Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review allegations regarding internal endocrine consult management, endocrine clinic utilization, and patient access to gender-affirming hormone therapy (GAHT) at the VA Fayetteville Coastal Healthcare System (system) in North Carolina. The OIG also reviewed leaders’ awareness of and response to these concerns.

The OIG substantiated that the chief of medicine (COM) did not effectively manage internal consults. Specifically, the COM did not communicate endocrine consult management process changes to key stakeholders, did not process consults according to Veterans Health Administration (VHA) timeliness requirements, canceled a large volume of consults without communicating to sending providers, converted face-to face consults to e-consults without providing a mechanism for sending providers to communicate concerns, and delayed implementation of a required service line agreement. 

The COM’s deficient management of endocrine consults negatively impacted endocrine clinic utilization and resulted in provider-created workarounds and patients not receiving timely endocrine appointments. From February through early October 2024, patient access to GAHT was delayed because of the COM’s actions, resulting in adverse clinical outcomes. The OIG found the COM’s interpersonal communication skills did not reflect the high reliability organization (HRO) values of clear communication and respect for others, and negatively affected system staff across multiple services.

The OIG made one recommendation to the Veterans Integrated Service Network Director to review the leadership performance of the COM, and six recommendations to the System Director related to reviewing the endocrine consult management process, reviewing patients affected by delayed endocrine consults, ensuring service line agreements are developed, confirming effective utilization of endocrine clinic appointments, ensuring there is a process for monitoring and tracking clinic profile modification requests, and evaluating communication gaps between leaders to comply with HRO goals.

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the West Palm Beach VA Healthcare System in Florida. 

This evaluation focused on five key content domains:
     •    Culture
     •    Environment of care
     •    Patient safety
     •    Primary care
     •    Veteran-centered safety net

The OIG issued no recommendations.

The Office of the Inspector General (OIG) found that the U.S. Nuclear Regulatory Commission (NRC) generally administered performance awards effectively; however, the OIG identified deficiencies in administering special act awards that require improvement. Specifically, the NRC granted special act awards frequently, often without sufficient justification, raising concerns about compliance with the policy criteria intended to recognize exceptional or superior achievements or contributions. In some cases, award justifications appeared to be duplicated, and some awards were miscoded in employee records, further highlighting weaknesses in award processing and documentation practices.
The NRC can improve the accuracy and consistency of its performance award determinations. The issues identified by the OIG included overlapping appraisal periods and failure to prorate awards for some part-time employees, resulting in noncompliance with award limits. In addition, time off was granted in excess of the NRC policy limits, underscoring the need to enhance oversight of time-off awards to prevent future occurrences.
The report makes nine recommendations to strengthen the documentation, justification, and oversight of awards to ensure compliance with applicable rules and agency policy.

U.S. Customs and Border Protection (CBP) did not effectively manage and secure its mobile devices, resulting in vulnerabilities and higher susceptibility to cyberattacks, potential unauthorized access to law enforcement and operational sensitive information, and waste and abuse from under- or over-usage.  Specifically, we found that CBP did not: • Consistently implement required security settings to protect its mobile devices or mitigate risks from applications installed on these devices; • Use its mobile device management system to fully manage and secure its mobile devices; • Address software vulnerabilities within the mobile device management system; • Increase monitoring and protection for devices used outside the United States, which are at a higher risk of cyberattacks; • Perform required steps to reduce risks associated with the disposal, loss, or theft of its mobile devices; and • Monitor its mobile devices for under- or over-usage. CBP allowed mobile devices to operate without completing a security authorization process to ensure required security controls; did not establish or implement sufficient security policies and processes; relied on unclear or contradictory guidance; and did not address its increased mobile device losses.  Moreover, the Department did not provide oversight to ensure that CBP fulfilled DHS requirements for monitoring mobile devices outside the United States and CBP did not enforce its policies.   

Why We Did This Report

The U.S. Environmental Protection Agency Office of Inspector General has identified concerns regarding the installation and use of unauthorized software, specifically jiggler software, on EPA computers and networks. Commonly referred to as “mouse jigglers,” jiggler software simulates activity on a laptop, preventing the laptop from entering sleep mode and locking out its user. After running network scans in two EPA regions in November and December 2024, the Agency discovered 120 employees and contractors using jiggler software.

Summary of Findings

Our investigation found that jiggler software could bypass the Agency’s Windows Installer settings, that some of the EPA’s information technology specialists believed they were exempt from the policy, and that other EPA employees and contractors installed the software without authorization. Furthermore, we discovered inconsistencies in how quickly the regional offices acted to remove the jiggler software after it was detected. The installation and use of unauthorized software on EPA computers and networks represent critical cybersecurity risks and ethics violations for the Agency.

Access to retail services is an important part of the Postal Service’s universal service obligation. The Postal Service relies on a network of over 31,000 facilities (“units”) where customers can conduct various retail transactions, and this network hosted over 655 million visits in fiscal year 2024. It is imperative for retail units to be accessible to customers by being open during scheduled hours and not closed for prolonged periods of time (such as suspensions).

We found that DOI may have misstated its total acres by 82 percent in its FY 2023 AFR.