Federal Reports

What We Looked AtAs required by law, we report annually on the Department of Transportation's (DOT) most significant challenges to meeting its mission. We considered several criteria in identifying DOT's top management challenges for fiscal year 2022, including their impact on safety, documented vulnerabilities, large dollar implications, and the ability of the Department to effect change. In addition, we recognize that the Department faces the extraordinary task of meeting these challenges while also responding to the COVID-19 pandemic. Accordingly, we included COVID-19 considerations in all nine of our top management challenges.What We FoundWe identified the following top management challenge areas for fiscal year 2022: Aviation safety. Key challenges: maintaining confidence in the aircraft certification process and advancing FAA's air carrier oversight to keep pace with safety management system requirements. Surface transportation safety. Key challenge: increasing compliance with surface safety transportation regulations and programs by improving monitoring and enforcement. Air traffic control and airspace modernization. Key challenges: delivering NextGen benefits to airspace users and deploying controller automation tools to improve efficiency. Surface transportation infrastructure. Key challenges: employing effective oversight of Federal funding for response, recovery, and rebuilding projects and enhancing risk-based oversight to improve project delivery and update and maintain surface transportation infrastructure. Contract and grant fund stewardship. Key challenges: managing domestic preference and supply chain risk and dedicating qualified and sufficient oversight resources for contract and grant funds. Information security. Key challenges: addressing DOT's recurring cybersecurity weaknesses and protecting DOT's IT infrastructure and sensitive information. Financial management. Key challenges: avoiding increases in improper payments and improving policies and procedures to monitor and report grantee spending. Innovation and the future of transportation. Key challenges: safely integrating new technologies into transportation systems and implementing executive orders and other Federal priorities to tackle the impact of climate change, advance equity, and promote resilience in infrastructure and supply chains. Evolving operations and workforce management. Key challenges: integrating lessons learned to facilitate workplace reentry and communicating fully and consistently with employees on workplace procedures, status, flexibility, and expectations.

What We Looked AtThe United States Merchant Marine Academy (USMMA) is a Federal service academy operated by the Maritime Administration (MARAD). Its mission is to graduate exemplary leaders committed to serve the Nation’s security, marine transportation, and economic needs. In support of its mission, USMMA procures contracts for operational products and services that, for fiscal years 2015 through 2019, totaled an estimated $99.2 million. Prior reviews found weaknesses in MARAD’s acquisition controls and processes, such as noncompliance with Federal and departmental procurement requirements. Accordingly, we initiated this audit with the following objective: to assess contract award and administration policies, procedures, and practices for MARAD’s USMMA acquisitions. What We FoundMARAD’s ability to achieve cost-effective USMMA contracts is compromised by several management control weaknesses. Specifically, its USMMA contract documentation is incomplete, which hinders the Agency’s decision making for new investments to support Academy missions. MARAD also could not demonstrate compliance with key procurement requirements, including those to help ensure fair and reasonable pricing, for 19 sample USMMA contracts totaling $45 million. Additionally, MARAD has gaps in its management of contracting officers and contracting officer representatives assigned to USMMA contracts, increasing the risk that unauthorized or improperly qualified individuals may execute, award, or manage these contracts. For example, a contracting officer without the appropriate warrant authority awarded a $1.9 million USMMA contract, and contracting officer’s representative assigned to USMMA contracts totaling $18.2 million lacked proper certifications. Finally, frequent changes to Academy plans have impeded efficient execution of Capital Improvement Program (CIP) contracts—USMMA’s highest dollar contracts—as MARAD does not have a process to adequately assess how such changes impact the overall CIP portfolio. As a result, USMMA’s CIP project contracts have experienced inefficiencies, including increased costs and schedule delays. We estimate that MARAD’s lack of adequate controls to verify compliance with requirements has put $57.5 million in Federal funds at risk. Our RecommendationsMARAD concurred with all 10 of our recommendations. We consider all recommendations resolved but open pending completion of planned actions.

During our work related to the Fiscal Year 2021 Financial Statement Audit, the Office of Inspector General (OIG) became aware of a new practice the United States Capitol Police (USCP or the Department) used for issuing ammunition to officers for use at non-USCP firing ranges. OIG reviewed the first 2 months of ammunition issued to officers for use at non-USCP firing ranges. 

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 Caribbean Healthcare System, which includes the San Juan VA Medical Center in Puerto Rico and multiple outpatient clinics in Puerto Rico and the U.S. Virgin Islands. The inspection covers key processes 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 healthcare system’s leaders had worked together in their positions for less than one month. However, they had worked together in other capacities for over two years. Employee survey results highlighted opportunities to improve staff feelings of moral distress. Patient experience survey results identified opportunities for improvement in specialty care settings. Review of the facility’s accreditation findings, sentinel events, and disclosures identified concerns with the system’s completion of institutional disclosures as well as the actions taken following serious adverse events. 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 10 recommendations for improvement in five areas:(1) Leadership and Organizational Risks• Institutional disclosures• Root cause analyses(2) Quality, Safety, and Value• Surgical work group meeting attendance(3) Registered Nurse Credentialing• Primary source verification(4) Care Coordination• Active medication list transmission• Nurse-to-nurse communication(5) High-Risk Processes• Disruptive behavior committee meeting attendance• Patient notification of Orders of Behavioral Restriction• Workplace Behavioral Risk Assessment• Staff training