Federal Reports

o U.S. Customs and Border Protection (CBP) does not comprehensively plan and conduct its covert testing, use test results to address vulnerability, or widely share lessons learned. CBP’s two covert testing groups do not use risk assessments or intelligence to plan and conduct covert tests at ports of entry and U.S. Border Patrol checkpoints, do not plan coordinated tests, and do not design system-wide tests. This occurred because CBP has not provided adequate guidance on risk- and intelligence-based test planning, directed the groups to coordinate, given them the required authority, or established performance goals and measures for covert testing. Following testing, CBP does not widely share covert test results, consistently make recommendations, or ensure corrective actions are taken. Results are not widely shared because CBP has not defined roles and responsibilities for such sharing. Covert testing groups do not make recommendations or ensure corrective actions are implemented due to insufficient authority and policies directing these actions. Finally, CBP does not effectively manage covert testing groups to ensure data reliability, completeness, and compliance with security requirements due to leadership changes and limited staff. Without comprehensive planning, incorporating lessons learned from test results, and program management accountability, CBP cannot ensure it addresses vulnerabilities, which may be exploited and threaten national security. We recommended CBP develop policies and procedures for conducting covert testing and assign roles and responsibilities for oversight of covert testing groups. We made seven recommendations that will strengthen its covert testing program. CBP concurred with all seven recommendations.

The Office of Special Reviews investigated allegations that a GS-14 employee in VA’s Office of Information and Technology misused his government email by sending personal emails during work hours, and also took advantage of his telework arrangement to handle personal matters during his duty hours. The OIG could not substantiate the misuse of official time or improper use of VA resources because the employee routinely worked outside of his regular duty hours with his supervisor’s approval, and VA has not established criteria defining how much personal use of VA email is excessive. While investigating these issues, the OIG became aware that the employee had referred staff who were planning conferences for his group to his wife, a sales manager for a large hotel chain, and sent emails providing direction about the arrangements for these conferences. The staff subsequently booked rooms for these events at hotels for which the employee’s wife had sales responsibility. Although the staff made the decision and the arrangements were advantageous to VA, the OIG determined that the employee’s conduct appeared contrary to ethical rules prohibiting an employee from using his public office for “his own private gain, for the endorsement of any product, service or enterprise, or for the private gain of friends, relatives, or persons with whom the employee is affiliated in a nongovernmental capacity….” The OIG made one recommendation relating to a supervisory review of the employee’s conduct and consideration of appropriate administrative action, if any. VA concurred with this recommendation.

Following the death of a Peace Corps/Ghana Volunteer, we conducted a review to assess the sufficiency of Volunteer training and Volunteer housing procedures to mitigate the risk of future accidents involving gas tanks used for cooking. Our report contains 4 recommendations to improve the agency's actions regarding gas cooking safety.

The VA Office of Inspector General (OIG) investigated a non-specific allegation that chief nurses within the Miami VA Health Care System (Miami HCS) violated the federal anti-nepotism statute by arranging to have their spouses hired for positions for which the spouses were not qualified. This allegation could not be substantiated. In addition, a specific allegation of nepotism was made pertaining to the conduct of a particular chief nurse. The OIG substantiated the allegation that the chief nurse violated the anti-nepotism statute by recommending the chief nurse’s spouse for a position at the Miami HCS. The chief nurse falls under the statutory definition of a public official and was prohibited from advocating for the employment by VA of the chief nurse’s spouse. The chief nurse was involved in two communications relating to the spouse’s possible employment at VA, one of which the OIG considered advocacy contrary to the federal anti-nepotism statute. The spouse withdrew his/her application without providing an explanation and was not hired by VA. The OIG made one recommendation relating to administrative action against the chief nurse if the Miami HCS Director deems it appropriate. VA concurred with the OIG’s finding and determined administrative action at this time is unwarranted. The OIG considers the recommendation closed.

The VA Office of Inspector General (OIG) conducted an inspection at the Washington DC VA Medical Center (facility) to assess care provided to a patient six days prior to death by suicide and an allegation that an Emergency Department physician made a statement to the effect of “[the patient] can go shoot [themself]. I do not care.” The OIG substantiated that the patient died by suicide six days after presenting to the Emergency Department with suicidal ideation and staff failed to complete required suicide prevention planning. During the 12-hour episode of care, the patient navigated two transitions between the Emergency Department and outpatient Mental Health Clinic and saw seven providers. Lack of collaboration between providers, hand-off process deficiencies, and providers’ failure to read the outpatient psychiatrist’s notes led to a compromised understanding of the patient’s medical needs and a failure to enact the outpatient psychiatrist’s recommended treatment plan. The OIG substantiated that an Emergency Department physician made a statement to the effect of “[the patient] can go shoot [themself]. I do not care,” which could be considered misconduct and patient abuse. Facility and contracted staff failed to report the behavior and did not receive required annual abuse and neglect policy education. The Emergency Department physician had a history of verbal misconduct. Despite facility leaders’ awareness by late spring 2019 of physician 2’s inappropriate statement regarding the patient and physician 2’s prior pattern of misconduct, facility leaders did not conduct a formal fact-finding or administrative investigation as required by VA. The Suicide Prevention Coordinator failed to complete the required suicide behavior report and the Emergency Department did not meet Veteran Health Administration’s requirements for a safe and secure mental health evaluation area. The OIG made one recommendation to the Veterans Integrated Service Network Director and 10 recommendations to the Facility Director.

On March 27, 2020, the President signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). To date, the CARES Act has provided the U.S. Department of the Interior (DOI) with $909.7 million, which includes direct apportionments of $756 million to support the needs of DOI programs, bureaus, Indian Country, and the Insular Areas and a $153.7 million transfer from the U.S. Department of Education to the Bureau of Indian Education in June.This report presents the DOI’s progress as of June 30, 2020, in spending CARES Act appropriations. Specifically, the DOI’s expenditures to date total $393,538,262 and its obligations total $534,545,127.We are also monitoring the DOI’s progress on reporting milestones established by the CARES Act and the Office of Management and Budget.We anticipate issuing updated status reports monthly.