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Reports
Audit of GSA’s Response to COVID-19: PBS Faces Challenges to Ensure Water Quality in GSA-Controlled Facilities
We recommend that the PBS Commissioner provide appropriate oversight to ensure water is safe to occupants in its buildings by defining roles and responsibilities for maintaining water quality in GSA-controlled facilities.
We recommend that the PBS Commissioner provide appropriate oversight to ensure water is safe to occupants in its buildings by ensuring that: water quality is maintained through consistent policies and practices nationwide; deviations to PBS’s Drinking Water Quality Management policy and the PBS water safety guidance are approved by PBS’s Central Office; and any water safety policies or guidance developed by regional offices do not contradict policies and guidance issued at the national level.
We recommend that the PBS Commissioner provide appropriate oversight to ensure water is safe to occupants in its buildings by ensuring that PBS’s water safety activities are incorporated into O&M contracts, recorded in PBS’s National Computerized Maintenance Management System, and overseen by PBS personnel.
We recommend that the PBS Commissioner provide appropriate oversight to ensure water is safe to occupants in its buildings by incorporating PBS’s water safety oversight responsibilities into quality assurance surveillance plans for O&M contracts to ensure contractor compliance with water safety activities.
We recommend that the PBS Commissioner provide appropriate oversight to ensure water is safe to occupants in its buildings by ensuring that PBS personnel and O&M contractors have access to tenant spaces so flushing can be performed.
We recommend that the PBS Commissioner provide appropriate oversight to ensure water is safe to occupants in its buildings by amending O&M and other contracts to ensure that energy efficiency and water conservation requirements do not conflict with PBS’s Drinking Water Quality Management policy and the PBS water safety guidance.
We recommend that the PBS Commissioner provide appropriate oversight to ensure water is safe to occupants in its buildings by ensuring that water is tested in GSA’s child care centers as required by PBS’s Drinking Water Quality Management policy.
We recommend that the PBS Commissioner provide appropriate oversight to ensure water is safe to occupants in its buildings by ensuring water quality test results—especially those above EPA action levels—are communicated timely to building tenants, GSA child care center operators, and parents and guardians of affected children.
We recommend that the PBS Commissioner provide appropriate oversight to ensure water is safe to occupants in its buildings by amending and implementing PBS’s Drinking Water Quality Management policy to: include reduced occupancy or decreased water usage as additional criteria for lead, copper, Legionella bacteria, and other contaminant testing; ensure requirements in PBS’s Drinking Water Quality Management policy, its companion Desk Guide for Drinking Water Quality Management, and the PBS water safety guidance are incorporated into the amended policy, unless there are safety reasons why such requirements cannot or should not be incorporated; and formalize its requirement to complete additional testing at child care centers that close for extended periods of time.
Audit of the Reliability of the DoD Coronavirus Disease–2019 Patient Health Data
Rec. 1: The DoD OIG recommended that the Director of the Defense Health Agency work with the Program Executive Officer of the Program Executive Office, Defense Healthcare Management Systems to document and implement the process for identifying and collecting patient health data of DoD patients in the Military Health System in current and future registries within their purview in a written document, such as a standard operating procedure. The procedure should identify, at a minimum, the internal controls throughout the process, the relevant data sources, data fields, and diagnostic codes used in the computer scripts, and should be reviewed and approved when updates occur.
Rec. 2: The DoD OIG recommended that the Senior Contracting Official of the U.S. Army Medical Research Acquisition Activity and the Chief of the Joint Trauma System work with the Joint Trauma System contracting officer's representative to revise the quality assurance surveillance plan. The plan should include an appropriate sampling methodology for selecting patient health records from the Coronavirus Disease-2019 Registry to verify that the contractor is achieving the contract-required accuracy rate for entering patient data, and submit the revised quality assurance surveillance plan to the contracting officer.
Rec. 2: The DoD OIG recommended that the Senior Contracting Official of the U.S. Army Medical Research Acquisition Activity and the Chief of the Joint Trauma System work with the Joint Trauma System contracting officer's representative to revise the quality assurance surveillance plan. The plan should include an appropriate sampling methodology for selecting patient health records from the Coronavirus Disease-2019 Registry to verify that the contractor is achieving the contract-required accuracy rate for entering patient data, and submit the revised quality assurance surveillance plan to the contracting officer.
Rec. 3: The DoD OIG recommended that the Chief of the Joint Trauma System conduct an analysis to determine whether the patient data entered into the Coronavirus Disease-2019 Registry met the 90 percent accuracy rate requirement for contract W81XWH-20-P-0197 and contract W81XWH-22-C-0151.
Rec. 3.a: If the contractor did not meet the 90 percent accuracy requirement, the DoD OIG recommended that the Chief of the Joint Trauma System work with the Senior Contracting Official of the U.S. Army Medical Research Acquisition Activity to update the contractor's rating in the contractor's performance assessment reports for contract W81XWH-22-C-0151 and contract W81XWH-20-P-0197, when feasible.
Rec. 3.b: If the contractor did not meet the 90 percent accuracy requirement, the DoD OIG recommended that the Chief of the Joint Trauma System work with the Senior Contracting Official of the U.S. Army Medical Research Acquisition Activity to recoup any of the $3.9 million in questioned costs paid for services that did not comply with the terms of contract W81XWH-20-P-0197, if feasible.
Rec. 3.c: If the contractor did not meet the 90 percent accuracy requirement, the DoD OIG recommended that the Chief of the Joint Trauma System work with the Senior Contracting Official of the U.S. Army Medical Research Acquisition Activity to recoup any of the $2.3 million in questioned costs paid for services that did not comply with the terms of contract W81XWH-22-C-0151.
Rec. 3.d: If the contractor did not meet the 90 percent accuracy requirement, the DoD OIG recommended that the Chief of the Joint Trauma System work with the Senior Contracting Official of the U.S. Army Medical Research Acquisition Activity to consider all available contract remedies for contract W81XWH-22-C-0151, including modifying and, if necessary, terminating and re-competing the contract, and take action to ensure that the Department receives full value for the funds it expends for contract W81XWH-22-C-0151.
Rec. 3.e: If the contractor did not meet the 90 percent accuracy requirement, the DoD OIG recommended that the Chief of the Joint Trauma System work with the Senior Contracting Official of the U.S. Army Medical Research Acquisition Activity to delegate an official to review the concerns identified in this report, including the actions of the contracting officials, and take administrative actions, as necessary. The review should include a determination on whether the contractor's performance assessment reports were accurate and make updates as necessary.
Rec. 4.a: The DoD OIG recommended that the Director of the Defense Health Agency work with the Chief of the Joint Trauma System establish and implement a process for selecting Coronavirus Disease-2019 events for entry into the Coronavirus Disease-2019 Registry to limit selection bias.
Rec. 4.b: The DoD OIG recommended that the Director of the Defense Health Agency work with the Chief of the Joint Trauma System to include a bias disclosure notice on all reports generated from the Coronavirus Disease-2019 Registry until the Coronavirus Disease-2019 Registry data represent the population of DoD patients who had a Coronavirus Disease-2019 event.
Rec. 5.a: The DoD OIG recommended that the Assistant Secretary of Defense (Health Affairs) establish and implement a policy for developing and populating patient registries that aligns with the Department of Health and Human Services best practices, "Agency for Healthcare Research and Quality, Registries for Evaluating Patient Outcomes: A User?s Guide," current edition.
Rec. 5.b: The DoD OIG recommended that the Assistant Secretary of Defense (Health Affairs) conduct a review of all patient registries in the Military Health System to verify the reliability of data in each registry and implement corrective actions, as necessary.
Audit of DoD Actions Taken to Implement Cybersecurity Protections Over Remote Access Software in the Coronavirus Disease–2019 Telework Environment
Rec. A.1: The DoD OIG recommended that the Director of the U.S. Southern Command - Joint Interagency Task Force South Command, Control, Communications, Computers, Cyber and Intelligence direct its network administrators to scan the VMware Horizon main virtual desktop for malware in accordance with the McAfee Endpoint Security Technical Implementation Guide, develop compensating controls, or formally accept the risk of not scanning the main virtual desktop.
Rec. A.2.a: The DoD OIG recommended that the Chief Information Officer of the Department of the Air Force revise its policy to align with the Windows 10 Security Technical Implementation Guide requirement for disabling inactive user accounts after no more than 35 days.
Rec. A.2.b: The DoD OIG recommended that the Chief Information Officer of the Department of the Air Force direct network and system administrators to disable inactive user accounts after no more than 35 days of inactivity in accordance with the Windows 10 Security Technical Implementation Guide, develop compensating controls, or formally accept the risk of not disabling the inactive user accounts.
Rec. A.3: The DoD OIG recommended that the Chief Information Officer of the Naval Surface Warfare Center - Panama City Division direct network and system administrators to disable inactive user accounts after no more than 35 days of inactivity in accordance with the Windows 10 Security Technical Implementation Guide, develop compensating controls, or formally accept the risk of not disabling the inactive user accounts.
Rec. A.4.a: The DoD OIG recommended that the Chief Information Officer of the Defense Intelligence Agency revise its policy to align with the Windows 10 Security Technical Implementation Guide requirement for disabling inactive users after no more than 35 days.
Rec. A.4.b: The DoD OIG recommended that the Chief Information Officer of the Defense Intelligence Agency direct network and system administrators to disable inactive user accounts after no more than 35 days of inactivity in accordance with the Windows 10 Security Technical Implementation Guide, develop compensating controls, or formally accept the risk of not disabling the inactive user accounts.
Rec. A.5.a: The DoD OIG recommended that the Director of the Marine Corps Information Command, Control, Communications, and Computers revise the organization's policy to align with the Windows 10 Security Technical Implementation Guide requirement for disabling inactive users after no more than 35 days.
Rec. A.5.b: The DoD OIG recommended that the Director of the Marine Corps Information Command, Control, Communications, and Computers direct network and system administrators to disable inactive user accounts after no more than 35 days of inactivity in accordance with the Windows 10 Security Technical Implementation Guide, develop compensating controls, or formally accept the risk of not disabling the inactive user accounts.
Rec. A.6: The DoD OIG recommended that the Director of the Defense Information Systems Agency Joint Service Provider direct network and system administrators to disable inactive user accounts after no more than 35 days of inactivity in accordance with the Windows 10 Security Technical Implementation Guide, develop compensating controls, or formally accept the risk of not disabling the inactive user accounts.
Rec. B.1: The DoD OIG recommended that the Director of the Defense Information Systems Agency Joint Service Provider direct network and system administrators to revise the vulnerability management program to include mitigation timeframes for all vulnerabilities and develop plans of actions and milestones for all vulnerabilities that cannot be mitigated in a timely manner.
Capstone Review of the Federal Bureau of Prisons' Response to the Coronavirus Disease 2019 Pandemic
Conduct a thorough assessment of single-celling policies and processes, including those applicable to inmates housed in quarantine and medical isolation units and to inmates vulnerable to suicide.
Assess how to improve staff and inmate compliance with healthcare protective equipment measures at its facilities and issue clear guidance to facilities about the importance of compliance.
Ensure that actions, including any policy revisions, the BOP takes to close the two open recommendations from our 2017 restrictive housing report that reference single-celling also apply to single-celling during quarantine and medical isolation.
Explore options for permanent changes to facility infrastructures that would allow for better implementation of social distancing and other infection control measures.
Immediately update guidance regarding (1) when staff should notify the families of inmates who become seriously ill or die, including a specific timeframe, and (2) uniform criteria for what constitutes a serious illness.
Ensure that inmate family information, or the inmate emergency contact form, is updated according to policy and readily available for BOP staff who need to notify next of kin in cases of inmate serious illness or death.
Audit of the Management and Coordination of Pandemic-Related Fraud Allegations and Referrals Between the Criminal Division and Executive Office for U.S. Attorneys
Evaluation of Department of Defense Military Medical Treatment Facility Challenges During the Coronavirus Disease-2019 (COVID-19) Pandemic in Fiscal Year 2021
Rec. A.1.a: The DoD OIG recommended that the Director of the Defense Health Agency, in conjunction with the Secretaries of the Military Departments, establish a working group to address the staffing challenges identified by Military Medical Treatment Facilities during this evaluation. The working group should establish milestones to streamline the hiring process to allow Military Medical Treatment Facilities to more quickly fill civilian staffing positions.
Rec. A.1.b: The DoD OIG recommended that the Director of the Defense Health Agency, in conjunction with the Secretaries of the Military Departments, establish a working group to address the staffing challenges identified by Military Medical Treatment Facilities during this evaluation. The working group should establish milestones to determine if salaries for Military Medical Treatment Facility civilian nurses are commensurate with each facility's local market and if military treatment facilities are able to hire nurses at those salaries. For locations where military treatment facility salaries are not commensurate with the local market, take appropriate actions that will reduce the disparity in those markets.
Rec. A.1.c: The DoD OIG recommended that the Director of the Defense Health Agency, in conjunction with the Secretaries of the Military Departments, establish a working group to address the staffing challenges identified by Military Medical Treatment Facilities during this evaluation. The working group should establish milestones to establish a central authority with the knowledge of the Services' requests for individual and large group deployments of medical staff coming out of Military Medical Treatment Facilities and the associated risks to health care delivery.
Rec. A.1.d: The DoD OIG recommended that the Director of the Defense Health Agency, in conjunction with the Secretaries of the Military Departments, establish a working group to address the staffing challenges identified by Military Medical Treatment Facilities during this evaluation. The working group should establish milestones to assess the ability of Military Medical Treatment Facilities to rapidly receive augmentation of medical staff from the Reserve Components.
Rec. A.2.a: The DoD OIG recommended that the Director of the Defense Health Agency, in coordination with the Secretaries of the Military Departments establish the manpower requirements for the coronavirus disease-2019 mission within the Military Medical Treatment Facilities for the staff required to support testing, vaccinations, contact tracing, and acute respiratory clinics.
Rec. A.2.b: The DoD OIG recommended that the Director of the Defense Health Agency, in coordination with the Secretaries of the Military Departments identify the medical personnel requirements within the Military Medical Treatment Facilities, including clinicians, nurses, and support staff, needed for future long-term pandemic response and biological incidents.
Rec. B: The DoD OIG recommended that the Assistant Secretary of Defense (Health Affairs) develop DoD policy for the maximum consecutive hours to be worked, maximum shifts per week, and coverage of duties when absent, for Military Health System staff (at minimum, active duty military and civilian physicians, nurses, respiratory therapists, and lab technicians) working in Military Medical Treatment Facilities to reduce the physical impacts leading to fatigue and burnout, and develop the appropriate waivers of this policy for Military Health System staff.
Rec. C: The DoD OIG recommended that the Assistant Secretary of Defense (Health Affairs) direct a new or existing working group to develop a plan to implement the recommendations in the Military Health System COVID-19 After Action Report and to develop and monitor milestones for each recommendation.
Audit of Entitlements for Activated Army National Guard and Air National Guard Members Supporting the Coronavirus Disease–2019 Mission
Rec. 1.a: The DoD OIG recommended that the Under Secretary of Defense (Comptroller)/Chief Financial Officer, DoD, in coordination with the Under Secretary of Defense for Personnel and Readiness, update the DoD Financial Management Regulation, volume 7A, "Military Pay Policy - Active Duty and Reserve Pay," chapter 27, "Family Separation Allowance" to clearly state that the permanent duty station of a Reserve Component member on temporary duty status is the member's primary residence for the purpose of determining Family Separation Allowance entitlement.
Rec. 1.b: The DoD OIG recommended that the Under Secretary of Defense (Comptroller)/Chief Financial Officer, DoD, in coordination with the Under Secretary of Defense for Personnel and Readiness, update the DoD Financial Management Regulation, volume 7A, "Military Pay Policy - Active Duty and Reserve Pay," chapter 27, "Family Separation Allowance" to clarify that Family Separation Allowance entitlement determination is based on the commuting distance between the member's primary residence and their temporary duty location.
Rec. 2.a: The DoD OIG recommended that the Chief, National Guard Bureau, in coordination with the Director of the Army National Guard and the Director of the Air National Guard, develop and implement policies and procedures to require the Army National Guard and Air National Guard to complete a review of proof of residency documentation when the member's primary residency is established or changed for the Basic Allowance for Housing entitlement to ensure consistency throughout all Army National Guard and Air National Guard units and organizations within every state, territory, and the District. The policies and procedures should also include requirements that: * document a member's primary residence address; * require members to provide proof of their primary residence address; * certify the primary address of members and review supporting documentation; and * provide oversight to ensure primary residence address information is complete and accurate.
Rec. 2.b: The DoD OIG recommended that the Chief, National Guard Bureau, in coordination with the Director of the Army National Guard and the Director of the Air National Guard, develop and implement policies and procedures to outline the process and frequency of recertification for Basic Allowance for Housing entitlement that Army National Guard and Air National Guard officials will use to verify and fully document the dependency status of members to provide clarification to the DoD Financial Management Regulation, volume 7A, chapter 26. These procedures should include: * how recertifications will be completed; * which members will complete a recertification; and * how Army National Guard and Air National Guard officials will provide oversight to ensure that information is complete and accurate.
Rec. 2.c: The DoD OIG recommended that the Chief, National Guard Bureau, in coordination with the Director of the Army National Guard and the Director of the Air National Guard, develop and implement policies and procedures to require Army National Guard and Air National Guard officials to review and document the status of a military member married to another military member regardless of which Military Service, Reserve or Active Component, or Army National Guard or Air National Guard unit the member's spouse belongs to, and identify which member will claim any applicable dependents.
Rec. 2.d: The DoD OIG recommended that the Chief, National Guard Bureau, in coordination with the Director of the Army National Guard and the Director of the Air National Guard, develop and implement policies and procedures to specify the methods for confirming eligibility and paying Family Separation Allowance for Army National Guard and Air National Guard members, in accordance with the DoD Financial Management Regulation, volume 7A, chapter 27, and include the: * timeliness of payments; * determination of Family Separation Allowance eligibility for back to back orders; * members assigned to their normal duty locations; and * requirement to track members to know when they return to their primary residence.
Rec. 2.e: The DoD OIG recommended that the Chief, National Guard Bureau, in coordination with the Director of the Army National Guard and the Director of the Air National Guard, develop and implement policies and procedures to establish formal dissemination and communication procedures for National Guard Bureau policies related to entitlements provided to the Army National Guard and Air National Guard, including the policies in the preceding recommendations. The procedures should require: * creation of a central location where policies and procedures will be kept for easy access by all states, territories, and the District; and * confirmation of receipt from all of the states, territories, and the District when procedures are communicated or obtained.
Rec. 3: The DoD OIG recommended that the Chief, National Guard Bureau, in coordination with the Director of the Army National Guard and the Director of the Air National Guard, develop and implement additional internal control procedures for the review of transactions manually submitted by the Army National Guard and Air National Guard to the payment system prior to payment to ensure the completeness and accuracy of transactions.
Management Advisory Regarding Results from Research for Future Audits and Evaluations Related to the Effects of the 2019 Novel Coronavirus on DoD Operations
Rec. 1: The DoD OIG recommended that the Under Secretary of Defense (Comptroller)/Chief Financial Officer, DoD work with DoD Components to implement procedures to ensure award amounts funded under the Coronavirus Aid, Relief, and Economic Security Act are appropriately recorded and reported with the accurate Disaster Emergency Fund Codes through the respective reporting systems.
Rec. 2: The DoD OIG recommended that the Under Secretary of Defense (Comptroller)/Chief Financial Officer, DoD work with the Navy and the Marine Corps to ensure that the Coronavirus Aid, Relief, and Economic Security Act obligation and disbursement transactions processed through their accounting systems and journal vouchers are properly reported in USASpending.gov.
Rec. 3.a: The DoD OIG recommended that the Under Secretary of Defense (Comptroller)/Chief Financial Officer, DoD develop procedures to confirm that DoD Components have appropriately implemented the policies DoD prescribed for coding Coronavirus Aid, Relief, and Economic Security Act fund transactions.
Rec. 3.b: The DoD OIG recommended that the Under Secretary of Defense (Comptroller)/Chief Financial Officer, DoD issue funding authorization documents that include a Disaster Emergency Fund Code value to ensure all DoD budget and accounting systems have a consistent basis to record and report funding and execution by Disaster Emergency Fund Code, in accordance with Office of Management and Budget Memorandum M-18-08.