Federal Reports

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 New York Harbor Healthcare System. The inspection covered key clinical and administrative processes associated with promoting quality care, focusing on 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.At the time of the OIG inspection, the system’s three permanently assigned leaders had worked together for over four years. However, the leadership team also had two vacant positions and one position that was detailed after a two-and-a-half-year vacancy. Employee satisfaction survey scores for leaders were generally similar to or better than VHA averages. Outpatients appeared satisfied with their care, although overall and gender-specific inpatient survey results were lower than VHA averages. The OIG found deficiencies with identifying sentinel events and conducting institutional disclosures. Additionally, there were repeat findings from the June 2017 comprehensive healthcare inspection related to inter-facility transfers. Executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue taking actions to sustain and improve performance.The OIG issued eight recommendations for improvement in five areas:(1) Leadership and Organizational Risks• Sentinel events and institutional disclosures(2) Quality, Safety, and Value • Peer reviews(3) Mental Health• Staff suicide safety plan training(4) Care Coordination• Inter-facility transfer forms(5) High-Risk Processes• Disruptive behavior committee attendance• Orders of Behavior Restriction• Staff training

The results of the Federal Election Commission (FEC) Office of Inspector General’s (OIG) Special Review of the Contracting Officers Representative (COR) Program.

The Office of Inspector General (OIG) found that the Small Business Administration (SBA) did not have an organizational structure with clearly defined roles, responsibilities, and processes to manage and handle potentially fraudulent Paycheck Protection Program (PPP) loans across the program. In addition, the agency did not establish a centralized entity to design, lead, and manage fraud risk. This problem occurred because the agency did not establish a sufficient fraud risk framework at the start of and throughout PPP implementation. Management stated this was partly due to the speed of the delivery of PPP and the continuous and rapid discovery of different kinds of fraud schemes. Lenders also were not always clear on how to handle PPP fraud or recover funds obtained fraudulently from the PPP that remained in the borrower’s account. SBA did not provide lenders sufficient specific guidance to effectively identify, track, address, and resolve potentially fraudulent PPP loans. During our review, SBA established a Fraud Risk Management Board.To better mitigate fraud, we recommend SBA establish clearly defined and detailed roles, responsibilities, and processes and provide lenders formal guidance for managing and handling potentially fraudulent loans.SBA management generally agreed with the findings and agreed with both recommendations. Management plans to document the roles, responsibilities, and processes for all SBA offices responsible for managing and handling potentially fraudulent PPP loans. Management also plans to consolidate its existing guidance to lenders regarding fraud and provide new guidance as appropriate.

The audit found the agency had significant issues implementing the Coronavirus Aid, Relief, and Economic Security (CARES) Act. The agency did not sufficiently review CARES invoices due to changing guidelines, reduced contract oversight staffing during the pandemic, overreliance on contractor-provided information, and the lack of clear and comprehensive Contracting Officer Representative (COR) oversight procedures for CARES invoices. As a result, the OIG questioned more than $16.4 million, or 40 percent of the sampled CARES invoice charges. As of June 8, 2021, NSA reported $917 million in CARES invoices.

An Amtrak conductor based in Miami, Florida, resigned from his position on April 12, 2022, prior to his administrative hearing. Our investigation found that the former employee violated company policies by stealing supplies from a contractor doing business with Amtrak. The former employee was captured on video entering the contractor’s building, which is co-located at the Amtrak yard, and stealing the supplies and loading them into the trunk of his personally-owned car.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Carmel Main Post Office in Carmel, IN (Project Number 22-086). The Carmel Main Post Office is in the Indiana District of the Central Area and services ZIP Codes 46032 and 46033, which serves about 76,498 people and is considered an urban community. We judgmentally selected the Carmel Main Post Office based on the number of stop-the-clock (STC) scans occurring at the delivery unit, rather than at the customer’s delivery address.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Plainfield Main Post Office (MPO) in Plainfield, IN (Project Number 22-085). The Plainfield MPO is in the Indiana District of the Central Area and services ZIP Code 46168, which serves about 29,744 people and is considered an urban community. We judgmentally selected the Plainfield MPO based on the number of stop-the-clock (STC) scans occurring at the delivery unit, rather than at the customer’s delivery address.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Linwood Station in Indianapolis, IN (Project Number 22-087). The Linwood Station is in the Indiana District of the Central Area and services ZIP Code 46201, which serves about 30,926 people and is considered an urban community. We judgmentally selected the Linwood Station based on the number of customer inquiries per route the unit received. From November 1, 2021, through January 31, 2022, the unit received 22 inquiries per route, which was more than the average of 7.36 inquiries per route for all sites serviced by the Indianapolis Processing and Distribution Center (P&DC).

This letter to Congress reports on NCUA OIG's assessment of the NCUA's 2021 compliance under the requirements of the Payment Integrity Information Act of 2019 (PIIA).