Federal Reports

In accordance with our statutory authority Public Law (P.L.) 109-SS, the USCP Office of Inspector General (OIG) began a review of the events surrounding the takeover of the U.S. Capitol on January 6, 2021. Our objectives for this review were to determine if the Department (1) established adequate measures for ensuring the safety and security of the Capitol Complex as well as Members of Congress, (2) established adequate internal controls and processes for ensuring compliance with Department policies, and (3) complied with applicable policies and procedures as well as applicable laws and regulations. The scope included controls, processes, and operations surrounding the security measures prior to the planned demonstrations and response during the takeover of the Capitol building.

This report contains information about recommendations from the OIG's audits, evaluations, reviews, and other reports that the OIG had not closed as of the specified date because it had not determined that the Department of Justice had fully implemented them. The list omits information that the Department of Justice determined to be limited official use or classified, and therefore unsuitable for public release.The status of each recommendation was accurate as of the specified date and is subject to change. Specifically, a recommendation identified as not closed as of the specified date may subsequently have been closed.

The OIG examined whether the VHA had effective procedures for (1) purchasing, (2) inventorying, and (3) tracking biologic implants such as skin substitutes and corneal or dental implants. The OIG found deficiencies in all three areas at four medical facilities it visited.The audit team determined that purchasing agents did not always record implant purchases properly or use the appropriate funds. The purchasing agents did not record 2,931 of 10,305 purchased biologic implants in the appropriate system. Instead, agents documented the implants in various local spreadsheets, databases, and third party systems. Purchasing agents sometimes improperly used logistics funds instead of prosthetic funds, which makes it difficult for VHA to fully account for biologic implant spending and effectively budget or use funds for other purposes.The OIG found that due to inadequate guidance, the facilities visited had an inaccurate inventory of biologic implants, did not use a standardized system, and did not consistently review inventory on hand. At the four facilities visited, staff could not locate 714 biologic implants in inventory, valued at almost $1.1 million. The audit team also found 288 unrecorded additional items, valued at almost $433,000, in storage locations. Poor inventory management can jeopardize prompt care, as medical providers may need to delay or cancel procedures if implants are unavailable.Finally, the facilities visited failed to track at least 45 percent of implants reported as used from October 2017 through March 2019. Further, VHA did not designate responsibility for overseeing tracking, develop a national policy on how facilities should track biologic implants, or have a standard tracking system that meets accreditation requirements. Effective tracking is needed for facilities to notify veterans if their implants are recalled by the manufacturers.VHA concurred with the OIG’s 11 recommendations to improve how it purchases, inventories, and tracks biologic implants.

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Washington DC VA Medical Center (facility) pursuant to a request by several members of Congress. The members had learned that the facility was not in compliance with the Veterans Health Administration (VHA) policy on communicating exam results and letters had not been appropriately mailed to patients who had breast imaging studies.After discovery of the unsent letters, facility staff completed reviews and all patients were notified of abnormal findings. The OIG identified nine additional mammography exams not included in the facility’s reviews due to errors in diagnostic coding. The facility reviewed and determined the exams were not abnormal.The facility identified two patients and the OIG identified two additional patients who had clinically significant mammography exams (breast cancer). Though the four patients did not receive timely letters, all four breast cancer patients received timely notification by the ordering provider. The OIG found that ordering providers did not consistently document patient notification of abnormal mammography results as required.At the time of the OIG review, the facility did not have a functional mammography program due to loss of staff. The facility had not fully implemented the September 2019 National Radiology Program Office (NRPO) site visit recommendations.The NRPO did not cite the facility for lack of a program standard operating procedure manual.The facility did not fully implement program procedural changes including oversight of staff duties and training, appropriate oversight and quality controls in delegating the task of mailing patient lay summary letters, and development of a formalized training program for mammography staff to ensure monitoring and tracking of patients.The OIG made seven recommendations related to documentation and notification processes, action plans, standard operating procedures, staff training, and NRPO reviews and requirements.

The Barrington Station is located in the Los Angeles District of the West Pac Area. OIG data analytics identified the Barrington Station as having four consecutive floor stamp inventory count shortages totaling about $8,781 for fiscal year (FY) 2020. We determined the Barrington Station properly accounted for money orders but did not always properly account for stamps and cash.

The Postal Service’s Peak Season lasts about eight weeks, starting on or around Thanksgiving Day in November and ending on or around Martin Luther King, Jr. Day in January. Since FY 2018, the average cost of the Postal Service’s air network per day during Peak Season increased from $8.7 million to $9.8 million (12.6 percent increase). The highest Peak Season average volume per day was [redacted] million pounds in FY 2019. Despite less volume during the FY 2020 Peak Season (November 28, 2019 – January 20, 2020), the cost per pound to transport mail by air continued to rise – from [redacted] in FY 2018 to [redacted] in FY 2020 (10.9 percent increase). Our objective was to assess the Postal Service’s efforts to reduce Peak Season air transportation operational costs while maintaining service during fiscal year (FY) 2019 and FY 2020.

Our objective for this report was to assess the extent to which the company is incorporating its injury claims financial data into its Safety Management System (SMS).We found that the company’s Safety and Operations departments currently use injury and accident reports to identify the most frequent incidents in their efforts to assess and manage safety risks and inform the SMS. These departments have not, however, had regular access to company data on employee and passenger injury claims, including settlement data, which resides with the company’s claims group. Our work determined these data could allow the Safety and Operations departments to better identify additional risks and mitigation strategies and, in turn, help improve safety outcomes and minimize the impact of safety incidents on the company.We recommended that the company develop a policy and process to regularly share legally appropriate injury claims data internally and use these data to help identify and mitigate safety risks as part of its risk management process.