Federal Reports

Our objective was to assess the company’s efforts to provide high-quality customer service to passengers with disabilities.

We found that although the company has ongoing efforts to improve the service it provides to these customers, it faces challenges in two key areas. First, it does not have an overarching strategy with goals, metrics, and priorities to guide its efforts to improve customer service to passengers with disabilities. Second, it does not have full visibility over the quality of service it provides to passengers with disabilities because it does not regularly analyze key data that could provide insights. 

Without a strategy informed by relevant data, the company may not be focusing its resources on improvement initiatives with the highest potential impact. Further, it could be exposed to unnecessary financial, reputational, and legal risks from service that does not consistently meet its standards. Given the company’s limited visibility over the service it provides to passengers with disabilities, we assessed the customer experience and identified three areas where it has opportunities to improve: (1) interactions with customer-facing employees, (2) communication of essential travel information, and (3) access to onboard amenities.

We recommended that the company develop an overarching strategy and analyze the data necessary to measure its service quality. It should also implement plans and processes to address challenges in the three improvement areas we identified.

The IRS’s FY 2024 enterprise-wide examination plan signaled a shift towards auditing high-income individuals, which we found consistent with the goals of the 2022 Treasury Directive.

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

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

The OIG issued 11 recommendations for improvement in two domains:
  1.    Environment of care
     •    Processes to prevent repeat findings
     •    Biological hazard signs
     •    Safe and clean patient care areas
     •    Medication storage areas
           o    Restricted access
           o    Pharmacy staff inspections
           o    Temperature and humidity
     •    Urgent Care Center operates according to VHA Directive 1101.13
     •    Repeat findings and sustained improvements
     •    Trends, performance improvement plans, and outcome measures
  2.    Patient safety
     •    Test result communication policy complies with VHA directives for critical test results

In July 2022, the VA Office of Inspector General (OIG) published a report finding that Veterans Benefits Administration (VBA) staff prematurely denied service connected compensation to veterans with conditions that could be associated with burn pit exposure. The OIG made seven recommendations, and VBA took corrective action on five, which the OIG closed. The two remaining recommendations were to review two datasets the OIG believed contained prematurely denied claims of veterans seeking service connection for burn pit-related conditions, correct any errors, and provide certification of completion. In May and August 2024, VBA requested closure of both open recommendations, asserting it had taken corrective actions as needed on all the claims. However, further review by the OIG of the claim population, as detailed in this management advisory memorandum, determined VBA did not take required corrective actions on at least an estimated 25 percent of veterans’ denied claims related to burn pit exposure.

Given the considerable errors identified in this second review of claims, the OIG lacks assurance that VBA has taken sufficient corrective action to address the original findings and remains concerned that, after nearly three years, veterans affected by these errors could still be missing service-connected compensation benefits to which they are entitled. Accordingly, the OIG did not concur with VBA’s requests to close recommendations 2 and 3 from the July 2022 report. These recommendations will remain open, and the OIG will continue to request quarterly updates from VBA on the progress it has made to appropriately remediate all errors and ensure corrective actions are taken for veterans’ denied claims related to burn pit exposure from the population identified by the OIG. In response to this memorandum, VBA will establish a workgroup to develop and implement a plan to correct the identified issues.