s obligations reported in the ARP Act plan submitted to Congress.The OIG made two recommendations to the assistant secretary for management/chief financial officer to improve the quality and sufficiency of information reported to Congress: (1) consult with appropriate VA financial and legal officials to determine whether the use of emergency funds for the shrine project violates the law and correct if necessary, and (2) determine obligations for sustaining essential information technology investments, provide an updated spending plan to Congress, and include this information in future biweekly updates.

This report presents a summary of the results of our self-initiated audits assessing mail delivery, customer service, and property conditions at four select delivery units in the Portland, OR, region (Project Number 22-001). These delivery units included the Beaverton, OR, and Vancouver, WA, Main Post Offices (MPO) and the Parkrose and Piedmont Stations in Portland, OR. 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 Portland Processing and Distribution Center (P&DC), which services these four delivery units.All four delivery units are in the WestPac Area. The Beaverton MPO and the Parkrose and Piedmont Stations are in the Idaho-Montana-Oregon District and the Vancouver MPO is in the Washington District. The four delivery units have a combined total of 188 city routes and 16 rural routes. Staffing at the delivery units, at the time of our audit, included 226 full-time city carriers, 64 part-time city carriers, 15 full-time rural carriers, 11 part-time rural carriers, 45 full-time clerks, and 20 part-time clerks.The delivery units service about 330,190 people in several ZIP codes which are considered predominantly urban communities.

OIG issues an Immediate Release and Advisory alerting Lifeline, Emergency Broadband Benefit, and Affordable Connectivity Program providers and consumers to improper and abusive enrollment practices that are part of some providers’ online enrollment processes.

The Peace Corps Office of Inspector General reviewed the system of quality control for the NCUA OIG in effect for the year ending September 30, 2021. A system of quality control encompasses the NCUA OIG's organizational structure, the policies adopted and procedures established to provide it with a reasonable assurance of conforming in all material respects with Government Auditing Standards and applicable legal and regulatory requirements. The elements of quality control are described in Government Auditing Standards. The Peace Corps OIG opined that the system of quality control for the NCUA OIG in effect for the year ending September 30, 2021, has been suitably designed and complied with to provide NCUA OIG with reasonable assurance of performing and reporting in conformity with applicable professional standards and applicable legal and regulatory requirements in all material respects. Audit organizations can receive a rating of pass, pass with deficiencies, or fail. NCUA OIG received an External Peer Review rating of pass.

The objective was to conduct an unannounced inspection of Torrance County Detention Center to monitor compliance with select ICE detention standards. We also conducted a limited review of the facility’s COVID-19 pandemic preparedness measures.

The objective was to conduct an unannounced inspection of Torrance County Detention Facility to monitor compliance with select ICE detention standards.

This healthcare inspection report is the second of three associated with implementation of the new electronic health record system (new EHR) at the Mann-Grandstaff VA Medical Center in Spokane, Washington. It details OIG findings on a range of allegations regarding clinical care coordination challenges and potential patient safety issues.The OIG found that the new EHR implementation had created difficulties for users in eight areas:1. Patient record flags, including failures to transfer flags and information related to patients at high risk for suicide2. Data migration errors leading to inaccurate name, gender, and contact information3. Scheduling process issues, such as delays in primary care scheduling4. VA Video Connect problems, including inoperable and misdirected links5. Referral management deficiencies, including lost or unaddressed referrals6. Laboratory orders “disappearing” that affected workflow and tracking, and delayed results7. Patient portal and secure messaging being inaccessible8. Documentation processes, including creating additional work and limiting providers’ ability to correctly code patient diagnosesAlthough the OIG did not identify any associated patient deaths during this inspection, future deployment of the new EHR without resolving deficiencies can increase risks to patient safety. The OIG recommended the Deputy Secretary review and address the remaining unresolved deficiencies.Further discussion of allegations related to medication management issues after go-live, ticket process concerns identified by the OIG during evaluation of the allegations, and underlying factors related to all substantiated allegations can be found in the OIG’s companion reports.

This report details the OIG’s concerns with the new electronic health record system (new EHR) process for resolving problems and requests for assistance through “tickets.” It also examines the underlying factors that contributed to deficiencies found by the OIG in prior inspections of medication management and care coordination at the Mann-Grandstaff VA Medical Center in Spokane, Washington.From October 24, 2020, through March 31, 2021, new EHR end users placed over 38,700 tickets. Of the 221 medication management tickets reviewed, the OIG found that 33 percent were closed without a documented resolution. The OIG reviewed 210 tickets related to care coordination and found that 1 percent of tickets were closed without a documented resolution.The OIG identified ticket process challenges with reporting, tracking, and resolving problems. These included Cerner being unable to view or replicate reported issues, tickets being closed before resolution, status not being reported to end users, staff employing workarounds without placing tickets, and an ineffective change request process hindering EHR changes. These challenges impaired the ability of Cerner service desk support staff to address end users’ problems, led to end users’ disengagement, and prompted workarounds that may increase patient safety risks.This report also details five factors that the OIG found contributed to the problems identified in its two prior healthcare inspections on how the new EHR complicated medication management and care coordination.1. EHR usability problems2. Training deficits3. Interoperability challenges4. Post-go-live fixes and refinement needs5. Problem-resolution process challengesResolving these underlying factors and addressing OIG-identified deficiencies before further deployment of the new EHR can help reduce risks to patient safety.VA concurred with the OIG’s three recommendations to evaluate and address EHR problem-resolution processes, redress the underlying factors of previous OIG-identified EHR deficiencies, and create a deployment schedule that reflects corrective actions.

RMA was engaged by the U.S. AbilityOne Commission Office of Inspector General (OIG) to conduct the performance audit and issue its report. The objectives of the audit were to assess 1) the completeness, accuracy, timeliness, and quality of the Q2 FY 2021 financial and award data submitted by the Commission for publication on USASpending.gov, and 2) the Commission’s implementation and use of the government-wide financial data standards established by the Office of Management and Budget (OMB) and the U.S. Treasury (Treasury). To answer the audit objectives, the RMA team obtained and identified information about applicable records from Commission and 3rd party data systems. RMA then sampled, reviewed, and reconciled Q2 FY 2021 financial and award data submitted by the Commission for publication on USASpending.gov. The team also assessed 1) controls in place for the extraction of data from source systems and for the reporting of data to the Treasury, 2) the completeness, accuracy, timeliness, quality of the financial as well as award data sampled, and 3) the Commission’s implementation and use of the 59 data elements and standards established by OMB and Treasury.

In this white paper, the OIG sought to identify opportunities and challenges in adopting electric delivery vehicles. We assessed the suitability of using electric vehicles as delivery vehicles and analyzed the potential long-term cost savings of a new electric delivery vehicle compared to a new gas-powered vehicle. We also benchmarked the electric vehicle experiences of other federal agencies, foreign posts, and companies in the logistics and shipping sector. We identified several clear benefits of adopting electric vehicles into the postal delivery fleet, including improved sustainability and environmental impacts. Our research confirms that electric vehicle technology is generally capable of meeting the Postal Service’s needs.

This report details the OIG’s healthcare inspection to assess a range of allegations regarding medication management deficiencies and potential patient safety issues associated with implementation of the new electronic health record (new EHR) at the Mann-Grandstaff VA Medical Center in Spokane, Washington.The OIG found that the new EHR implementation was deficient in numerous areas affecting medication management, including (1) data migration issues leading to inaccurate contact information and medication lists; (2) medication order processes erroneously discontinuing certain medications, permitting registered nurses to enter orders without authorization, and failing to notify providers of important prescribing information; and (3) medication reconciliation processes being impeded by incomplete medication lists that led to staff developing time-consuming workarounds, which increased risks of errors.Many of the medication management deficiencies remained unresolved during the OIG’s inspection from January to early June 2021. Although the OIG did not identify any associated patient deaths during this inspection, deployment of the new EHR without resolution of deficiencies may present risks to patient safety and affect providers’ treatment decisions.Findings can be found in two companion reports related to clinical care coordination issues after going live, concerns identified with the process for addressing “tickets” for resolving problems, and factors that contributed to deficiencies.The OIG made two recommendations to the Deputy Secretary: Ensure that substantiated and unresolved allegations are reviewed and addressed, and notify the OIG of any other medication management issues identified after the healthcare inspection. VA concurred with the first recommendation but not with the second, stating the recommendation creates a continuous reporting requirement to the OIG that prevents its closure. The OIG reminded the VA of its duty to provide this information and will close the recommendation when VA demonstrates an effective and sustainable process to identify and address patient safety issues.

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 Salem VA Medical Center in Virginia. 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 OIG inspection, the medical center’s leaders, except the Assistant Director, had worked together for over one year. Employee satisfaction survey data revealed opportunities for the Associate Director–Patient/Nursing Services to improve employee attitudes toward leaders and the workplace. Overall, results for inpatient and patient-centered medical home experience surveys were generally higher for both genders when compared to the corresponding VHA averages. However, survey results highlighted an opportunity for leaders to improve female patients’ ability to obtain urgent specialty care appointments.The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. The leaders were able to speak in depth about actions taken during the previous 12 months to maintain or improve organizational performance, employee satisfaction, or patient experiences.The OIG issued two recommendations for improvement in two areas:(1) Care Coordination• Monitoring and evaluation of patient transfers(2) High-Risk Processes• Disruptive behavior committee meeting attendance

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Lewis Center Main Office in Lewis Center, OH (Project Number 22-042). The Lewis Center Main Office is in the Ohio-2 District of the Central Area and services ZIP Code 43035, which serves about 24,760 people in what is considered an urban community. We judgmentally selected the Lewis Center Main Office based on the number of stop-the-clock (STC) scans occurring at the delivery unit, rather than at the customer’s delivery address.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the South Columbus Station in Columbus, OH (Project Number 22-043). The South Columbus Station is in the Ohio-2 District of the Central Area and services ZIP Code 432071 which serves about 45,1622 people and is considered an urban community. We judgmentally selected the South Columbus Station based on the number of customer inquiries per route that the unit received. From August 1 through October 31, 2021, the unit received 14.94 inquiries per route, which was more than the average of 7.60 inquiries per route for all sites serviced by the Columbus, OH, Processing and Distribution Center (P&DC).

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the East City Annex in Columbus, OH (Project Number 22-044). The East City Annex is in the Ohio 2 District of the Central Area. The carrier annex services ZIP Codes 43201, 43203, 43205, and 43210. There are about 64,494 people living in these ZIP Codes, which are considered urban communities. We judgmentally chose the East City Annex based on the number of stop-the-clock (STC) scans occurring at the delivery unit, rather than at the customer’s delivery address.

Surface Transfer Centers (STC) are contracted mail facilities that distribute, consolidate, dispatch, and transfer all mail classes within the surface network. They also divert mail volume from air to surface transportation and serve as a concentration point for consolidating mail from under-utilized surface trips. There are 13 STCs in the U.S. Postal Service network, four of which are in the Southern Region. These facilities are an integral part of the Postal Service’s plan to optimize its transportation by moving more mail on the surface network.

The OIG found that the CSB was fully compliant with improper payments legislation and guidance during fiscal year 2021.

We conducted a performance audit on two National Endowment for the Arts (NEA) Partnership awards issued to the South Carolina Arts Commission (Commission). We conducted this performance audit in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient and appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe the evidence obtained during the audit provides a reasonable basis for our findings and conclusions based on our audit objectives. We questioned $45,028 in costs, and the report includes 13 recommendations to address the audit findings – nine to the Commission and four to the NEA.

The Office of Inspector General (OIG) contracted with the independent certified public accountingfirm of Harper, Rains, Knight & Company, P.A. (HRK) to conduct a performance audit of EEOC’sinformation security program and practices in accordance with the Federal Information SecurityModernization Act of 2014 (FISMA). The contract required HRK conduct the audit in accordancewith U.S. generally accepted government auditing standards (GAGAS) contained in GovernmentAuditing Standards, issued by the Comptroller General of the United States.The objective of this performance audit was to assess the effectiveness of the EEOC’s informationsecurity program and practices for the period October 1, 2020 through September 30, 2021. HRKfound that EEOC has established and maintained an effective information security program andpractices, consistent with applicable guidance. HRK has identified areas of improvement in theform of findings and recommendations. EEOC’s management was given the opportunity to reviewthe draft report. Management’s responses are included in the report.

This report presents the results of our self-initiated audit of fuel expenses, cash, stamps, and money orders at the Charlotte, NC, Ballantyne Station Post Office (PO) (Project Number 22-018). This site is in the North Carolina District of the Atlantic Area. This audit was designed to provide U.S. Postal Service management with timely information on potential financial control risks at Postal Service locations.Management assigns every Postal Service-owned vehicle a Voyager Fleet card (Voyager card) to pay for its commercially purchased fuel, oil, and routine maintenance. U.S. Bank operates the Postal Service fleet card program and Voyager provides a weekly electronic transaction detail file of all Voyager card transactions to the Postal Service’s Fuel Asset Management System (FAMS) eFleet application. Site managers are responsible for monitoring Voyager card transactions in the FAMS eFleet application.The U.S. Postal Service Office of Inspector General (OIG) used data analytics to identify that the Ballantyne Station had a large number of expenses recorded to account identifier code (AIC) 594, Vehicle Supplies Expense, which were paid by cash or money order. This unit had $14,283 — or 35 percent of the North Carolina District’s total — for the period October 1, 2020, through September 30, 2021.

What We Looked AtThe Federal Aviation Administration (FAA) is responsible for managing and operating the busiest and most complex airspace system in the world. The FAA Reauthorization Act of 2018 (Act) required the Secretary of Transportation to establish metrics for evaluating FAA’s management and performance related to (1) the timely and cost-effective completion of projects and (2) the effectiveness in achieving the goals for an expedited, coordinated environmental review process for major safety, security, and capacity projects. Also, the Act required our office to report on FAA’s progress. Our objectives were to determine FAA’s progress in meeting the performance targets for (1) the timely and cost-effective completion of projects and (2) the achievement of an expedited, coordinated environmental review process. What We FoundFAA did not meet its major system targets in fiscal years 2019 and 2020, and full accountability and transparency in reporting is limited. Specifically, FAA did not meet its performance measure for 90 percent of major baselined acquisition programs to be within 10 percent of the current cost, schedule, and performance baselines. Also, we found weaknesses in FAA’s reporting that limited transparency and accountability. For example, FAA does not disclose when it removes programs from the measure that exceed baselines by over 10 percent and no longer reports them. In contrast, FAA reported meeting the environmental performance target to achieve on-schedule performance for 90 percent of FAA-led major transportation projects and to reduce the average time to complete environmental reviews. However, FAA’s actual results are unclear because the Agency may not have included all major projects or captured when project milestones were late in the measure. As a result, FAA’s reporting may not provide an accurate picture on how major system investments are performing or the extent to which the Agency meets its goals in the environmental measure. Our RecommendationsWe made three recommendations to improve FAA’s reporting on performance measures for major system investments and environmental review processes. FAA concurred with one recommendation and partially concurred with two. FAA proposed appropriate planned actions.

The NASA Office of Inspector General examined whether NASA has implemented an effective insider threat program in accordance with federal policies, its own Agency policies, and cybersecurity leading practices.

In accordance with our Annual Performance Plan Fiscal Year 2022, dated November 2021, the Office of Inspector General (OIG) conducted a review of the United States Capitol Police (USCP or the Department) Post-January 6, 2021, Overtime Usage and Status of the Emergency Security Supplemental Appropriation. OIG objectives were to determine (1) how the Department had utilized overtime post January 6, 2021, and (2) the status of the emergency security supplemental appropriation. The scope of the review included the period January 7, 2021 through September 30, 2021.

A General Foreman based in Washington, D.C., was terminated from the company on March 12, 2022. Our investigation found that from July 14, 2021, to January 12, 2022, the former employee violated company policies by falsely claiming and accepting payment for hours he did not work while attending an in-person class and virtual classes. In addition, we found that the former employee also misused his company-owned computer to attend classes, access school websites, conduct research, and access non-work-related websites, such as YouTube, NFL Game Access, Facebook, and various other shopping sites during company time, thereby failing to attend to his work duties and responsibilities. We interviewed the employee who admitted to using his company-owned computer to attend virtual classes and to attending one class in-person during his shift. The former employee is not eligible for rehire.

Our objective for this report was to assess the effectiveness of the company’s efforts to identify the technology needs of its business departments and implement projects in response to those needs.We found that the company has implemented a process for more effectively identifying the business departments’ technology projects. Nevertheless, the company can do more to systemically gather and robustly define a project’s technology requirements. Three factors contributed to unclear or incomplete requirements. First, business department staff did not understand their responsibilities in working with IT to clearly define project requirements. Second, some project requirements were not clear or complete because the company did not resource projects with sufficient IT staff, business staff, or both. Third, some project requirements were incomplete because IT project teams did not include staff from the appropriate business departments to ensure that the requirements included all their needs.To improve the effectiveness of implementing technology projects, we recommend that the Chief Information Officer (CIO) clarify roles to ensure that staff assigned to these projects understand their responsibilities. We also recommend that the CIO coordinate with the business departments to develop a process to identify and plan for the company’s technology resource needs beyond the upcoming year. The company agreed with our recommendations and plans on taking corrective action.

The US Office of Special Counsel referred a whistleblower disclosure to VA on July 19, 2021. The whistleblower alleged that the Houston National Cemetery’s equipment, headstones, gravesites, and other cemetery features were not maintained as required. VA referred the disclosure to the VA Office of Inspector General (OIG) to assess these allegations. Although the Houston National Cemetery was generally well maintained, the OIG substantiated some of the whistleblower’s allegations. Four pieces of motorized equipment were not maintained in accordance with National Cemetery Administration standards because the cemetery staff stopped conducting routine preventive maintenance checks during the COVID-19 pandemic. Some gravesites were also improperly maintained, and one water feature had a pump that was not working. None of the substantiated allegations at the Houston National Cemetery were pervasive issues, and cemetery staff were working to fix all of them. The OIG recommended that the cemetery director revise the equipment policy to ensure that routine activities, such as preventive maintenance checks, are resumed after natural disasters or emergencies and provide an action plan to repair the gravesites that the OIG team identified as improperly maintained. VA concurred with the recommendations and recognizes that maintenance of cemetery equipment and gravesites is essential to honor veterans and their eligible family members with lasting tributes commemorating their service and sacrifices. VA provided sufficient evidence to close the first recommendation as implemented and has taken action on the second, which will be closed when additional documentation has been received.

The objective of the review is to determine the effectiveness of the Commission’sinformation security program and practices. The review will assess information security program controls to support the OIG’s reporting of FISMA metrics into the Department ofHomeland Security’s Cyberscope application.

The VA Office of Inspector General (OIG) reviewed whether the Veterans Benefits Administration (VBA) complied with legal requirements to reinstate disability benefits questionnaire forms from non-VA medical providers. The forms are used to submit medical information needed for processing veterans’ disability claims. The OIG also examined whether VBA claims processors followed VA procedures for using the published questionnaires.Previous OIG reports found significant internal control problems with publicly available questionnaires. In February 2020, the OIG issued a report responsive to allegations that some veterans’ benefits claims using publicly available questionnaires were potentially fraudulent. The report noted that while VBA had taken some steps to mitigate this risk, there were further internal control and procedural deficiencies.This report finds that VBA complied with the requirements of the law by reinstating 69 questionnaires on its public-facing website. However, disability benefits questionnaires that were incomplete, inaccurate, or of questionable authenticity from non-VA medical providers were not always processed correctly when determining benefits entitlement—causing underpayments of about $13,900 and overpayments of $74,800 over the nine months studied.Improper processing occurred because VBA lacked sufficient controls to ensure disability benefits questionnaires from non-VA medical providers were properly relied on when determining entitlement to benefits.VBA concurred with the OIG’s five recommendations, including that VBA correct all identified processing errors and report back the results. Additionally, the VBA’s adjudication procedures manual should be revised and updated to clarify and communicate steps claims processors must take to verify all certification elements on the publicly available questionnaires; clarify the intent of guidance involving authenticity, face value, and validation of the questionnaires; and define valid rationale to ensure medical opinions are well supported. Finally, the OIG recommended VBA ensures claims processors understand the need to document the evaluation of evidence when using publicly available benefits questionnaires.

Due to an elevated number of human performance events in Gas Operations and Hydro Generation organizations in fiscal year 2020, we initiated an evaluation to determine if TVA was taking appropriate actions in response to human performance events.We determined appropriate actions were taken in response to human performance events in Gas and Hydro. Specifically, we determined (1) actions were taken or planned to be taken in response to human performance events and (2) initiatives were created to improve human performance in the organizations.

We evaluated FSA’s administration of MFP. Specifically, we evaluated FSA’s oversight of producer eligibility and certifications, as well as the accuracy of MFP payments.

We audited the U.S. Department of Housing and Urban Development’s (HUD) grant closeout processes and compliance with the Grants Oversight and New Efficiency (GONE) Act. The GONE Act required that we conduct a risk assessment to determine whether an audit of HUD’s grant closeout process was warranted. We initiated this review based on the results of our risk assessment conducted in fiscal year 2018, which found that an audit was warranted. Our objectives were to determine whether HUD (1) implemented adequate grant closeout processes to ensure compliance with GONE Act requirements and (2) ensured that reports related to its compliance with the GONE Act were accurate.HUD did not implement adequate GONE Act grant closeout processes, and related data and reports were not always accurate. Specifically, it implemented bulk closeout procedures that bypassed requirements, and its data used to compile reports included inconsistencies and incorrect information. These conditions occurred because HUD (1) focused on closing its backlog of expired grants as quickly as possible; (2) did not have adequate controls over its GONE Act grant closeout, data, and reporting processes; and (3) had not developed and implemented clear and consistent guidance on GONE Act requirements for its program offices. As a result, HUD made errors in grant closeouts and was unable to ensure that related data and reports to Congress and other stakeholders were accurate. Although HUD’s reporting responsibilities under the GONE Act have ended, it should address the weaknesses identified to ensure future compliance with grant closeout requirements and consistent and accurate reporting of grant information to stakeholders.We recommend that HUD develop and implement controls (1) for use of the bulk grant closeout process going forward to ensure that grants are closed in accordance with all applicable requirements and (2) to ensure that future grant data reporting to stakeholders is consistent and accurate.

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 Hunter Holmes McGuire VA Medical Center and associated outpatient clinics in Virginia. The inspection covered key clinical and administrative processes that are associated with promoting quality care. For this inspection, the areas of focus were 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.When the team conducted this inspection, the medical center’s leaders had worked together in their positions for 19 months. Employee survey results highlighted opportunities to improve employee attitudes toward leaders and the workplace, and reduce staff feelings of moral distress. Patient survey results identified opportunities to improve care experiences. Review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify substantial organizational risk factors. The executive leaders spoke knowledgeably within their scope of responsibilities about VHA data and factors contributing to poorly performing quality and efficiency measures.The OIG issued nine recommendations for improvement in three areas:(1) Quality, Safety, and Value• Tracking of improvement capabilities and projects• Peer review processes• Surgical death reviews(2) Care Coordination• Inter-facility transfer monitoring and evaluation• Transfer form completion• Medical record transmission(3) High-Risk Processes• Disruptive behavior committee meeting attendance• Staff training

The objective was to evaluate I&A’s responsibility for providing intelligence to state and local officials in advance of the January 6 events, and whether and how I&A fulfilled its responsibility.