Federal Reports

The OIG’s administrative investigation examined the circumstances surrounding the death of a veteran on the Edith Nourse Rogers Memorial Veterans Hospital campus in Bedford, Massachusetts (the medical center). Mr. Timothy White was a resident of the Bedford Veterans Quarters (BVQ), an independent living facility operated by Caritas Communities, Inc. (Caritas), in space leased to it through VA’s enhanced-use lease program. A month after Mr. White was reported missing, his body was found in the emergency exit stairwell of the building that houses the BVQ. This stairwell down the hall from his room was VA property and not leased to Caritas.The VA police department’s failure to locate Mr. White resulted in part from the police and others at VA not considering the veteran an at-risk missing patient, which would have required a stairwell search. The Veterans Health Administration and the Office of Security and Law Enforcement lacked clear guidance regarding the obligations of VA police to search for nonpatients reported missing on VA property.VA police also did not discover Mr. White in the stairwell because of an improper order by the then police chief to cease patrols of the building in which Mr. White was found. The OIG found that the VA police chief exceeded his authority as both VA policy and the lease required VA police to patrol VA property.Lastly, because medical center staff mistakenly believed the emergency exit stairwells were not VA space, they did not clean them. The confusion among medical center leaders and staff regarding the lease scope and VA’s obligations stemmed from a lack of clear guidance from the Office of Asset and Enterprise Management. Routine police patrols and stairwell cleanings likely would have led to Mr. White being found earlier.VA concurred with the OIG’s seven recommendations to improve policies and procedures.

The Cybersecurity and Infrastructure Security Agency (CISA) cannot demonstrate how its oversight has improved Dams Sector security and resilience. We attribute this to CISA’s inadequate management of Dams Sector activities. Specifically, CISA has not:coordinated or tracked its Dams Sector activities;updated overarching national critical infrastructure or Dams Sector plans; orcollected and evaluated performance information on Dams Sector activities.In addition, CISA does not consistently provide information to the Federal Emergency Management Agency (FEMA) to help ensure FEMA’s assistance addresses the most pressing needs of the Dams Sector. CISA and FEMA also do not coordinate their flood mapping information. Finally, CISA does not effectively use the Homeland Security Information Network Critical Infrastructure Dams Portal to provide external Dams Sector stakeholders with critical information.As a result, CISA could improve its oversight, coordination, and communication to better support the Dams Sector security and resilience. These changes would enhance the Sector’s ability to adapt to the risk environment and decrease the likelihood of future dam failures and flooding events.

NASA manages more than 5,000 buildings and structures, a $2.66 billion deferred maintenance backlog, and a $357 million annual facility construction budget. In this audit, we assessed whether NASA is effectively managing its facility construction efforts to modernize, consolidate, and repair its critical infrastructure.

The OIG is conducting an audit to determine whether VA’s Financial Management Business Transformation Service identified and addressed issues with a new IT system following its initial deployment at the National Cemetery Administration (NCA). The Integrated Financial and Acquisition Management System will be used throughout VA to manage budgetary, financial, and contracting activities.The OIG issued a management advisory memorandum to share observations from the ongoing audit and expects to publish the final report in fiscal year 2022.The audit team found that NCA was experiencing significant challenges with the system’s ability to produce business intelligence reports that it needs to make well informed, mission critical decisions. Although the Financial Management Business Transformation Service attempted some corrective actions, issues persisted as of July 8, 2021, or about eight months after go-live. As of this date, NCA did not have a comprehensive report showing the total amount of funds available for the administration. This was despite the fact that NCA leaders informed the Financial Management Business Transformation Service in April 2019 that the report was the administration’s highest priority and needed to identify funding available at every level of the budget. Other high priority reports used to track and forecast payroll and full-time equivalent employees were also not available for NCA’s widespread use. These reports would allow staff to monitor how much has been expended in payroll and project the funding required to pay employee salaries throughout the fiscal year. NCA staff noted that they spend considerable time trying to understand and validate reports by extracting data from other reports and queries and manipulating that data in spreadsheets.The OIG requested that the Office of Management inform the OIG what action, if any, the Office of Management takes to address the issued identified.