Federal Reports

The VA Office of Inspector General (OIG) conducted a follow-up healthcare inspection in response to a 2023 OIG report regarding mistreatment of a resident at the Miles City VA Community Living Center (CLC) and the Fort Harrison VA Medical Center (facility). The OIG did not receive new allegations but initiated the inspection to review the current state of the CLC, including corrective actions and sustainability of changes implemented by system leaders. In addition, the OIG reviewed staffing shortages affecting the quality of care for CLC residents.
The 2023 OIG report substantiated an allegation of resident mistreatment and identified issues related to reporting and oversight processes. The OIG made seven recommendations that were closed as of May 9, 2024. The OIG determined system leaders’ actions to address previously identified CLC deficiencies specific to rights of residents to refuse treatment, patient safety reporting, screening and admissions, physician care oversight and documentation, and nursing care operations were sustained; therefore, the OIG did not have recommendations related to these areas. 
The OIG, however, identified gaps in CLC physician coverage and staffing shortages for the CLC physical therapist and social worker positions, affecting quality of care for residents. The OIG found that when the CLC physician was on extended leave, medical coverage was by phone to the facility medical officer of the day located over 300 miles away. Physical therapy needs, such as timely access to durable medical equipment, were still being covered by existing system staff. A social worker, to address residents’ psychosocial needs, had been hired as of September 11, 2024. While the OIG did not find that the CLC staffing shortages resulted in resident harm, the gaps and shortages may limit access to and continuity of care for residents. The OIG made two recommendations to the Facility Director regarding staffing.

This report presents the results of our audit of progress on improvements at Richmond, VA, Regional Processing and Distribution Center.
 

We discuss DOI’s progress in implementing Government charge card recommendations in FY 2024 and other DOI-related charge card activities. 

The Federal Emergency Management Agency (FEMA) obligated $267.7 billion (95.3 percent) of disaster relief funding available between fiscal years 2017 and 2023 for disaster-related activities, as authorized by the Robert T. Stafford Disaster Relief and Emergency Assistance Act, as amended, 42 United States Code 5121 et seq. (Stafford Act). Approximately $8.1 billion (2.9 percent of the disaster relief funding available) was set aside or transferred to other programs in accordance with applicable laws. Specifically, FEMA set aside $4.6 billion for pre-disaster mitigation and transferred $3.5 billion out of the Disaster Relief Fund to other appropriations.

A train director based in Chicago, Illinois, pleaded guilty on January 27, 2025, in Marion Superior Court, Indiana, to felony theft. The same day, the employee was sentenced to a 545-day suspended sentence and 545 days of probation. The employee was ordered to take an anti-theft class and pay restitution in the amount of $8,978 to the Indiana Department of Workforce Development. Our investigation found that the employee fraudulently applied for and received pandemic unemployment related funds to which she was not entitled.

The Office of the Inspector General (OIG) contracted with Sikich to conduct this performance audit.  The objective was to assess the effectiveness of the information security policies, procedures, and practices of the U.S. Nuclear Regulatory Commission’s (NRC) Technical Training Center (TTC).  The findings and conclusions presented in this report are the responsibility of Sikich.  The OIG’s responsibility is to provide oversight of the contractor’s work in accordance with generally accepted government auditing standards. 

Based on its assessment period from March 2024 through October 2024, Sikich found that although the NRC generally implemented effective information security policies, procedures, and practices for the TTC, the agency’s implementation of a subset of selected controls was not fully effective.  There were weaknesses in the TTC’s information security program and practices.  As a result, six recommendations were made to assist the TTC in strengthening its information security program.