Federal Reports

As of December 31st, 2021, there are 67 open recommendations, 8 of which were reported as “implemented” by management; and none of the remaining 59 categorized as “Overdue.” Since the date of the OIG’s last recommendation status report, dated September 30th, 2021, 16 new recommendations were added, and 9 recommendations were closed.

The Pandemic Response Accountability Committee (PRAC) is charged with conducting oversight of pandemic-related spending to prevent and detect fraud, waste, abuse, and mismanagement. In May 2021, we engaged MITRE, a not-for-profit federally funded research and development center, to conduct an independent study of lessons learned from the administration of pandemic-related emergency funding for unemployment insurance (UI) benefit programs in a sample of states. The objective of this study was to increase understanding of how states implemented pandemic UI benefit programs and how their different implementation approaches may have reduced the fraud risk, including identity theft-related fraud. MITRE, in coordination with the U.S. Department of Labor (DOL), contacted all 54 state and territory workforce agencies (SWAs) and 12 responded. This report summarizes the responses of those 12 SWAs except where otherwise indicated.

KPMG LLP’s (KPMG) report on its financial statement audit of the National Credit Union Administration’s (NCUA) financial statements, which includes the Share Insurance Fund, the Operating Fund, the Central Liquidity Facility, and the Community Development Revolving Loan Fund, as of and for the years ended December 31, 2021 and 2020. The NCUA prepared financial statements in accordance with the Office of Management and Budget (OMB) Circular No. A-136 Revised, Financial Reporting Requirements, and subjected them to audit.

This report communicates the results of the Fiscal Year 2021 Federal Trade Commission Office of Inspector General review of the FTC’s compliance with the Payment Integrity Information Act of 2019 (PIIA) (Public Law 116-117).

The Federal Information Security Modernization Act of 2014 (FISMA) requires all federal agencies to conduct independent security technical verification testing on a sampling of information systems annually. In conjunction with our fiscal year 2021 FISMA evaluation (2021-OE-0001), we conducted a targeted security testing assessment of sample systems that resulted in a Topic Brief. The objective of this application vulnerability testing was to determine whether the U.S. Department of Housing and Urban Development (HUD) sample systems contained potential security weaknesses. We identified potential vulnerabilities among the tested HUD applications and categorized them into low, medium, and high risk. HUD should prioritize those risks for review and remediation. No formal recommendations were documented in the report. The OIG has determined that the contents of this report would not be appropriate for public disclosure and has therefore limited its distribution to selected officials.

We audited the U.S. Department of Housing and Urban Development’s (HUD) transitioning of offices from mandatory to maximum telework during the coronavirus disease 2019 (COVID-19) pandemic, based on a request from Representative Gerald Connolly, to review whether HUD was employing best practices and existing guidance when deciding whether or when to require Federal employees to return to their offices. Transitioning an office to maximum telework allowed HUD employees to voluntarily return to an office.We focused our audit on whether HUD complied with its internal Resuming Normal Operations Guide, COVID-19 Response, for Headquarters and Field Offices (Guide) when transitioning offices from mandatory to maximum telework during the COVID-19 pandemic. Specifically, our audit objective was to determine whether the memorandums that HUD’s regional administrators and Assistant Secretary for Administration submitted to the Deputy Secretary, which recommended allowing the voluntary reentry of employees to HUD’s offices (reentry memorandums), sufficiently addressed the criteria in HUD’s Guide regarding the transition to maximum telework.HUD issued its Guide in June 2020 to provide a framework to resume normal operations safely and efficiently, including transitioning offices from mandatory to maximum telework. The Guide detailed gating criteria, data-driven conditions that geographic areas were to satisfy before proceeding to phased openings, and required checklist tasks that were to be met before HUD transitioned offices to maximum telework. However, HUD did not always comply with its Guide when transitioning its offices. Specifically, the reentry memorandums reviewed for seven selected offices that transitioned did not sufficiently address the gating criteria. HUD also did not (1) provide sufficient documentation to support that the gating criteria were met and (2) establish metrics for determining whether the offices met the gating criteria to transition. Further, regional administrators for two offices recommended transitioning the offices, although all tasks required had not been completed. These conditions occurred because HUD did not have sufficient policies and controls to ensure that (1) applicable gating criteria were met in the geographic areas where offices were located and (2) required checklist tasks were sufficiently completed, before transitioning offices. As a result, HUD lacked assurance that its offices were transitioned to maximum telework in accordance with its Guide and in a consistent manner.We recommend that the General Deputy Assistant Secretary for Administration ensure that future policies and guidance developed to return HUD’s offices to normal operations include the specific criteria, metrics, and defined geographic area to be used by all offices as applicable. We also recommend that the General Deputy Assistant Secretary for Administration develop and implement sufficient policies and controls to ensure that (1) applicable criteria in any future guidance are met and all safety measures are sufficiently completed before returning HUD’s offices to normal operations and (2) sufficient documentation is maintained to support that the applicable criteria were met.

What We Looked AtIn August and September 2017, three costly hurricanes hit the United States and caused devastation to transportation infrastructure, particularly highways and bridges. The Department of Transportation (DOT) provided emergency aid for infrastructure repairs through the Federal Highway Administration's (FHWA) emergency relief programs. Due to the size of DOT's investment and the speed required for emergency relief, we initiated this audit. Specifically, we assessed FHWA's controls over the use of its emergency relief funds.What We FoundFHWA does not always deallocate funds that have not been obligated by the end of the fiscal year, as its policy requires. For example, of the $48,022,716 that FHWA allocated to Florida in 2018 and 2019 for hurricane damages, approximately $46 million remained unobligated in March 2020, but had not been deallocated. FHWA's Division Offices also do not always deallocate unobligated quick release funds--funds that are allocated quickly for emergency repairs--as required. We noted that Florida DOT took over 10 months to obligate $13.4 million of $25 million in quick release funds, FHWA officials stated that the Agency is not statutorily required to deallocate these funds. FHWA also did not document required approvals for $48 million in quick release funds, and has not deobligated almost $2 million in unneeded emergency relief funds allocated to Texas DOT. FHWA is required to maintain adequate internal financial management controls. By not following its own policies, the Agency increases the risk that unused quick release funds and unobligated allocations will not be available for other States in need. Furthermore, the Highways ER Manual, last updated in May 2013, does not reflect current practices or align with other Agency policies. Still, despite these oversight weaknesses, we found a low incidence of improper payments in a sample of Highways disbursements.RecommendationsFHWA partially concurred with our recommendation 1, did not concur with our recommendation 2, and concurred with our recommendations 3 through 6.

The USGS reported no safety incidents or violations of applicable guidelines and the USGS followed applicable Federal directives for this study.

The 8(a) Business Development Program helps small businesses owned by socially and economically disadvantaged individuals gain business skills and access to federal contracting opportunities so that they can better compete in the open marketplace. We set out to determine to what extent SBA measures and monitors an 8(a) firm’s progress and ensures 8(a) firms receive the help needed to meet their goals. We also examined whether the program adapted successfully during the Coronavirus Disease 2019 pandemic to help firms.We reviewed the business development assistance SBA provided 8(a) program participants from 2011-2020, which included reviewing the files for 40 of the firms assigned to 5 district offices. We also reviewed applicable public laws, regulations, policies, and procedures and interviewed program officials. We found that 15 of the 40 firms we tested did not have approved business plans, making these firms ineligible to receive $93 million in 8(a) awards. We also found SBA did not consistently document that its staff assessed the needs, counseled, or conducted field visits with 8(a) firms to ensure they received the assistance needed to be prepared to compete for contracts without further 8(a) assistance.However, we found SBA program officials offered program flexibilities to all 8(a) participants during the pandemic, adapting business development assistance to help firms stay in business and remain in the program. We made eight recommendations for the agency to measure, monitor, and better deliver training and other business development assistance to 8(a) firms.

An Administrative Judge violated ethics regulations and did not comply with an ethics recusal and prohibited holdings waiver.

We substantiated allegations that a U.S. Bureau of Reclamation employee illegally used a Government purchase card and falsified time records.

A Foreman in New York City violated Amtrak policy by dishonestly taking medical leave while in police custody for a recent arrest. We confirmed that on August 2, 2021, officers with the Burlington County Prosecutor’s Office in New Jersey arrested the employee and charged him with endangering the welfare of a child. The foreman resigned in lieu of his disciplinary hearing. The employee is not eligible for rehire.

This report presents the results of our self-initiated audit of Voyager Card Transactions – Acredale Station, Virginia Beach, VA (Project Number 21-241). The Acredale Station is in the Virginia 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. The U.S. Postal Service Office of Inspector General (OIG) uses data analytics to identify offices with potentially fraudulent Voyager card activity. The Acredale Station had 2,742 Voyager card transactions from January 1, 2021, through June 30, 2021, totaling $71,025, of which FAMS flagged 34 transactions as high risk and 91 transactions where the grade of fuel purchased exceeded what was allowable by policy. In addition, 270 Voyager card purchases, valued at $6,436, were conducted by one employee’s PIN.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of Veterans Health Administration (VHA) facilities’ selected requirements and guidelines for care coordination. This evaluation focused on compliance with program requirements related to life-sustaining treatment decisions for hospice patients.This report describes care coordination findings from healthcare inspections initiated at 36 VHA medical facilities from November 4, 2019, through September 21, 2020, and electronic health record review at five additional randomly selected facilities. Each inspection involved interviews with facility leaders and staff and reviews of clinical and administrative processes. The results in this report are a snapshot of VHA performance at the time of the fiscal year 2020 OIG reviews.During the time frame of this retrospective review, VHA policy required certain elements of goals of care conversations to be documented in patients’ electronic health records. However, in March 2020, VHA revised its policy to require fewer elements. The OIG observed general compliance with the selected requirements after these rules were updated during the review period. However, under the original VHA requirements in place when patients received their care, the OIG estimated that providers did not consistently• identify a surrogate should the patient lose decision-making capacity;• address previous advance directives, state-authorized portable orders, and/or life-sustaining treatment plans; or• address the patient or surrogate’s understanding of the patient’s condition.The OIG did not issue recommendations but developed this summary report for leaders to consider when improving operations and clinical care at VHA facilities.

The objectives of the audit were to determine whether the State of Missouri (Missouri) designed and implemented awarding processes that ensured that the Governor's Emergency Education Relief Fund (GEER grant) was used to support local educational agencies (LEAs) and institutions of higher education (IHEs) that were most significantly impacted by the coronavirus or LEAs, IHEs, or other education-related entities within the State that were deemed essential for carrying out emergency educational services; and monitoring processes to ensure that subgrantees used GEER grant funds in accordance with the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) and other applicable Federal requirements.We found that for two of the initiatives Missouri funded with its GEER grant (LEA Transportation Supplement Initiative and IHE Initiative), Missouri’s DESE and DHEWD designed and implemented awarding processes that ensured the GEER grant was used to support LEAs and IHEs that were most significantly impacted by the coronavirus, as determined by the State. However, for the third initiative (LEA Connectivity Initiative), while DESE created a methodology designed to ensure the GEER grant funds were used to support LEAs that were most significantly impacted by the coronavirus, it did not correctly implement the process it designed. We found that for all three initiatives, Missouri ensured that the LEAs and IHEs that received a GEER grant allocation submitted the required applications and assurances. We also found that Missouri followed cash management requirements. We found that Missouri’s DHEWD designed and implemented a comprehensive reimbursement process as its monitoring strategy to ensure that subgrantees of its IHE Initiative used GEER grant funds in accordance with the CARES Act and other applicable Federal requirements. However, we found that DESE’s plan for monitoring subgrantees of its LEA Connectivity and LEA Transportation Supplement initiatives could be strengthened.

This letter responds to October 2020, December 2020, and February 2021 letters from Representatives Comer, Davis, and Hice requesting a review of the State of California's SKD Knickerbocker, LLC award and requesting assurance that Coronavirus Aid, Relief, and Economic Security Act and Help America Vote Act funds were used as intended.

An Amtrak manager based in Chicago, Illinois, was issued a letter of counseling on February 9, 2022, following the issuance of our report. Our investigation found that the employee performed military duties on days when he was also scheduled to be working for the company. As a result, the employee received compensation from the military for days in which he was also paid by the company. The employee failed to remit the wages paid by the government to the company upon returning from military leave. Our investigation found no compelling evidence that the employee intended to defraud the company. The employee agreed to repay the company a total of $27,904.50.

VA must submit an annual report to Congress documenting its capacity to provide specialized treatment comparable to that available as of October 9, 1996, for veterans with spinal cord injuries and disorders, traumatic brain injury, blindness, prosthetic and sensory aids, or mental health issues. This requirement was set by Congress to ensure that the decentralization of the Veterans Health Administration’s field management structure in the late 1990s did not adversely affect VA’s ability to care for veterans with disabilities. Each year, the VA Office of Inspector General (OIG) is required to report to Congress on the accuracy of VA’s special disabilities capacity report. This OIG report identified some minor errors, data omissions, inaccuracies, and inconsistencies in the fiscal year (FY) 2020 capacity report that have persisted from the OIG’s FY 2019 review. For example, VA cannot report mental health capacity data comparable to that from 1996 as required by law because of changes in how treatment outcomes of veterans with mental illness are defined and tracked. VA issued its FY 2020 report before the OIG released its FY 2019 review and therefore couldn’t correct some of the identified issues. Congress would be better served by modernizing the reporting metrics to assess VA’s capacity to provide care for these veterans. Additionally, VA continues to not report its capacity on all required data at the national, Veterans Integrated Service Network, and medical facility levels where such services are provided.

We determined that FEMA did not ensure Puerto Rico effectively implemented the STEP Pilot Program following Hurricanes Irma and Maria in September 2017.

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) standards.

Beginning in May 2019, U.S. Immigration and Customs Enforcement (ICE), Homeland Security Investigations (HSI) piloted Rapid DNA technology to verify claimed parent-child relationships.

We present the status of identified environmental concerns related to the Office of Navajo and Hopi Indian Relocation’s administration of land.

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 company's cost proposal was fairly stated for a planned 5-year, $25 million contract.In our opinion, the company's cost proposal was overstated. Specifically, the proposed labor markup rates, for recovery of the company's indirect costs, were overstated compared to recent actual costs. We estimated TVA could avoid about $3.5 million over the planned $25 million contract by negotiating reduced markup rates to more accurately reflect the company's recent actual costs. In addition, we found the company's proposed (1) costs for the RFP's fixed price example projects were overstated by $417,189 and (2) equipment rates were not reflective of its actual equipment costs.(Summary Only)

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 company's cost proposal was fairly stated for a planned 5-year, $100 million contract.In our opinion, the company's cost proposal was overstated. Specifically, the proposed markup rates on craft wages for recovery of the company's indirect costs were overstated compared to recent actual costs. We estimated TVA could avoid about $2.2 million over the planned $100 million contract by negotiating reduced markups to more accurately reflect the company's recent actual costs.(Summary Only)

What We Looked AtWe queried and downloaded 56 single audit reports prepared by non-Federal auditors and submitted to the Federal Audit Clearinghouse between October 1, 2021 and December 31, 2021, to identify significant findings related to programs directly funded by the Department of Transportation (DOT). What We FoundWe found that reports contained a range of findings that impacted DOT programs. The auditors reported significant noncompliance with Federal guidelines related to 12 grantees that require prompt action from DOT’s Operating Administrations (OA). The auditors also identified questioned costs totaling $5,409,880 for five grantees. Of this amount, $2.8 million was related to the Crow Tribes of Indians and $2.4 million to the Confederated Tribes of the Colville Reservation. RecommendationsWe recommend that DOT coordinate with the impacted OAs to develop a corrective action plan to resolve and close the findings identified in this report. We also recommend that DOT determine the allowability of the questioned transactions and recover $5,409,880, if applicable.

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA Eastern Colorado Health Care System (facility) in Aurora to assess allegations that a lack of care coordination and a lack of hepatocellular carcinoma (HCC) surveillance led to a delay in a patient being diagnosed with HCC.The OIG substantiated that a lack of care coordination occurred when the patient transferred between primary care providers, which contributed to a lack of HCC surveillance and varices monitoring. Facility leaders have an unwritten expectation that primary care providers conduct a thorough historical review of the patient’s electronic health record starting with the most recent annual note; however, the OIG found that not all of the patient’s providers conducted historical reviews, but instead focused on current issues and problems identified by the patient.The OIG determined that the patient’s providers, and facility providers in general, did not maintain an accurate problem list, creating another missed opportunity to conduct necessary HCC surveillance. Furthermore, facility providers did not consistently comply with the recommended HCC surveillance for other patients with a similar diagnosis. Surveillance, if done correctly, could have led to an earlier diagnosis of HCC in the patient.The OIG made six recommendations to the Facility Director related to care coordination, developing and updating patient problem lists, reviewing an established patient’s medical record, conducting a clinical review of the care of the patients discussed in the report and determining if adverse events occurred, and ensuring that patients receive HCC surveillance and varices monitoring.

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 Hudson Valley Health Care System in Montrose, New York. The inspection covered key clinical and administrative processes that are associated with promoting quality care, focusing on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.At the time of the review, the healthcare system’s leaders had worked together for one year, with the Director, Associate Director for Patient Care Services, and Chief of Staff serving since May 2020, December 2015, and August 2019, respectively. The Associate Director was appointed in December 2020 and also covered the open assistant director position. Employee survey scores for the healthcare system were lower than the VHA averages, although scores for most leaders were generally similar to or higher than VHA and healthcare system averages. Outpatient satisfaction survey results generally reflected higher care ratings than VHA averages. However, they also highlighted opportunities to improve patient perceptions of inpatient care, as well as outpatient providers and access to outpatient services. The OIG’s review of the system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors but position turnover in the Quality Management Service was noted as an area of vulnerability. Executive leaders were very knowledgeable about selected data used in Strategic Analytics for Improvement and Learning measures.The OIG issued seven recommendations for improvement in three areas:(1) Quality, Safety, and Value• Protected peer review process(2) Care Coordination• Inter-facility transfer policy and documentation• Nurse-to-nurse communication(3) High Risk Processes• Staff training

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Beaverton Main Post Office in Beaverton, OR (Project Number 22-031). The Beaverton Main Post Office is in the Idaho-Montana-Oregon District of the WestPac Area. The post office services ZIP Codes 97005 and 97008. There are about 54,806 people living in these ZIP Codes, which are considered urban communities. We chose the Beaverton Main Post Office based on the number of stop-the-clock3 (STC) scans occurring at the delivery unit, rather than at the customer’s delivery address.

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, $25 million contract.In our opinion, the company's cost proposal was overstated. We found the proposed labor markup rates, for recovery of indirect costs, were overstated compared to recent actual costs. We estimated TVA could avoid about $783,000 over the planned $25 million contract by negotiating revised labor markup rates to more accurately reflect the company's recent actual costs. (Summary Only)

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This report recaps OIG achievements in 2021, in core mission as well as organizational improvements.

The Office of the Inspector General included an audit of the Tennessee Valley Authority’s (TVA) maintenance of its owned gas pipelines in our annual audit plan due to pipeline issues identified at other utilities and potential risks to TVA. Our audit objective was to determine if TVA’s maintenance of its owned gas pipelines is adequate. We found TVA did not provide sufficient oversight of the two Contract Operations Providers and the Contract Engineering Provider. We found the lack of oversight resulted in inadequate maintenance in some areas and inconsistencies in reporting that hindered TVA’s ability to track and correct the identified deficiencies. In addition, we found TVA’s Gas Transmission Pipelines Policy (TVA Power Operations Standard Programs and Processes 09.120, Natural Gas Transmission Pipeline Operations) in place between July 2016 and October 2020 was limited and outdated on contractor oversight.

We audited the U.S. Department of Housing and Urban Development’s (HUD) oversight of its public housing agencies’ (PHA) reasonable accommodation policies and procedures. We initiated this audit because we identified an increase in housing discrimination complaints based on a failure to provide a reasonable accommodation, even as the total number of all housing discrimination complaints was decreasing. Our audit objective was to determine whether HUD had adequate policies and procedures for ensuring that PHAs properly addressed, assessed, and fulfilled requests for reasonable accommodation, including COVID-19 related requests. HUD did not have adequate policies and procedures for ensuring that PHAs properly addressed, assessed, and fulfilled requests for reasonable accommodation. HUD also did not perform civil rights front-end reviews as required. These conditions occurred because HUD (1) did not include in its compliance monitoring guidance a requirement for personnel to review PHAs reasonable accommodation policies and procedures, (2) had not updated its guidance to ensure that it was centralized, and (3) did not believe it was responsible for conducting civil rights front-end reviews. As a result, PHAs did not receive consistent oversight in this area nationwide and may not be properly implementing existing requirements or not understand all their responsibilities related to requests for reasonable accommodation. Also, HUD’s Office of Public and Indian Housing (PIH) did not have the benefit of the information the reviews would have collected and HUD’s Office of Fair Housing and Equal Opportunity (FHEO) could not use the information to address issues that may have been identified or to pursue any corrective action. We recommend that HUD’s Deputy Assistant Secretary for Public Housing and Voucher Programs (1) update its compliance monitoring guidance to include a requirement for personnel to review PHAs reasonable accommodations policies and procedures (2) update and consolidate its reasonable accommodation policies and procedures to ensure that there is centralized guidance available for the field offices and PHAs; (3) conduct additional outreach efforts to educate tenants and PHAs on their rights and responsibilities related to requests for reasonable accommodation; (4) require that PHAs track requests for reasonable accommodation, including the date of the request, the type of request, and the disposition and date of any action taken that should be made available to HUD at its request; (5) review the joint agreement with HUD FHEO, and related Section 504 checklist, and modify, update, or recommit to it to ensure that the roles and responsibilities of the Office of Public and Indian Housing for conducting civil rights front-end reviews is clearly defined; and (6) ensure that personnel receive training on how to conduct the civil rights front-end reviews, including a review of PHAs reasonable accommodation policies and procedures.

Our objective for this report was to assess the extent to which the company has a program management framework to govern how it will complete its current and future work across the Gateway projects.While the company has started hiring staff and building a schedule, among other things, to manage the volume of work it will soon encounter on Gateway, we found that the company has not fully developed a thorough program management framework that describes the processes its departments will follow and the tools they will use to manage the program now and in the years ahead. The company is facing three challenges on Gateway without this framework. First, although Amtrak has recently added staff to the Gateway program team, it has been overtasked because the company has not assessed the resources that the team and departments providing major support to Gateway need to manage current and future work. Second, while the company has some mechanisms in place to update certain key stakeholders, it has not determined how it will collect and provide comprehensive and consolidated information on the program’s overall status—including budget and schedule—to all internal company stakeholders with responsibilities for Gateway. Third, although the company has assessed risks to individual projects in coordination with its partners, it has not assessed the broader program-wide risks it may face managing its Gateway commitments, such as potential impacts to other company acquisitions or projects. To build a thorough program management framework for Gateway, we recommended that the company (1) build out its program management plan, (2) assess its current and future resource needs, (3) implement communication protocols to manage how it will generate, collect and distribute program information to internal company stakeholders, and (4) develop a process to identify and mitigate its program risks.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Parkrose Station in Portland, OR (Project Number 22-029). The Parkrose Station is in the Idaho-Montana-Oregon District of the WestPac Area. The station services ZIP Codes 92720, 97230, and 97233. There are about 108,739 people living in these ZIP Codes, which are considered urban communities. We judgmentally selected the Parkrose Station based on the number of customer inquiries the unit received per route. From June 1, 2021, through August 31, 2021, the unit received about 39.96 inquiries per route, which was larger than the average of 10.62 inquiries per route for all sites serviced by the Portland Processing and Distribution Center (P&DC).

The U.S. Postal Service owns over 8,400 facilities where it provides services, which includes maintaining proper ventilation and filtration in these facilities to ensure they are clean and safe. Ventilation and filtration are often provided by heating, ventilation, and air conditioning systems in a facility. Industry standards recommend minimum ventilation rates and inspection and maintenance activities.Our objective was to assess Postal Service efforts to ensure proper ventilation and filtration in facilities and identify opportunities for improvement. For this audit, we statistically sampled 193 Postal Service-owned retail and delivery facilities with an interior size ranging from 1,000 to 100,000 square feet from a universe of 6,709 facilities.

Lack of consistent oversight and persistent Title V fee challenges may undermine Title V program implementation.

For our final report on the audit of the National Oceanic and Atmospheric Administration’s (NOAA’s) management of its Active Directories, our audit objective was to determine whether NOAA has adequately managed its Active Directories to protect mission critical systems and data. To address this objective, we utilized a specialized Active Directory assessment tool and evaluated fundamental security practices, relationships, and configurations to determine whether any deficiencies existed within each Active Directory. Overall, we found that NOAA inadequately managed its Active Directories. Specifically, we found the following: I. excessive privileges could increase the risk of a successful compromise; II. inadequately managed accounts provided more opportunities for cyberattacks; and III. end-of-life operating systems were vulnerable to security exploitation.

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 Durham VA Health Care System in North Carolina. 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 review, the executive team had worked together in a permanent capacity for four months; however, the Executive Director and the Chief of Staff had served in their positions for over three years. Healthcare system leaders had recently received approval and started recruiting for a second assistant director. Employee survey data revealed satisfaction with leadership, but highlighted opportunities to reduce employees’ feelings of moral distress at work. Selected patient survey results implied lower satisfaction than the VHA average and highlighted opportunities to improve inpatient and outpatient care experiences.The OIG’s review of the healthcare system’s accreditation findings, sentinel events, and disclosures of adverse patient events did not identify any substantial organizational risk factors. Executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to improve performance.The OIG issued eight recommendations for improvement in four areas:(1) Registered Nurse Credentialing• Primary source verification of licenses(2) Mental Health• Suicide prevention training(3) Care Coordination• Transfer monitoring and evaluation• Transfer form completion• Medication list transmission(4) High-Risk Processes• Disruptive behavior committee attendance• Patient notification of Orders of Behavioral Restriction• Staff training

The U.S. Commodity Futures Trading Commission Office of Inspector General reviewed the audit operations of Denali Commission OIG.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Vancouver Main Post Office (MPO) in Vancouver, WA (Project Number 22-032). The Vancouver MPO is in the Washington District of the WestPac Area. The post office services ZIP Codes 98660, 98661, 98663, 98665, 98685, and 98686. There are about 135,114 people living in these ZIP Code areas, with about 133,721 (99 percent) living in urban communities and about 1,393 (1 percent) living in rural communities. We judgmentally selected the Vancouver MPO based on the number of customer inquiries per route the unit received. From June 1 through August 31, 2021, the unit received 12 inquiries per route, which was more than the average of 10.62 inquiries per route for all sites serviced by the Portland Processing and Distribution Center (P&DC).

A Customer Service Representative at Rensselaer Station, New York, violated Amtrak policies by committing theft of a co-worker’s personal property while on duty. During the joint investigation with the Amtrak Police Department, the employee admitted to the thefts and resigned from the company shortly thereafter. The employee is ineligible for rehire.

As part of our annual audit plan, we audited costs billed to the Tennessee Valley Authority (TVA) by World Wide Technology, LLC (WWT) under Contract No. 10786 for Cisco hardware, maintenance, services, and support. The contract provided for TVA to compensate WWT for products and services on either a time and materials or fixed price basis. Our audit objective was to determine if costs were billed in compliance with the contract's terms. Our audit scope included about $72.5 million in costs billed to TVA for the period of December 1, 2015, through December 31, 2020.In summary, we determined WWT: Overbilled TVA $38,302 in labor service costs, including (1) $31,341 for unsupported labor hours, and (2) $6,961 in excessive hourly pay rates. Could not provide adequate support for the Cisco list prices used to apply contractual discounts for products and maintenance. Therefore, we could not determine if the majority of costs billed for products and maintenance agreements were in accordance with the contract terms. Overbilled TVA $4,051 because the contractual discounts were not applied correctly on the limited product costs we were able to review. (Summary Only)