Semiannual Report to Congress — Pandemic Response Accountability Committee (2021-04-01)

Full text

A Committee of the
Council of the Inspectors General
on Integrity and Efficiency
PANDEMIC RESPONSE ACCOUNTABILITY COMMITTEE
Semiannual Report to Congress
APRIL 1, 2021–SEPTEMBER 30, 2021

SEMIANNUAL REPORT TO CONGRESS  |  APRIL 1, 2021–SEPTEMBER 30, 2021
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Message from the Chair
I’m proud to present the Pandemic Response
Accountability Committee’s (PRAC) Semiannual
Report to Congress for April 1, 2021, through
September 30, 2021. The Coronavirus Aid,
Relief, and Economic Security (CARES) Act
created the PRAC to provide oversight of
pandemic relief spending, which currently
approximates $5 trillion and has funded more
than 375 pandemic relief programs. To put our
job in perspective, just one pandemic relief
program—the $800 billion Paycheck Protection
Program (PPP)—is equal to the federal
government’s entire response to the 2008-
2009 financial crisis.
The PRAC and its 22 member Inspectors
General (IGs) have exhibited an extraordinary
level of oversight over these funds. We continue
to look for fraud, waste, and abuse, while
working to ensure that critical financial relief—
like unemployment benefits or disaster relief
loans—reach the individuals and businesses it
was intended to help.
During the past six months, the PRAC and
the IG community issued 118 reports that
identified risks, issued recommendations to
improve programs, and identified misspent
funds for potential recovery. In July 2021,
reports from our state and local oversight
partners became available on our website,
PandemicOversight.gov, so now the public
and policymakers can see a full inventory of
pandemic oversight work.
We have given the public robust data and
insights into programs like the Paycheck
Protection Program and the Coronavirus Relief
Fund (CRF) via our website. And in June 2021,
we added another dataset—the $186 billion
Provider Relief Fund. With that addition, the
public can access all pandemic relief spending
data in one place. We’re also adding more
visualizations, data stories, and other features
to make the data easier for the public to use
and understand.
We regularly work with IGs and other oversight
partners, including state and local auditors
and the Government Accountability Office, to
support high-impact oversight and minimize
duplicative work. Most of our collaboration
occurs through specialized working groups
created to help solve problems exacerbated by
the pandemic, such as identity theft. We also
work closely with the Office of Management
& Budget (OMB), the American Rescue Plan
implementation team, and partner IGs to
address issues with pandemic relief data and
opportunities to enhance payment integrity.

SEMIANNUAL REPORT TO CONGRESS  |  APRIL 1, 2021–SEPTEMBER 30, 2021
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With the funding Congress provided in the
American Rescue Plan Act, we built the
Pandemic Analytics Center of Excellence
(the PACE) to deliver analytic, audit, and
investigative support to the federal oversight
community. We’re sharing dozens of public
and non-public federal datasets with 29 IGs to
help investigators find fraud across pandemic
relief programs. We’ve also hired the best and
brightest data science talent, placing 15 data
science fellows with our member OIGs to help
them analyze pandemic relief data.
The PRAC’s Fraud Task Force serves as a
resource for the IG community by focusing
investigative resources on pandemic loan
fraud. Thirty-four agents from nine OIGs are
working Task Force cases while on detail to
the PRAC. These agents are located around
the country and are working cases that would
otherwise go unaddressed due to the scale of
the fraud we are seeing.
We also began co-sponsoring a virtual event
series with the National Academy for Public
Administration that features experts from
academia, think tanks, and non-profits to
discuss aspects of the pandemic relief effort
such as rental assistance in underserved
communities. We’ll continue this series to
increase the public’s awareness of how their
tax dollars are being spent and promote ideas
that may improve the government’s response to
this and future crises.
I hope you find this semiannual report
interesting and insightful.
The Honorable Michael E. Horowitz
Chair, PRAC
Inspector General, U.S. Department of Justice

SEMIANNUAL REPORT TO CONGRESS  |  APRIL 1, 2021–SEPTEMBER 30, 2021
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Contents
i
Message from the Chair
1
Highlights
2
Background
4
PRAC Accomplishments
11  Holding Wrongdoers Accountable
Through Investigations
20 Insights Through Oversight Reports
37 Appendix A: Acronyms
38  Appendix B: Pandemic-Related Reports by Office of
Inspector General
82 Appendix C: Hotline

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APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

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Highlights
Joint Alert with OMB
on Payment Integrity
April 21, 2021
Correctional Facilities
Capping Report
May 12, 2021
Data Release:
Provider Relief Fund
June 3, 2021
International
Data Forum
July 1, 2021
State and Local
Reports Available
July 8, 2021
Identity Fraud
Working Group
July 15, 2021
Data Release:
Paycheck Protection
Program Loan Forgiveness
July 21, 2021
House Committee
on Transportation and
Infrastructure Testimony
July 29, 2021
Pandemic Relief
in Underserved
Communities Event
August 12, 2021
Lessons
Learned Report
August 31, 2021

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APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

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WRONGDOERS
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INSIGHTS THROUGH
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Background
Established in March 2020 by the CARES Act,
the PRAC is a Committee of the Council of the
Inspectors General on Integrity and Efficiency
(CIGIE). CIGIE is an independent entity within
the executive branch by the Inspector General
Act of 1978, as amended, which includes the
75 statutorily created federal IGs.
The CARES Act identifies IGs from nine
agencies as members of the PRAC. The Chair
can designate additional IGs to serve on the
Committee from any agency that receives
pandemic funds or is involved in the federal
government’s response to the COVID-19
pandemic. The IGs serving on the Committee
continue to perform their normal duties.
The PRAC is comprised of 22 IGs (see PRAC
membership below). We are staffed by a full-
time Executive Director and 40 employees
distributed across three lines of business
(Oversight & Accountability, Outreach &
Engagement, and Transparency) and three
support functions (Chief Information Officer,
Chief Counsel, and Chief Data Officer).
The PRAC promotes transparency and provides
Congress and the public with objective, reliable
information about the $5 trillion in pandemic
relief dollars at PandemicOversight.gov. We
also work with IGs to develop recommendations
for program improvements, refer matters for
criminal investigations, and identify misspent
funds for recovery.
PRAC Membership
Name

Department or Agency
Michael E. Horowitz, Chair

Department of Justice
Paul K. Martin, Vice Chair

National Aeronautics and Space Association
Mark Bialek

Federal Reserve Board / Consumer Financial Protection Bureau
Sandra D. Bruce

Department of Education
Kathy A. Buller

Peace Corps
Joseph Cuffari

Department of Homeland Security
Rae Oliver Davis

Department of Housing and Urban Development
Mark Lee Greenblatt

Department of the Interior
Richard Delmar

Department of the Treasury
Eric J. Soskin

Department of Transportation
Phyllis K. Fong

Department of Agriculture
J. Russell George

Treasury Inspector General for Tax Administration
Susan S. Gibson

National Reconnaissance Office
Christi A. Grimm

Department of Health and Human Services
Allison C. Lerner

National Science Foundation
Jay N. Lerner

Federal Deposit Insurance Corporation
Brian D. Miller

Special Inspector General for Pandemic Recovery
Michael J. Missal

Department of Veterans Affairs
Sean W. O’Donnell

Department of Defense
Larry D. Turner

Department of Labor
Hannibal “Mike” Ware

Small Business Administration
Tammy L. Whitcomb

U.S. Postal Service

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APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

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The PRAC released its Strategic Plan for 2020 through 2025 in July 2020. The plan identifies four
goals to carry out the PRAC’s mission and vision (see Figure 1). These goals and objectives are not
mutually exclusive—audits, investigations, reviews, and other activities may meet more than one goal
or objective.
BACKGROUND
MISSION
To serve the American public by promoting transparency and the
coordinated oversight of the Federal Government’s coronavirus response to
prevent and detect fraud, waste, abuse, and mismanagement and mitigate
major risks that cross program and agency boundaries.
VISION
Sound stewardship of taxpayer funds and an effective and efficient
coronavirus response across the Federal Government, the oversight of which
will be data-driven, risk-focused, and technology-enabled.
GOALS
1
Promote
Transparency
2
Promote
Coordinated,
Comprehensive
Oversight
3
Prevent &
Detect Fraud,
Waste, Abuse, &
Mismanagement
4
Ensure Effective
& Efficient PRAC
Operations
Figure 1. PRAC Mission, Vision, and Goals

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!
PRAC Accomplishments
The PRAC was established to serve the
American public by promoting transparency
and facilitating coordinated oversight of the
Federal Government’s COVID-19 pandemic
response and associated spending. Our
goals are to detect fraud, waste, abuse, and
mismanagement and to identify and mitigate
major risks that cross program and agency
boundaries. We aim to serve as the eyes and
ears of the American public, monitoring the
government’s pandemic response spending
and reporting accessible, timely, accurate,
comprehensive data that can be translated into
actionable insights. The PRAC’s Strategic Plan
for 2020 through 2025 identifies the following
goals to carry out PRAC’s mission and vision
(see Figure 2).
Redesigned
website
PandemicOversight.gov
1
Promote
Transparency
Lessons Learned
Report
New issue group
on identity fraud
2
Promote
Coordinated,
Comprehensive
Oversight
Pandemic Analytics
Center of Excellence
HUD OIG/PRAC Fraud
Risk Assessment
3
Prevent &
Detect Fraud,
Waste, Abuse, &
Mismanagement
33 new
employees hired
4
Ensure Effective
& Efficient PRAC
Operations
Figure 2. PRAC’s Accomplishments Aligned to Strategic Goals

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Goal One: Promote Transparency
Provide the Public with Timely Data and
Information on Covered Funds and the
Coronavirus Response
Transparency is core to the PRAC mission laid
out by Congress in the CARES Act. We continue
to explore ways to engage the public and
empower them to act as citizen watchdogs.
We do this primarily through our website,
PandemicOversight.gov, and public events.
Our website includes important information
about the PRAC and makes publicly available a
wide range of data related to how emergency
pandemic funds are spent. The website includes
interactive dashboards, enabling anyone to
search through names and businesses that
received Paycheck Protection Program loans or
money from the Coronavirus Relief Fund. This
gives the power of oversight to the public to
search through trillions of dollars’ worth of relief
funding directly from our website.
We recently redesigned our website and created
new features that let the public sift through
complex data with easy-to-use interactive
tools. We recognize the complexity of federal
programs and spending and worked hard to
ensure our new website makes information
accessible and easy to understand. For
example, we created a new feature called Data
Stories that breaks down data in short and
simple stories. We’ve shared stories that define
unfamiliar terms—like “prime recipient”—to
the public and show how much states spent
in emergency rental assistance or how many
businesses had PPP loans forgiven. It’s part of
our commitment to educating the public so they
can understand how their tax dollars are spent.
We also continue to add more data to make
our website the one place to track all pandemic
spending. In June 2021, we worked with the
Department of Health and Human Services
to add data from the Provider Relief Fund, a
$186.5 billion fund to help reimburse hospitals
and health care providers for expenses or lost
revenue due to the pandemic. In July 2021, we
created more data visualizations on the PPP to
include information on which businesses had
their loans forgiven, and for how much.
During the reporting period, 110 reports from
state and local oversight agencies became
available on our website. We will continue to add
more as they are published so the public and
policymakers can see a full inventory of what
federal, state, and local agencies have found
in their oversight of the pandemic response.
For example, an August 2020 report from
the California State Auditor designated the
management of federal pandemic response
funds as high risk. The report states that
California must be able to properly account for
and report on its use of funds, like the costs
of its COVID-19-related emergency protective
measures, to ensure that it maximizes the
reimbursement that FEMA will provide. In
another example, work completed by the
New York Comptroller’s Office summarized
the pandemic’s impact on subway ridership,
highlighting that ridership levels will likely not
reach pre-pandemic levels until sometime in
2021.
During the reporting period we also began
co-sponsoring a virtual event series with the
National Academy for Public Administration. It
features experts from academia, think tanks,
and non-profits that discuss the impact of
pandemic relief, like rental assistance, in
ACCOMPLISHMENTS

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underserved communities. We share videos
of these events online, and we’ll continue this
series to increase the public’s awareness of how
their tax dollars are being spent and promote
ideas that may improve the government’s
response to this crisis.
We also keep Congress informed of our
oversight efforts. In July 2021, the PRAC
Chair testified before the U.S. House of
Representatives Committee on Transportation
and Infrastructure about the federal response to
the COVID-19 pandemic, areas for improvement,
and the impact of pandemic relief on the
transportation and infrastructure sectors and
their workers. We regularly brief congressional
staff on the status of our work and our oversight
findings. In September 2021, we issued a
lessons learned report that summarized the
work done across the pandemic oversight
community. It highlighted issues, like self-
certification, that our member IGs found led
to potential fraud in separate relief programs
run by the Small Business Administration and
the Department of Labor. As the PRAC and our
members issue more work, we will update the
report so that policymakers are made aware of
opportunities to improve the response to the
pandemic.
ACCOMPLISHMENTS

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Goal Two:
Promote Coordinated, Comprehensive Oversight
Facilitate Exceptional Coordination and
Collaboration to Ensure High-Impact Results
The PRAC has established five subcommittees
and four issue groups (healthcare, financial
institutions, data sharing, and identity fraud
reduction & redress) to share ongoing oversight
and accountability efforts, best practices, and
lessons learned among our 22 member IGs.
These efforts include:
•	 Ongoing reviews of multi-dipping, or
recipients of pandemic funds using multiple
sources of funds for the same purpose,
•	 A PPP working group that discusses
outcomes from oversight and inspections of
fraud and misuse,
•	 Sharing of data analytics and data across
the pandemic response community to
create a more cohesive response to
pandemic oversight, and,
•	 State and local coordination with the federal
community (including the Government
Accountability Office) on high risks and
areas of concern.
The Identity Fraud Reduction & Redress issue
group formed in July 2021 and brings together
six IGs that are members of the PRAC. The
group is taking a holistic approach to help
reduce identity fraud in government programs
with an emphasis on assisting victims in
recovering from what can be devastating
impacts from identity fraud. The public are
often twice victimized in pandemic identity theft
schemes: once when their personal information
is stolen, and again when the benefits are
diverted to the pockets of scammers and
thieves.
We also created an interactive timeline on our
website to raise public awareness of identity
theft in pandemic relief programs. Identity
theft is a significant threat that cuts across
agency and program boundaries. According to
the Federal Trade Commission, identity thieves
targeted pandemic unemployment insurance
benefits in record numbers, with over 394,000
people reporting that their personal information
was misused to apply for a government benefit—
an increase of nearly 3,000% from 2019. Our
timeline shows how watchdogs at all levels of
government are working to mitigate this issue.
Ensure Efficient Sharing of Data, Analytics, and
Other Information
With the funding Congress provided in the
American Rescue Plan Act, we launched the
Pandemic Analytics Center of Excellence (the
PACE) to deliver analytic, audit, and investigative
support to the oversight community. We’ve
acquired dozens of public and non-public
federal datasets and shared them with 29
IGs to help investigators find fraud across
relief programs. We’ve brought in the best and
brightest data science talent and have trained
and placed 15 data science fellows with our
members to help analyze pandemic relief data.
The PACE is currently supporting the
Department of the Treasury Office of Inspector
General (OIG) in its oversight of the Coronavirus
Relief Fund, a $150 billion program created
to help state, local, and Tribal governments
respond to the pandemic. It’s a new program
ACCOMPLISHMENTS

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APPENDICES
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that requires data to be reported by more
than 700 recipients (who receive data from
thousands and thousands of subrecipients).
The PACE is helping to perfect the data being
reported, and then applying a risk scoring
model that flags recipients for potential
investigation based on numerous factors. Some
of these risk factors look to see if a recipient
has been debarred from doing business with
the government, if they have a foreign address,
or if they are “double dipping” and getting
money from other pandemic relief programs.
Another risk modeling project from the PACE
is being used to help the Small Business
Administration OIG triage the huge increase in
hotline complaints they experienced during the
pandemic. They typically get less than 1,000
complaints per year but are now receiving
complaints at a rate of 6,000 per week. The
PACE is saving them time by helping them
assess which complaints are worth pursuing.
We also built a sophisticated analytic tool
that can help IGs identify a certain type of
complaint, even if the underlying data is missing
or incomplete. For example, the PACE helped
review a large portion of over 200,000 SBA
OIG hotline complaints and found that 40% are
estimated to be related to identity theft.
In June 2021, the PACE hosted a Data Analytics
Expo for the oversight community to highlight
current analytic tools, standards, and practices.
In July 2021, the PRAC’s Data Sharing issue
group held an International Data Forum with
counterparts from the United Kingdom and
Australia that featured discussion of pandemic
relief programs in each country, the challenges
faced in overseeing those relief programs, and
how innovative approaches to data sharing
and analytics allowed officials to address those
challenges.
Foster Sound Stewardship of Covered Funds
and Programs
Efficient and effective management and
administration of taxpayer-funded programs
are essential to ensure that coronavirus
relief programs provide relief to intended
individuals and businesses. Because of the
size and scale of the financial response to the
pandemic, numerous federal agencies awarded
contracts for critical goods and services to
support federal, state, and local response
efforts. Contracting during emergencies can
present unique challenges, as officials may
face pressure to provide goods and services as
quickly as possible, which can result in fraud
and improper payments.
In July 2021, we issued a report that
examined the pandemic’s impact on federal
contracting. We found that between April 1,
2020, and September 30, 2020, $4.4 billion
worth of pandemic response contracts went
to businesses or individuals who had never
worked with the government. Approximately
$128 million (3%) was deobligated, meaning
that funds were removed from contracts for
performance reasons such as failure to meet
requirements or complete contract terms.
Another unique challenge the pandemic caused
was limiting the transmission of the coronavirus
in correctional and detention facilities
maintained and operated by the Departments
of Justice, Homeland Security, and the
Interior. In May 2021, we issued a report that
summarized the work from those OIGs related
to preventing the spread and mitigating the
impact of the coronavirus in federal correctional
and detention facilities. The report notes that
some facilities were not designed to enable
social distancing and staffing shortages made
it difficult to implement strategies to reduce the
spread of the virus.
ACCOMPLISHMENTS

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APPENDICES
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Goal Three:
Prevent & Detect Fraud, Waste, Abuse, & Mismanagement
Hold Wrongdoers Accountable
The PRAC’s Fraud Task Force serves as a
resource for the IG community by surging
investigative resources into areas with the
greatest need: pandemic loan fraud. We have
34 agents from nine OIGs who have been
detailed to work on Task Force cases. These
agents are located around the country and
are working cases that would otherwise go
unaddressed due to the scale of the fraud we
are seeing.
The idea behind our Task Force is to harness
the expertise of the oversight community
and attack this problem with every tool we
have: criminal, civil, forfeitures of money and
property, suspension and debarments. Our
PRAC Fraud Task Force works closely with
other initiatives to combat pandemic fraud
such as the Department of Justice COVID-19
Fraud Enforcement Task Force. The Pandemic
Analytics Center of Excellence provides
investigative support to the Task Force, flagging
anomalies or potential leads in pandemic relief
data.
Mitigate Major Risks That Cut Across Program
Boundaries
The PRAC works with our members to identify
emerging fraud risks created by the pandemic.
During the reporting period, we partnered with
the Housing & Urban Development (HUD) OIG
to help protect more than $9 billion that went to
the Community Development Block Grant and
Emergency Solutions Grant programs.
In a recent report, HUD OIG and the PRAC
identified 31 fraud schemes more likely to
occur during the pandemic. For example,
ghost employees (when an individual submits
requests for reimbursement for employees
who either don’t exist or are not on payroll)
have been a common fraud scheme during
the pandemic because social distancing
has made onsite monitoring and physical
inspection by HUD officials more difficult. Many
recipients of HUD funds also rely on numerous
subcontractors for services, increasing the
likelihood of kickbacks during the pandemic
due to the increase in funding and recipients.
By documenting these different fraud schemes,
HUD OIG and the PRAC discovered insights that
can be shared with other agencies that are
reviewing fraud cases in other pandemic relief
programs.
We continually work with the Office of
Management & Budget (OMB), the American
Rescue Plan implementation team, and partner
IGs to address issues with pandemic relief data
and opportunities to enhance payment integrity.
In April 2021, we issued a Joint Alert with OMB
on payment integrity. The alert identifies risk
factors and mitigating strategies that agencies
can consider when assessing impact to their
respective programs. In July 2021, we issued
a second Joint Alert with OMB, this time
emphasizing the benefits of using automation
and data analytics in reducing the risk of
improper payments.
In August 2021, we worked closely with the
Department of Labor Office of Inspector
General on facilitating access for Department of
Labor Inspector General and the PRAC to state
workforce agencies’ data on unemployment
insurance programs and referrals of suspected
unemployment insurance fraud.
ACCOMPLISHMENTS

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Goal Four:
Ensure Effective and Efficient PRAC Operations
Build a Diverse Team of Innovative Thought
Leaders
To recruit and retain the best candidates,
provide a positive work environment, and
mitigate the risk of current and future
pandemic-related workplace disruptions,
the PRAC is organized and managed as a
distributed workforce in a virtual workplace.
During the reporting period, we opened a
safe and modest office in Washington, DC
that enables employees to collaborate when
necessary.
We also created an internal wellness
committee, an employee-led initiative that
advocates for a positive workplace culture. The
committee’s mission is to create a professional
environment that supports social, physical,
and mental wellbeing and ensures that our
policies advance equity, inclusion, diversity, and
accessibility.
The PRAC also hired a human resources
specialist to streamline and organize our
administrative functions. This has been crucial
as we onboard additional staff in each of our
lines of business. Between April 1, 2021, and
September 30, 2021, 33 new PRAC employees
were hired. We also hired a dedicated
information technology support specialist
to improve processes and ensure the PRAC
maximizes the technological advantages of a
remote workforce.
Support the Independent Oversight of
Inspectors General
The PRAC is mindful of the complexity of the
federal programs involved in the pandemic
response and the need for deep programmatic
expertise in these programs to ensure efficient
and effective auditing and review. Inspectors
General have specialized expertise and
institutional knowledge regarding the programs
of their respective agencies and the most
effective oversight methods for those programs.
This expertise, experience, credibility, and
institutional knowledge is critical to fulfilling
the PRAC’s mission. Accordingly, the PRAC
relies on the existing expertise and experience
of individual agency IGs while respecting
their autonomy to conduct their own audits or
investigations.
ACCOMPLISHMENTS

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APPENDICES
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Holding Wrongdoers Accountable
Through Investigations
A key role of OIGs is to support law enforcement in pursuing fraud investigations and criminal
enforcement. A total of 14 OIGs have indictments/complaints, arrests, and/or convictions from April
1, 2021, through September 30, 2021, related to the federal government’s COVID-19 pandemic
response. The following section provides the total number of accountability actions organized by
agency and highlights cases categorized by criminal activity.
Percentage of Cases by Pandemic Relief Program
(April 1, 2021, through September 30, 2021)
Program Area
Percentage of Cases by Program
Paycheck Protection Program
49%
Pandemic Unemployment
45%
Economic Injury Disaster Loans
27%
Health & Safety (Vaccination, Testing, PPE, Bio)
7%
Other (Coronavirus Food Assistance Program,
Price Gouging, Economic Impact Payments)
1%
Source: Assembled by the PRAC from DOJ RSS Feed.
Note: The percentages above credit all agencies involved in a single case in the individual totals. Combined totals only count
unique totals; therefore, the total count will not equal the total of each OIG’s statistics.

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APPENDICES
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Investigative Results (April 1, 2021, through September 30, 2021)
Indictments/
Criminal Complaints
(# of Defendants)
Arrests
Convictions
U.S. Agency for International Development
0
1
1
Department of Agriculture
0
1
1
Department of Homeland Security
13
9
8
Department of Labor
312
312
99
Department of the Treasury
1
0
1
Department of Veterans Affairs
2
2
1
Federal Deposit Insurance Corporation
26
15
23
Federal Housing Finance Agency
5
2
13
Federal Reserve Board
27
15
27
Department of Health and Human Services
26
0
6
Small Business Administration
98
69
64
Social Security Administration
20
0
1
U.S. Postal Service
1
0
0
Treasury Inspector General for Tax Administration
13
15
23
Source: Assembled by the PRAC from DOJ RSS Feed
Note: The percentages above credit all agencies involved in a single case in the individual totals. Combined totals only count
unique totals, and therefore, the total count will not equal the total of each OIG’s statistics.
HOLDING WRONGDOERS
ACCOUNTABLE
Paycheck Protection Program/Economic Injury Disaster Loan
Case Highlights
Department of the Treasury (Treasury) OIG
Middlesex Man Admits Paycheck Protection
Program Fraud Scheme and Obtaining Funds
from a Deposited Stolen and Altered U.S.
Treasury Check
The defendant pled guilty to fraudulently receiving
Payment Protection Program (PPP) funds and
depositing a stolen and altered U.S. Treasury
check and was charged with bank fraud and theft
of government funds. The defendant devised a
scheme through which a stolen and altered
U.S. Treasury check was deposited into a
corporate bank account he created in the
name of a business. The check was altered
to be made payable to that business in the
amount of $211,886 and was then deposited
into an account the defendant controlled.
The defendant later withdrew or transferred
the stolen proceeds from the bank account
before the bank could detect the fraud.

Semiannual Report to Congress  |  APRIL 1, 2021–SEPTEMBER 30, 2021
13
APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

HOLDING
WRONGDOERS
ACCOUNTABLE
INSIGHTS THROUGH
OVERSIGHT
REPORTS
On June 24, 2020, the defendant caused to be
submitted a fraudulent PPP loan application to
a lender on behalf of a company, a purported
business that the defendant controlled. The
defendants PPP application falsely represented
the number of employees, the monthly payroll
expenses, mortgage/lease expenses that
they possessed. The company did not, in fact,
employ any employees, nor did it incur payroll
or utility expenses. Based on the defendant’s
misrepresentations, the defendants PPP
loan application was approved in the amount
$481,502. The defendant then converted the
proceeds for his own use.
Federal Deposit Insurance Corporation (FDIC) OIG
Florida Man Sentenced After Fraudulently
Obtaining $3.9 Million in PPP Loans
The defendant was sentenced in May 2021 to
more than 6 years in prison for fraudulently
obtaining approximately $3.9 million in
Paycheck Protection Program (PPP) loans
and using those funds, in part, to purchase
a $318,000 Lamborghini luxury car for
himself, pleading guilty to one count of wire
fraud in February 2021. The defendant
submitted multiple PPP applications to a PPP-
participating lender, claiming to have had
dozens of employees and millions of dollars
in monthly payroll. In addition to submitting
false and fraudulent IRS forms to support the
applications, the defendant also assisted other
individuals in obtaining fraudulent PPP loans.
As part of the sentence, the defendant was
ordered to forfeit the $3.4 million in fraudulent
loan proceeds that law enforcement seized
and the 2020 Lamborghini Huracan that was
purchased for approximately $318,000.
FDIC OIG
Texas Man Sentenced for $24 Million Covid-19
Relief Fraud Scheme
The defendant was sentenced in July 2021 to
more than 11 years in prison for wire fraud and
money-laundering offenses in connection with
his fraudulent scheme to obtain approximately
$24.8 million in forgivable Paycheck Protection
Program (PPP) loans.  The defendant submitted
15 fraudulent applications under names
of various purported businesses he owned
or controlled to eight different lenders.  He
claimed his businesses had numerous
employees and hundreds of thousands of
dollars in payroll expenses when, in fact,
no business had employees or paid wages
consistent with the amounts claimed in the
PPP applications.  As part of his guilty plea in
March 2021, the defendant agreed to forfeit
eight homes, six luxury vehicles, and more than
$9 million in fraudulent proceeds.  He was also
ordered to pay over $17 million in restitution at
sentencing.
Federal Housing Finance Agency OIG
Georgia Woman Pleads Guilty to Bank Fraud
For COVID-Relief Fraud Scheme
In August 2021, the defendant pleaded guilty in
the Northern District of Georgia for perpetrating
a scheme to fraudulently obtain more than
$7.9 million in Paycheck Protection Program
(PPP) loans guaranteed by the Small Business
Administration (SBA) under the Coronavirus Aid,
Relief, and Economic Security (CARES) Act.
According to court documents, the defendant
submitted six fraudulent PPP loan applications
to four different lenders on behalf of entities
she owned or controlled, namely: Georgia
Nephrology Physician Associated, United
HOLDING WRONGDOERS
ACCOUNTABLE

Semiannual Report to Congress  |  APRIL 1, 2021–SEPTEMBER 30, 2021
14
APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

HOLDING
WRONGDOERS
ACCOUNTABLE
INSIGHTS THROUGH
OVERSIGHT
REPORTS
Healthcare Group & Co., Nephrology Network
Group LLC, First Corporate International,
Corkrum Consolidated Inc., and Kiwi
International Inc. Through the six PPP loan
applications, the defendant fraudulently sought
more than $7.9 million in PPP loan funds, of
which more than $6 million was disbursed to
accounts controlled by the defendant.
The defendant also falsely represented the
number of employees and payroll expenses
in each of the six PPP loan applications. To
support the fraudulent PPP loan applications,
the defendant submitted fraudulent tax records,
bank statements, and payroll reports.
The Department of Justice, working with
the Federal Housing Finance Agency and
the Federal Bureau of Investigations seized
and recovered approximately $2.1 million of
the disbursed PPP funds in this matter. An
additional $1.6 million of the disbursed PPP
funds were seized by a bank and returned to
the lender.
Federal Reserve Board
Two Texas Men And One Oregon Man Charged
With Fraud Scheme To Obtain Over $14 Million
In Covid-Relief Loans
Three individuals were charged with
participating in a fraudulent scheme to obtain
over $14 million in Government-guaranteed
loans designed to provide relief to small
businesses during the novel coronavirus/
COVID-19 pandemic.
This scheme resulted in the approval of
fraudulently procured loans for two companies
both located in the Southern District of New
York, totaling approximately $4 million, and
the distribution of the proceeds of these
fraudulently obtained funds to a series of bank
accounts located in the United States and
elsewhere, including bank accounts controlled
by the defendants.
Small Business Administration OIG
D.C. Man Indicted on Charges in Scheme to
Steal More Than $17 Million in COVID-19 Relief
Funds
The defendant was indicted on charges
alleging that he perpetrated a scheme to steal
more than $17 million in Paycheck Protection
Program (PPP) and Economic Injury and
Disaster Loan (EIDL) funds where he devised
a scheme to use tax returns stolen from a
Washington, D.C. consulting firm and stolen
identities to fraudulently obtain more than $17
million in name of his company, Alias Systems,
LLC. The indictment alleges that the   defendant
attempted to steal a total of $17 million and
successfully stole more than $2.3 million from
PPP and EIDL programs.
The defendant carried out the scheme from at
least July 2020 to July 2021 in which he filed
at least 13 fraudulent PPP loan applications
and an EIDL application in the name of Alias
Systems, LLC, using stolen identities and stolen
tax returns that were fraudulently doctored to
appear to be tax returns of Alias Systems, LLC.
The defendant was charged with five counts of
wire fraud, 14 counts of engaging in monetary
transactions in criminally derived property, 14
counts of aggravated identity theft, and one
count of destruction or removal of property to
prevent seizure.

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APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

HOLDING
WRONGDOERS
ACCOUNTABLE
INSIGHTS THROUGH
OVERSIGHT
REPORTS
Social Security Administration OIG
New York City Man Charged with Nearly $4
Million COVID-19 Relief Fraud Scheme and
Money Laundering
A criminal complaint was filed charging the
defendant dual-resident of New York and Florida
with fraudulently obtaining and laundering
nearly $4 million in funds from the COVID-19
relief Paycheck Protection Program (PPP).
According to court documents, the defendant
is alleged to have used a variety of false
representations to fraudulently obtain more
than $3.8 million in federal COVID-19 PPP
funds. To obtain the loan money, the defendant
is alleged to have submitted eight falsified
loan applications to numerous lenders on
behalf of five of the defendant’s businesses.
It is further alleged that to obtain the loans
the defendant submitted false information,
including the number of his employees, federal
tax returns for his businesses, and his payroll
documentation, and he certified that he would
use the loan money only for business-related
purposes. After fraudulently obtaining the loans,
the defendant is alleged to have laundered and
misused the loan proceeds by, among other
things, transferring those proceeds to brokerage
accounts and placing more than $3 million in
losing stock trades.
Treasury Inspector General for Tax Administration
Twenty-two defendants charged in connection
with alleged $11.1 million Paycheck Protection
Program fraud scheme
Twenty-two individuals were charged in
connection with a fraudulent scheme to obtain
approximately $11.1 million in Paycheck
Protection Program (PPP) loans and to use
those funds to purchase luxury vehicles, jewelry,
and other personal items. From April 2020
through August 2020, the conspirators in the
scheme allegedly submitted, or assisted in
the submission of, PPP loan applications on
behalf of fourteen businesses, seeking loans of
approximately $700,000 - $850,000 for each
company.
In the loan applications, the defendants
certified that each applicant business was
in operation on February 15, 2020, and had
employees for whom it paid salaries and payroll
taxes or paid independent contractors; that
the funds would be used to retain workers
and maintain payroll or make mortgage
interest payments, lease payments, and utility
payments; and that the information provided in
the application and in all supporting documents
and forms was true and accurate in all material
respects.
The PPP loan applications reported that each
business had between 59 and 69 employees
and approximately $295,000 to $342,000
in average monthly payroll expenses. To
support these payroll figures, each business’s
loan application was accompanied by an
Internal Revenue Service Form 941, which
employers use to report payroll taxes, for each
quarter of 2019 and by a bank statement or
a spreadsheet reflecting payroll expenses.
In reality, however, none of the businesses
had employees or payroll expenses. After
the PPP loan proceeds were deposited into
the businesses’ accounts, the businesses
transferred more than $5.5 million of the PPP
loan proceeds into accounts controlled by the
scheme’s mastermind.

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16
APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

HOLDING
WRONGDOERS
ACCOUNTABLE
INSIGHTS THROUGH
OVERSIGHT
REPORTS
Pandemic Unemployment Case Highlights
Department of Homeland Security OIG
Virginia Woman Pleads Guilty to Fraudulently
Obtaining COVID-Related Unemployment
Benefits for Prison Inmates
June 2021, the defendant pled guilty to
mail fraud for their role in a conspiracy
to fraudulently obtain pandemic-related
unemployment benefits for 22 prison
inmates, which she shared with the inmates’
beneficiaries. The defendant conspired with
inmates at Baskerville Correctional Center to
collect the Personally Identifiable Information
(PII) of inmates to fraudulently apply for Virginia
unemployment benefits from June 2020 to
January 2021, during the COVID-19 pandemic.
The defendant with the assistance of inmate co-
conspirators, submitted successful applications
for Virginia unemployment benefits for at least
22 inmates resulting in the dispersal of at least
$223,984.72 in fraudulent benefits.
The applications contained several false
statements such as a false physical address,
rather than the address of the correctional
facility at which the inmates were actually living;
a false last employer; and a false certification
that the inmates were ready, willing, and able
to work in the event employment became
available.
Department of Labor OIG
Three Maryland Men Facing Federal Indictment
for Filing More Than 600 Fraudulent Claims
for Unemployment Resulting in Losses of More
Than $2.7 Million
In September 2021, a grand jury returned
an indictment charging three Maryland men
on federal charges related to a scheme to
fraudulently obtain more than $2.7 million
in unemployment benefits. According to the
indictment, from February 2020 through
February 2021, the defendants allegedly
conspired to impersonate victims to submit
fraudulent UI claims. To accomplish this,
the defendants allegedly obtained victims’
personally identifiable information (PII) of
victims, often under false pretenses. The
defendants allegedly shared the PII amongst
themselves and with others and used the
victims’ PII to submit fraudulent applications
for UI benefits in Maryland, Michigan, and
Tennessee.
The indictment alleges that the fraudulent
applications contained false representations
concerning the victims’ contact information,
addresses, work availability, and whether they
were newly unemployed.  The defendants
allegedly used false physical addresses for UI
applications, so that any UI benefits paid by
the state would be received by the defendants,
rather than by the victims. In some instances,
the defendants are alleged to have used their
own physical addresses in UI applications
to receive the victims’ UI benefits. In other
instances, the defendants allegedly used the
addresses of nearby vacant residences to avoid
detection by government authorities.
As described in the indictment, once the
defendants received the fraudulently obtained
payments in the form of debit cards, they
made cash withdrawals and other transactions
throughout Maryland and used the cash for
their own benefit and for the benefit of others
who also were not entitled to the money. As
HOLDING WRONGDOERS
ACCOUNTABLE

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17
APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

HOLDING
WRONGDOERS
ACCOUNTABLE
INSIGHTS THROUGH
OVERSIGHT
REPORTS
a result of the conspiracy, the defendants
and co-conspirators allegedly caused at least
600 fraudulent UI claims to be submitted in
Maryland, Michigan, Tennessee, and at least
sixteen other states, resulting in more than
S2.7 million in actual losses
U.S. Postal Service OIG
Twelve Individuals Indicted And Arrested
For Unemployment Benefits And Pandemic
Unemployment Assistance (PUA) Fraud
On April 7 and 8, 2021, the Federal Grand
Jury in the District of Puerto Rico returned
eleven separate indictments charging twelve
(12) individuals with fraud against the
Unemployment Insurance and Pandemic
Unemployment Assistance Program. According
to the indictments, the defendants engaged
in schemes to defraud the Puerto Rico
Department of Labor and Human Resources
by submitting fraudulent applications for
unemployment insurance benefits, including
Pandemic Unemployment Assistance (PUA)
benefits. The false information submitted
included false social security numbers and false
employment information. The loss associated
with these cases totals $419,580.
In separate indictment, two defendants, one of
which was a U.S. Postal Employee were charged
with conspiracy to commit mail fraud, mail
fraud and theft of government moneys in an
amount of $11,388. The defendants conspired
to fraudulently represent that one of the
individuals was an unemployed barber, when
in fact he was a mail carrier employed by the
United States Postal Service.
HOLDING WRONGDOERS
ACCOUNTABLE

Semiannual Report to Congress  |  APRIL 1, 2021–SEPTEMBER 30, 2021
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APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

HOLDING
WRONGDOERS
ACCOUNTABLE
INSIGHTS THROUGH
OVERSIGHT
REPORTS
Health Care/Medicare Fraud Case Highlights
Department of Health and Human Services (HHS)
OIG
National Health Care Fraud Enforcement Action
Results in Charges Involving Over $1.4 Billion
in Alleged Losses
In September 2021, the Department of Justice
announced criminal charges against 138
defendants, including 42 doctors, nurses, and
other licensed medical professionals, in 31
federal districts across the United States for
their alleged participation in various health care
fraud schemes that resulted in approximately
$1.4 billion in alleged losses.
The charges target approximately $1.1 billion in
telefraud, $29 million in COVID-19 health care
fraud, $133 million connected to substance
abuse treatment facilities, or “sober homes,”
and $160 million connected to other health
care fraud and illegal opioid distribution
schemes across the country.
The enforcement actions were led and
coordinated by the Health Care Fraud Unit
of the Criminal Division’s Fraud Section,
in conjunction with its Health Care Fraud
and Appalachian Regional Prescription
Opioid (ARPO) Strike Force program and its
core partners, the U.S. Attorneys’ Offices,
Department of Health and Human Services
OIG, Federal Bureau of Investigations, and Drug
Enforcement Administration.
Nine defendants in the cases announced
engaged in various health care fraud schemes
designed to exploit the COVID-19 pandemic,
which resulted in the submission of over $29
million in false billings. Defendants allegedly
misused patient information to submit claims to
Medicare for unrelated, medically unnecessary,
and expensive laboratory tests, including
cancer genetic testing. The enforcement
action also included criminal charges against
five defendants who allegedly engaged in the
misuse of Provider Relief Fund monies.
HOLDING WRONGDOERS
ACCOUNTABLE

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19
APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

HOLDING
WRONGDOERS
ACCOUNTABLE
INSIGHTS THROUGH
OVERSIGHT
REPORTS
Other Case Highlights
U.S. Agency for International Development OIG
Florida Man Charged With Stealing Ventilators
Intended for Critically Ill COVID-19 Patients in
El Salvador Arrested in Texas
The defendant was arrested May 2021 in an
indictment charging him with stealing 192 U.S.
government-owned medical ventilators worth
about three million dollars. According to the
indictment he defendants stole a tractor trailer
loaded with the medical ventilators, during
its transport by truck to Miami International
Airport. USAID had acquired the ventilators
and was sending them to the Government of
El Salvador as part of an aid program to treat
critically ill COVID-19 patients there. Following
the investigation, law enforcement recovered
191 of the stolen ventilators.
The defendants were charged with federal
conspiracy, possession of stolen goods being
shipped interstate, and theft of government
property and one pleaded guilty to theft of
government property in September 2021.
U.S. Department of Agriculture
Stonecrest man sentenced to jail for
defrauding the USDA COVID-19 Relief Program
The defendant was sentenced to two years
and six months in prison for defrauding the
USDA’s Coronavirus Food Relief Program and
attempting to defraud the IRS’s COVID-19 relief
program. The defendant submitted a false claim
to the USDA’s Coronavirus Food Assistance
Program (CFAP) for the claimed loss of livestock
at his commercial farming operation.  CFAP
provided direct relief to producers who faced
price declines and additional marketing costs
due to COVID-19.
The defendant did not own or operate a
commercial farming operation and did not
have losses associated with any livestock when
he made a claim under CFAP.  The defendant
submitted a fraudulent IRS Form 7200, which,
when used legitimately, allows an employer
to request an advance payment of employer
credits under the Families First Coronavirus
Response Act (FFCRA). In total, the defendant
attempted to obtain over $1.5 million in
COVID-19 relief funding.
Department of Homeland Security (DHS) OIG and
Veterans Affairs OIG
Two Defendants Charged in Separate, Covid-19
Vaccination Record Card Frauds
According to the complaint, the defendant
was responsible for stealing or embezzling
authentic Covid-19 Vaccination Record Cards
from the VA hospital—along with vaccine lot
numbers necessary to make the cards appear
legitimate—and then reselling those cards and
information to individuals within the metro
Detroit community. The complaint alleges that
the defendants theft of Covid-19 Vaccination
Record Cards began at least as early as May of
2021 and continued through September 2021.
The defendant sold the cards for $150-$200
each and communicated with buyers primarily
via Facebook Messenger.

HOLDING WRONGDOERS
ACCOUNTABLE

Semiannual Report to Congress  |  APRIL 1, 2021–SEPTEMBER 30, 2021
20
APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

HOLDING
WRONGDOERS
ACCOUNTABLE
INSIGHTS THROUGH
OVERSIGHT
REPORTS
Insights Through Oversight Reports
During the reporting period, 30 OIGs issued
119 oversight reports1 related to the COVID-19
pandemic response. OIGs continue to look for
new ways to conduct their work and coordinate
across agency boundaries—such as through the
issuance of the PRAC’s COVID-19 in correctional
and detention facilitates capping report which
pulled in insights from OIGs at the Departments
of Homeland Security, Justice, and the Interior.
OIGs have also directed their focus on building
upon, and finding opportunities to expand,
previous pandemic oversight work. As pandemic
programs mature, they have started looking
forward to establishing best practices and
identifying lessons learned that can apply
broadly to future situations as well.
This section identifies the total number of
issued reports for each top challenge area
and presents summaries of key reports. For a
complete list and summaries of all oversight
reports issued, see Appendix B on page 38.
Oversight Reports from April 1, 2021 through September 30, 2021
1 These oversight reports include all reports, memorandums, and advisories issued by the OIGs related to coronavirus response funding and programs.
Office of Inspector General
Report Count
U.S. Agency for International Development
3
Consumer Product Safety Commission
1
Department of Agriculture
4
Department of Commerce
2
Department of Defense
8
Department of the Interior
1
Department of Education
5
Department of Health and Human Services
7
Department of Homeland Security
8
Department of Housing and Urban Development
4
Department of Justice
3
Department of Labor
6
Department of State
2
Department of the Treasury
2
Department of Veterans Affairs
12
Environmental Protection Agency
5
General Services Administration
1
Farm Credit Administration
1
Federal Reserve Board
2
National Railroad Passenger Corporation
1
Office of Personnel Management
1
National Science Foundation
9
Pandemic Response Accountability Committee
2
U.S. Peace Corps
1
Small Business Administration
4
Special Inspector General for Pandemic Recovery
5
Special Inspector General for the Trouble Asset Relief Program
1
Social Security Administration
3
U.S. Postal Service
4
U.S. Treasury Inspector General for Tax Administration
11
Total Reports
119

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APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

HOLDING
WRONGDOERS
ACCOUNTABLE
INSIGHTS THROUGH
OVERSIGHT
REPORTS
Challenge:
Preventing and Detecting Fraud against Government Programs
Total Reports          3
Department of Labor (DOL) OIG, The U.S.
Department of Labor Complied with The
Payment Integrity Information Act for FY
2020, but Reported Unemployment Insurance
Information Did Not Represent Total Program
Year Expenses, 22-21-007-13-001, August 6,
2021
DOL’s reported Unemployment Insurance (UI)
improper payment rate of 9.17% was compliant
with Payment Integrity Information Act of 2019;
however, it was not representative of total
unemployment expenses for program year
2020. The improper payment rate excluded
information on: (1) CARES Act unemployment
insurance programs because these programs
had not been in existence for more than 12
months at the time; and (2) the fourth quarter
regular UI expenses because DOL received
approval from the Office of Management and
Budget (OMB) to utilize the results from the first
three quarters of the program year to reduce
the burden on program resources. The DOL
OIG’s initial pandemic audit and investigation
work indicated that the UI programs’ improper
payment rates, including fraudulent payments,
is likely higher than 10%.
DOL OIG, Alert Memorandum: The Employment
and Training Administration Needs to Issue
Guidance to Ensure State Workforce Agencies
Provide Requested Unemployment Insurance
Data to the Office of Inspector General, 19-21-
005-03-315, June 16, 2021
DOL’s interpretation of federal regulations and
the Employment and Training Administration’s
subsequent guidance to state workforce
agencies limited the state workforce agencies’
mandatory sharing of UI information in
only those circumstances where DOL OIG
was conducting an investigation into a
particular instance of suspected UI fraud.
This is contrary to the Inspector General
Act, which authorizes DOL OIG to obtain UI
information for all purposes (e.g., audit and
investigative) to prevent and detect fraud,
waste, and abuse within the UI program. These
disclosure limitations have prevented DOL
OIG from obtaining critical UI claim and wage
data needed to conduct timely investigative
and audit work and fulfill our oversight
responsibilities.
OVERSIGHT REPORTS
The unemployment insurance improper payment
rate for program year 2020 did not include CARES
Act programs because the programs had not been
in existence for more than 12 months

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APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

HOLDING
WRONGDOERS
ACCOUNTABLE
INSIGHTS THROUGH
OVERSIGHT
REPORTS
Challenge:
Informing and Protecting the Public against Pandemic-Related Fraud
Total Reports          3
Department of Housing and Urban
Development (HUD) OIG, COVID-19
Forbearance Data in HUD’s Single Family
Default Monitoring System Generally Agreed
With Information Maintained by Loan
Servicers, 2021-KC-0005, August 16, 2021
HUD OIG audited lender reporting of
COVID19 forbearances for Federal Housing
Administration-insured loans in the Single
Family Default Monitoring System. HUD OIG
compared default reporting data from Single
Family Default Monitoring System to loan data
provided by five sampled servicing lenders
that serviced a third of the FHA single-family
portfolio. The HUD OIG audit objective was to
determine whether COVID19 forbearance data
available in the Single Family Default Monitoring
System were consistent with the information
maintained by loan servicers. HUD OIG found
that COVID-19 forbearance data available in
the Single Family Default Monitoring System
were generally consistent with the information
maintained by the loan servicers reviewed.
U.S. Postal Service (USPS) OIG, U.S. Postal
Inspection Service Pandemic Response to Mail
Fraud and Mail Theft, 20-305-R21, May 20,
2021
USPS OIG’s objective was to assess the Postal
Inspection Service’s response to mail fraud
and mail theft during the COVID-19 pandemic.
Overall, USPS OIG found that the Postal
Inspection Service took appropriate action to
respond to mail fraud and mail theft during
the COVID-19 pandemic. For example, the
Mail Fraud Program employees participated in
federal task forces to investigate and disrupt
COVID-19 related scams. Postal inspectors also
coordinated with law enforcement agencies
when Economic Impact Payment checks were
mailed to help prevent mail theft.
Small Business Administration (SBA) OIG,
SBA’s Handling of Identity Theft in the
COVID-19 Economic Injury Disaster Loan
Program, 21-15, May 6, 2021
SBA OIG issued this evaluation report to notify
SBA officials of significant matters regarding
its handling of complaints of identity theft
in the COVID-19 Economic Injury Disaster
Loan (EIDL) program. SBA OIG recommended
the Administrator to direct the Associate
SBA OIG recommended that SBA
review over 150,000 returned billing
statements and resolve any that involve
identity theft, then refer fraudulent
loans to SBA OIG.
Administrator for the Office of Disaster
Assistance, the Chief Financial Officer for
the Office of Performance Management and
Chief Financial Officer, and the Associate
Administrator for the Office of Capital Access to:
(1) develop a process to maintain and track all
identity theft complaints; (2) develop a process
OVERSIGHT REPORTS

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APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

HOLDING
WRONGDOERS
ACCOUNTABLE
INSIGHTS THROUGH
OVERSIGHT
REPORTS
to provide status updates to each complainant
alleging identity theft; and (3) complete and
formalize a process to restore identity theft
victims to their condition prior to the fraud.
The process should include steps to stop the
loan billing statements, prevent delinquency
collections, and release them from loan liability
and Uniform Commercial Code liens. SBA OIG
also recommended that SBA develop a process
to remove any fraudulent loans and related
Uniform Commercial Code filing fees from its
financial records; and to review over 150,000
returned billing statements and resolve any
that involve identity theft, then refer fraudulent
loans to SBA OIG.
Challenge:
Data Transparency and Completeness
Total Reports          5
Department of Health and Human Services
(HHS) OIG, CMS’s COVID-19 Data Included
Required Information From the Vast Majority
of Nursing Homes, but CMS Could Take Actions
To Improve Completeness and Accuracy of the
Data, A-09-20-02005, September 3, 2021
The objective of this audit was to determine
whether the Centers for Medicare & Medicaid
Services’ (CMS’s) COVID-19 data for nursing
homes were complete and accurate. HHS OIG
found that CMS’s COVID-19 data for nursing
homes included the required data from the
vast majority of nursing homes; however, the
data were not complete or accurate for some
facilities. For about 5% of nursing homes, the
data did not include all of the COVID-19 data
that nursing homes were required to report
and/or were not complete or accurate after
CMS performed its quality assurance checks.
Department of Education (ED) OIG, Inconsistent
Grantee and Subgrantee Reporting of
Education Stabilization Fund Subprograms in
the Federal Audit Clearinghouse, F21NF0037,
August 26, 2021
The purpose of this flash report was to share
ED OIG’s observations concerning grantees and
subgrantees inconsistently reporting audit data
on ED’s subprograms, or unique components of
a program, to the Federal Audit Clearinghouse,
the designated repository of single audit data.
ED OIG found that grantees and subgrantees
were not consistently reporting expenditures
of Education Stabilization Fund subprogram
ED OIG found that grantees and
subgrantees were not consistently
reporting expenditures of Education
Stabilization Fund subprogram awards.

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APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

HOLDING
WRONGDOERS
ACCOUNTABLE
INSIGHTS THROUGH
OVERSIGHT
REPORTS
awards in the Federal Audit Clearinghouse.
Specifically, when entering federal award
information into the Data Collection Form,
grantees and subgrantees either (1) did not
identify which Education Stabilization Fund
subprogram their expenditures were awarded
under or (2) used widespread variations of
subprogram identifying information to identify
which subprogram their expenditures were
awarded under.
Challenge:
Federal Workforce Safety
Total Reports          12
Treasury Inspector General for Tax
Administration (TIGTA), Steps Were Taken
to Protect Employee Health and Safety, but
Additional Efforts Are Needed to Ensure
Compliance With Federal Guidelines During
Pandemics, 2021-16-073, September 16,
2021
This audit was initiated to evaluate the actions
the Internal Revenue Service (IRS) has taken
to execute its Pandemic Incident Management
47 percent of IRS employees who
tested positive for COVID-19 were
determined to pose a transmission risk
to other IRS employees.
Plan and protect the health and safety of its
employees during the COVID-19 pandemic.
Overall, the IRS completed necessary actions
related to the requirements outlined in its
Pandemic Incident Management Plan and
continues to take steps to ensure the health
and safety of its employees. In addition, the IRS
leveraged data related to employee infection
and transmission rates, employee telework
eligibility and status, and facility status to
allow for informed decision-making during the
pandemic. Further, as of June 30, 2021, 1,980
(47 percent) of the 4,198 IRS employees who
reported testing positive for COVID-19 were
determined to pose a transmission risk to other
IRS employees.
General Services Administration OIG, PBS Did
Not Always Follow CDC and Internal Guidance
to Limit the Risk of COVID-19 Exposure,
A201018/P/4/R21005, August 26, 2021
The General Services Administration OIG
found that their Public Buildings Service did
not always take appropriate action to limit
the risk of exposure to COVID-19 in its owned
and leased facilities. The General Services
Administration OIG also found that the Public
Buildings Service did not always receive or
provide timely notice of positive COVID-19
incidents in accordance with the Public
OVERSIGHT REPORTS

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APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

HOLDING
WRONGDOERS
ACCOUNTABLE
INSIGHTS THROUGH
OVERSIGHT
REPORTS
Buildings Service’s notification process. As a
result, the Public Buildings Service could not
take appropriate action to clean and disinfect
affected space. Further, building occupants,
contractors, and visitors may have unknowingly
passed through space contaminated by
individuals infected with COVID-19, and been at
increased risk of exposure to and transmission
of the disease.
SBA OIG, Evaluation of SBA’s Coronavirus
Reconstitution Plan, 21-18, July 12, 2021
SBA OIG found that SBA established its
May 2020 COVID-19 Reconstitution Plan
in accordance with applicable federal
guidance. SBA OIG identified issues with the
implementation of the reconstitution plan
that should be addressed to help the agency
safeguard its employees from contracting and
spreading COVID-19 in the workplace. SBA
OIG found the agency did not follow occupancy
procedures for advancing or reverting phases
at its Washington, DC headquarters. SBA also
did not implement exposure tracking protocols
to ensure it consistently traced COVID-19
cases. SBA OIG found the agency did not
consistently notify its staff of presumed or
confirmed COVID-19 cases in the sampling SBA
OIG analyzed. SBA did not consistently contact
potentially exposed personnel and ensure
employees completed 14-day quarantine
periods. SBA replaced the reconstitution
plan with its new COVID-19 Workplace Safety
Plan in February 2021. SBA OIG made one
recommendation for SBA to enforce the
requirements of its new workplace safety
plan by consistently applying procedures
for occupancy and exposure tracking and to
accurately record and maintain supporting
documentation for all reported COVID-19 cases.
Office of Personnel Management (OPM) OIG
Evaluation of OPM’s Response to the COVID-19
Pandemic, 4K-FS-00-20-042, May 6, 2021
In May 2020, OPM issued a Returning to
OPM Facilities Preparedness Guide to assist
managers with the transition to reopen
its offices during the COVID-19 pandemic.
The Guide did not specifically identify when
employees would return to the office but
provided a framework to support OPM
supervisors with guidelines and planning
considerations for evaluating the needs of
employees as OPM returns from a maximum
telework operating status. During OPM
OIG’s evaluation, they determined that: (1)
improvements were needed for processing
COVID-19 incidents; (2) OPM management did
not require workers to wear face coverings;
and (3) OPM needed to implement additional
signage for entering, social distancing, and
routine cleaning and disinfecting at the
Theodore Roosevelt Federal Building.

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APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

HOLDING
WRONGDOERS
ACCOUNTABLE
INSIGHTS THROUGH
OVERSIGHT
REPORTS
Challenge:
Financial Management of Relief Funding
Total Reports          8
Department of Veterans Affairs (VA) OIG,
Medical/Surgical Prime Vendor Contract
Emergency Supply Strategies Available Before
the COVID-19 Pandemic, 20-03075-138, June
14, 2021
VA medical facilities’ demand for PPE increased
dramatically during the COVID-19 pandemic.
VA OIG reviewed how the Veterans Health
Administration (VHA) ensured the Medical/
Surgical Prime Vendor-Next Generation
program and its prime vendors met contract
requirements by offering medical facilities
a no-cost option to develop advance-order
supply lists tailored to catastrophic events
and contingency plans. VA OIG also assessed
By not asking prime vendors to provide
services established in contingency
plans, VA medical facilities missed
opportunities to receive certain
needed medical supplies.
whether facilities took advantage of those
options and strategies and relied on the
contracts to obtain PPE during the pandemic.
All four Medical/Surgical Prime Vendor-
Next Generation prime vendors developed
contingency plans that included the advance-
order list. Three of the four vendors also
offered options to purchase and store medical
supplies in advance. Though the prime
vendors fulfilled their contract requirements,
VA OIG found none of 16 medical facilities
assessed took advantage of those emergency
strategies before the pandemic. Most facility
leaders did not know those plans existed. Most
medical facilities reported maintaining their
own contingency stocks, which were at risk of
quickly depleting. That risk increased when
prime vendors were unable to fulfill orders,
leading staff to purchase medical supplies
on the open market where the VHA’s data
showed they paid higher prices. By not asking
prime vendors to provide services established
in contingency plans, VA medical facilities
missed opportunities to receive certain needed
medical supplies. VA can apply lessons learned
during the pandemic by continuing to refine
its contract requirements for prime vendors to
address catastrophes.
Department of Defense (DoD) OIG, Audit
of the Reimbursement for Department of
Defense Mission Assignments for Coronavirus
Disease–2019 Pandemic Response in the U.S.
Northern Command Area of Responsibility,
DODIG-2021-091, June 9, 2021
The DoD OIG determined that DoD tasked-
unit personnel did not submit timely requests
for partial or final reimbursement from the
Federal Emergency Management Agency for
OVERSIGHT REPORTS
$

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APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

HOLDING
WRONGDOERS
ACCOUNTABLE
INSIGHTS THROUGH
OVERSIGHT
REPORTS
mission assignment support. As of July 31,
2020, DoD Components reported $221.6
million in incurred reimbursable costs for
11 of the 12 COVID-19 pandemic response
mission assignments reviewed, but had not
submitted timely reimbursement requests
for those costs. If DoD tasked-unit personnel
submitted timely and supported reimbursement
requests, then the DoD could have used the
$221.6 million reimbursed by the Federal
Emergency Management Agency to support
DoD operations. Because of the DoD’s untimely
requests for reimbursement, the Federal
Emergency Management Agency could not
accurately report disaster relief funding to
Congress or bill states for their shared portion
of the mission assignment costs.
TIGTA, Implementation of Economic Impact
Payments, 2021-46-034, May 24, 2021
This report presents the results of TIGTA’s
review to assess the IRS Economic Impact
Payment outreach and assistance to
individuals, accuracy of the computation of the
payment, and adequacy of controls to prevent
ineligible individuals from receiving a payment.
TIGTA found that as of May 21, 2020, the IRS
correctly computed 98% of the 157 million
issued Economic Impact Payments. However,
as of July 16, 2020, the IRS had issued over
4.4 million Economic Impact Payments totaling
nearly $5.5 billion to potentially ineligible
individuals. These payments included payments
made to deceased individuals, potentially
nonqualified dependents, nonresidents,
individuals in U.S. Territories (who have also
received payments from the Territories), and
individuals with filing status changes. As of
October 1, 2020, individuals that received
payments but were ineligible voluntarily
returned 65,447 payments totaling more than
$80 million.
OVERSIGHT REPORTS

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APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

HOLDING
WRONGDOERS
ACCOUNTABLE
INSIGHTS THROUGH
OVERSIGHT
REPORTS
Challenge:
Grants and Guaranteed Loan Management
Total Reports          31
Department of Justice (DOJ) OIG, Review of the
Office of Justice Programs’ Administration of
CARES Act Funding, 21-130, September 30,
2021
DOJ OIG reviewed the Office of Justice
Programs’ administration of CARES Act funding
to assess the Office of Justice Programs’
efforts to (1) distribute Coronavirus Emergency
Supplemental Funding awards in a timely and
efficient manner, and (2) review pre-awarded
activities to determine if Coronavirus Emergency
Supplemental Funding awards were made in
accordance with applicable laws, regulations,
and other guidelines. The Office of Justice
Programs was allocated $850 million (84% of
total DOJ appropriations from the CARES Act)
to award Coronavirus Emergency Supplemental
Funding grants for the purposes of preventing,
preparing for, and responding to the COVID-19
pandemic. The DOJ OIG found that the Office
of Justice Programs acted quickly to distribute
CESF funding and that most recipient spending
reviewed appeared allowable under the terms
and conditions of the awards. However, the
DOJ OIG noted that as of March 31, 2021,
nearly a year after the first award was made,
Coronavirus Emergency Supplemental Funding
recipients reported spending or obligating just
40% of the total amount awarded. The DOJ
OIG found that some Office of Justice Program
staff reported that they did not receive training
on the Coronavirus Emergency Supplemental
Funding program or were dissatisfied with
the training they received. Some award
managers reported that Coronavirus Emergency
Supplemental Funding performance reports
do not contain the information necessary to
effectively oversee Coronavirus Emergency
Supplemental Funding awards.
National Science Foundation (NSF) OIG,
Capstone Report: Observations on the OMB
COVID-19 Flexibilities, 21-6-003, August 3,
2021
In response to the COVID-19 pandemic, OMB
issued, and various federal agencies (including
the NSF) implemented, three memoranda
providing temporary administrative flexibilities
for federal financial assistance awards. NSF
OIG engaged a certified public accountant (CPA)
firm to conduct 10 audits of award recipients’
implementation of the COVID-19 flexibilities.
Although the certified public accountant firm
found that NSF award recipients generally
complied with relevant guidance, the report
identifies three common themes observed
during the course of the ten COVID-19 flexibility
audits: (1) recipients were not always able to
implement the flexibilities due to insufficient
time and/or guidance; (2) recipients were
hesitant to use the flexibilities based on
available guidance and federal funding sources;
and (3) recipients did not consistently track
or monitor their use of the flexibilities, as they
were not required to.
OVERSIGHT REPORTS

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APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

HOLDING
WRONGDOERS
ACCOUNTABLE
INSIGHTS THROUGH
OVERSIGHT
REPORTS
U.S. Peace Corps OIG, Management Implication
Report: Peace Corps/Ukraine’s PEPFAR Food
Voucher Program, IG-21-02-SR, July 15, 2021
In March 2021, the Peace Corps/Ukraine
director of management and operations and
deputy director of management and operations
submitted a complaint to Peace Corps OIG
about concerns of fraud and mismanagement
of the President’s Emergency Plan for AIDS
Relief Food Voucher Program. The Voucher
program was initiated and expanded during
a period of time when all volunteers had
been evacuated from Peace Corps/Ukraine
due to COVID-19. The complaint emphasized
that Peace Corps/Ukraine had inaccurately
reported data and food voucher project results,
mismanaged the approved project plan, and
lacked sufficient oversight over the voucher
program. The purpose of this report, which does
not make a recommendation, is to summarize
information concerning this complaint and
actions taken by Peace Corps response to the
complaint.
Special Inspector General for Trouble Asset
Relief Program (SIGTARP), Treasury Has Been
Effective at Shifting the Hardest Hit Fund
To Assist Homeowners Suffering Pandemic-
Related Hardships, Efforts That Could Be
Further Enhanced, 21-001, June 10, 2021
This evaluation report assessed the status of
the Hardest Hit Fund and Treasury’s planning
of the program wind down. SIGTARP found
that Treasury has been effective in shifting
the Hardest Hit Fund to help homeowners
suffering from unemployment, a loss of income,
or other hardships related to the pandemic.
Several state agencies in the Hardest Hit Fund
sought Treasury approval to ramp back up
unemployment mortgage assistance. However,
SIGTARP found that these efforts could be
further enhanced to assist more homeowners in
SIGTARP recommended that Treasury
shift the $118 million of recovered
funds to open Hardest Hit Fund
programs that, in addition to the
available $331 million, would provide a
total of $449 million.
need. For example, SIGTARP recommended on
April 8, 2020, that Treasury take urgent action
to put to better use all remaining unspent
Hardest Hit Funds and funds estimated to be
unspent in the Home Affordable Mortgage
Program for Hardest Hit Fund’s traditional
form of assistance—unemployment mortgage
assistance. Treasury did not implement
SIGTARP’s April 2020 recommendations.
SIGTARP found that Treasury applied an
additional $118 million in recovered funds
to the Home Affordable Mortgage Program
account even though the Home Affordable
Mortgage Program was no longer open to
new applicants. SIGTARP recommended that
Treasury shift the $118 million of recovered
funds to open Hardest Hit Fund programs that,
in addition to the available $331 million, would
provide a total of $449 million.
DOL OIG, COVID-19: States Struggled to
Implement Cares Act Unemployment Insurance
Programs, 19-21-004-03-315, May 28, 2021
DOL OIG concluded that DOL and the states
struggled to implement the three key CARES
Act UI programs. Specifically, DOL’s guidance
and oversight did not ensure states: (1)
implemented the programs and paid benefits
promptly; (2) performed required and
recommended improper payment detection
and recovery activities; and (3) reported
accurate and complete program activities.
DOL OIG found that the lack of adherence to
required and recommended reporting occurred
OVERSIGHT REPORTS

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APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

HOLDING
WRONGDOERS
ACCOUNTABLE
INSIGHTS THROUGH
OVERSIGHT
REPORTS
primarily because: (1) states’ information
technology systems were not modernized, (2)
staffing resources were insufficient to manage
the increased number of new claims, and (3)
guidance from the Employment and Training
Administration, according to state officials, was
untimely and unclear. DOL OIG estimated that
potentially up to $87.3 billion in UI benefits
could be paid improperly, including fraud, by the
conclusion of the programs.
Department of State (State) OIG, Review of
the Effects of the COVID-19 Pandemic on
the International Exchange Programs of the
Bureau of Educational and Cultural Affairs,
ISP-I-21-25, May 28, 2021
State OIG conducted this review to assess how
the Bureau of Educational and Cultural Affairs
responded from March 2020 through January
2021 to the risk management challenges
associated with the COVID-19 pandemic’s
impact on its exchange programs. Specifically,
State OIG reviewed the Bureau of Educational
and Cultural Affairs immediate crisis response,
including the repatriation of thousands of
exchange program participants; the effects
of the crisis on the Bureau of Educational
and Cultural Affairs’ budget and grants
administration; and the effects of the crisis on
exchange program operations. State OIG found
that the Bureau of Educational and Cultural
Affairs’ extensive experience in responding
to previous country-specific emergencies,
including the need to evacuate and repatriate
exchange program participants, helped prepare
it to respond to the COVID-19 pandemic.
Department of the Treasury (Treasury) OIG,
American Rescue Plan - Application of Lessons
Learned From the Coronavirus Relief Fund, OIG,
CA-21-020, May 17, 2021
The CARES Act assigned Treasury OIG with
responsibility for monitoring and oversight
of the receipt, disbursement, and use of
Coronavirus Relief Fund (CRF) monies. Through
its CRF monitoring and oversight work to
date, Treasury OIG identified certain lessons
learned with respect to the implementation and
administration of the CRF program to include
(1) the need for clear and timely guidance,
(2) the need for agreements with terms and
conditions, (3) balancing data reporting
& transparency and recipient burden, (4)
outreach, and (5) the need for performance
measures. Treasury OIG believes that these
lessons learned are valuable for Treasury
management’s consideration in implementing
the American Rescue Plan Act programs.

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APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

HOLDING
WRONGDOERS
ACCOUNTABLE
INSIGHTS THROUGH
OVERSIGHT
REPORTS
Challenge:
IT Security and Management
Total Reports          5
USPS OIG, U.S. Postal Service Protection
Against External Cyberattacks, 20-277-R21,
August 31, 2021
USPS OIG’s objective was to determine if
the Postal Service has an effective security
posture to protect its Information Technology
Infrastructure from external cyberattacks and
prevent unauthorized access to restricted
data. USPS OIG found that the Postal Service
generally has an effective security posture and
security awareness program to protect its IT
infrastructure from external cyberattacks.
DoD OIG, Special Report: The Missile Defense
Agency’s Access to Information Technology
and Communications During the Coronavirus
Disease–2019 Pandemic, DODIG-2021-113,
August 13, 2021
This special report provides a subset of the
results of the survey conducted to support
Report No. DODIG-2021-065, “Evaluation of
Access to Department of Defense Information
Technology and Communications During the
Coronavirus Disease–2019 Pandemic,” dated
March 30, 2021. The March report provided
consolidated information for the entire DoD.
This special report provides a subset of that
information directly related to the Missile
Defense Agency.
DoD OIG, Special Report: The Defense Logistics
Agency’s Access to Information Technology
and Communications During the Coronavirus
Disease–2019 Pandemic, DODIG-2021-112,
August 12, 2021
This special report provides a subset of the
results of the survey conducted to support
Report No. DODIG-2021-065, “Evaluation of
Access to Department of Defense Information
Technology and Communications During the
Coronavirus Disease–2019 Pandemic,” dated
March 30, 2021. The March report provided
consolidated information for the entire DoD.
This special report provides a subset of that
information directly related to the Defense
Logistics Agency.
OVERSIGHT REPORTS

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APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

HOLDING
WRONGDOERS
ACCOUNTABLE
INSIGHTS THROUGH
OVERSIGHT
REPORTS
Challenge:
Protecting the Health and Safety of the Public
Total Reports          27
Environmental Protection Agency (EPA) OIG,
Pandemic Highlights Need for Additional Tribal
Drinking Water Assistance and Oversight in
EPA Regions 9 and 10, 21-E-0254, September
27, 2021
EPA OIG found that the COVID-19 pandemic
negatively impacted the oversight and
assistance that Regions 9 and 10 provide
to the tribal drinking water systems under
their purview, as well as the capacity of
these systems to provide safe drinking water.
The pandemic also underscored the limitations
of both EPA resources and tribal drinking water
system resiliency. As a result, tribal drinking
water systems may be unable to operate safely
and comply with drinking water regulations.
Access to safe and clean water is critical at
all times, but even more so during pandemic
situations.
Department of Homeland Security (DHS) OIG,
ICE’s Management of COVID-19 in Its Detention
Facilities Provides Lessons Learned for Future
Pandemic Responses, OIG-21-58, September
9, 2021
The U.S. Immigration and Customs Enforcement
has taken various actions to prevent the
pandemic’s spread among detainees and
staff at their detention facilities. The DHS
OIG remotely inspected nine facilities, taking
measures including maintaining adequate
supplies of personal protective equipment
(PPE) such as face masks, enhanced cleaning,
and proper screening for new detainees and
staff. The DHS OIG found other areas in which
detention facilities struggled to properly manage
the health and safety of detainees, for example,
observing instances where staff and detainees
did not consistently wear face masks or socially
distance. In addition, the DHS OIG noted some
facilities did not consistently manage medical
sick calls and did not regularly communicate
COVID-19 test results to detainees. Although the
DHS OIG found that the U.S. Immigration and
Customs Enforcement was able to decrease
the detainee population to help mitigate the
spread of COVID-19, information on detainee
transfers was limited. The DHS OIG also found
that testing of both detainees and staff was
insufficient, and that U.S. Immigration and
Customs Enforcement headquarters did not
generally provide effective oversight of their
detention facilities during the pandemic. The
DHS OIG recommended the U.S. Immigration
and Customs Enforcement resolve these issues
to ensure it can meet the challenges of not only
the COVID-19 pandemic, but future pandemics
as well.
OVERSIGHT REPORTS

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APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

HOLDING
WRONGDOERS
ACCOUNTABLE
INSIGHTS THROUGH
OVERSIGHT
REPORTS
HHS OIG, Medicare Beneficiaries Hospitalized
With COVID-19 Experienced a Wide Range of
Serious, Complex Conditions, OEI-02-20-00410,
August 30, 2021
This report describes the complex care needs
of beneficiaries hospitalized with COVID-19. It
focuses on surges in COVID-19 hospitalizations
in six localities and builds upon prior HHS
OIG work that describes the extent to which
hospitals have been strained by COVID-19.
As HHS OIG noted in the 2021 report about
hospital experiences during the pandemic,
hospitals have been operating in “survival
mode” for an extended period of time. They
have also experienced difficulty balancing the
complex and resource-intensive care needed
for COVID-19 patients with efforts to resume
routine hospital care. HHS OIG found that
beneficiaries diagnosed with COVID-19 were
also treated for a variety of other conditions
(e.g., acute kidney failure), and Black, Hispanic,
and older beneficiaries were disproportionately
hospitalized with COVID-19 relative to the
Medicare population in the analyzed localities.
DHS OIG, CBP Needs to Strengthen Its
Oversight and Policy to Better Care for
Migrants Needing Medical Attention, OIG-21-
48, July 20, 2021
The U.S. Customs and Border Protection needs
better oversight and policy to adequately
safeguard migrants experiencing medical
emergencies or illnesses along the southwest
border. According to the U.S. Customs and
Border Protection’s policies, once an individual
is in custody, the U.S. Customs and Border
Protection agents and officers are required to
conduct health interviews and “regular and
frequent” welfare checks to identify individuals
who may be experiencing serious medical
conditions. However, the U.S. Customs and
Border Protection could not always demonstrate
staff conducted required medical screenings or
consistent welfare checks for all 98 individuals
whose medical cases were reviewed.
VA OIG, Comprehensive Healthcare Inspection
of Facilities’ COVID-19 Pandemic Readiness
and Response in Veterans Integrated Service
Network 19, 21-01699-175, July 7, 2021
This VA OIG Comprehensive Healthcare
Inspection Program report provided a focused
evaluation of Veterans Integrated Service
Network 19 facilities’ COVID-19 pandemic
readiness and response. This evaluation
focused on emergency preparedness; supplies,
equipment, and infrastructure; staffing; access
to care; community living center patient care
and operations; facility staff feedback; and VA
and Veterans Integrated Service Network 19
vaccination efforts. VA OIG aggregated findings
on COVID-19 preparedness and responsiveness
from routine inspections to ensure prompt
dissemination of information given the quickly
changing landscape as infection rates and
demands on facilities continually shift. Findings
of inspected medical facilities were grouped by
Veterans Integrated Service Networks, which
are regional offices that provide oversight
of medical centers in their area. This report,
the second in a series, describes findings on
COVID-19 practices from healthcare inspections
performed within Veterans Integrated Service
Network 19 during the weeks of November
30 and December 7, 2020. It also provides
a more recent snapshot of the pandemic’s
demands on these facilities’ operations based
on data compiled as of April 2021. Interviews
and survey results provide additional context
on lessons learned and perceptions of both
preparedness and response. This report also
provides data that illustrates the tremendous
OVERSIGHT REPORTS

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APPENDICES
HIGHLIGHTS
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ACCOMPLISHMENTS

HOLDING
WRONGDOERS
ACCOUNTABLE
INSIGHTS THROUGH
OVERSIGHT
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COVID-19-related demands on VA healthcare
services. It describes leader and staff
experiences, assessments, shared sentiments,
and best practices to help improve operations
and clinical care during public health crises. At
the time of the inspections, the VHA and the
Veterans Integrated Service Networks were
experiencing the highest number of cases
since the beginning of the pandemic and had
valuable information to share about their
experiences.
VA OIG, Deficiencies in Emergency
Preparedness for Veterans Health
Administration Telemental Health Care at VA
Clinic Locations Prior to the Pandemic, 19-
09808-171, June 24, 2021
The VA OIG staff interviewed VHA leaders from
the Office of Connected Care and the Office of
Mental Health and Suicide Prevention to gain
an understanding of national expectations
and telehealth emergency practices within
telemental health care. VA OIG concluded
that delays in intervention may have occurred
during telehealth emergencies as a result of
(1) Missing telehealth emergency plans and
procedures, (2) Emergency procedures not
specific to telehealth care or the patient-clinic
location, (3) Lack of a process for annual
updates to telehealth emergency procedures,
(4) Undefined telehealth staff roles and
responsibilities for telehealth emergency
plans, (5) Missing or insufficient emergency
contact information for relevant telehealth
staff, and (6) Lack of a process to verify and
communicate emergency contact information
among telehealth staff. VA OIG also concluded
that missed opportunities for patient safety and
a general lack of awareness for vulnerabilities
may have occurred without a consistent process
for patient safety event reporting that identifies
the telehealth setting.
HHS OIG, COVID-19 Had a Devastating Impact
on Medicare Beneficiaries in Nursing Homes
During 2020, OEI-02-20-00490, June 22, 2021
This data snapshot provides objective,
standardized data based on Medicare claims
for all Medicare beneficiaries in nursing homes
throughout the country. Nursing home residents
have been particularly affected by the disease,
as they are predominately elderly, tend to
have underlying conditions, and live in close
quarters. This snapshot is part of an HHS OIG
initiative focusing on COVID-19 and nursing
homes.
OVERSIGHT REPORTS

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Other: Agency Operations
Total Reports          25
Special Inspector General for Pandemic
Recovery (SIGPR), Alert Memorandum:
Caribbean Sun Airlines, Inc. Has Not
Responded to the Department of the
Treasury’s Notice of Non-Compliance with the
U.S. Treasury Aviation Loan and Guarantee
Agreement, SIGPR-A-21-002, September 8,
2021
On December 7, 2020, Caribbean Sun obtained
a loan from Treasury under Section 4003 of
the CARES Act for $6,768,749. On March 25,
2021, SIGPR issued a survey to Caribbean
Sun but did not receive a response. On August
2, 2021, they issued an Alert Memorandum,
notifying Treasury that Caribbean Sun was
non-responsive. On August 3, 2021, Treasury
issued a Notice of Non-compliance, requiring
Caribbean Sun to respond to our survey within
30 days. Pursuant to Treasury’s Notice of
Non-compliance, issued on August 3, 2021,
Caribbean Sun had until September 2, 2021,
to respond to SIGPR’s survey. As stated in
Treasury’s notice of non-compliance, failure
to respond to SIGPR’s survey by September 2,
2021, would constitute an “Event of Default”
under Section 7.01(d) of the Agreement. An
event of default would allow Treasury to pursue
remedies under the Agreement, including
declaring the loan immediately due and payable
in whole or in part.
U.S. Agency for International Development
(USAID) OIG, U.S. COVID-19 Vaccine
Contributions: USAID Should Consider
Enhancing Oversight to Mitigate Risk of Fraud,
Waste, and Abuse, E-000-21-002-M, September
1, 2021
USAID, a key player in U.S. international efforts
to respond to the COVID-19 pandemic and
address its secondary impacts, administers
U.S. government contributions to the Vaccine
Alliance and develops strategies to respond to
the pandemic. USAID OIG reviewed the status
of USAID’s effort to develop and implement
a COVID-19 vaccine strategy as of May 31,
2021 and found that USAID is finalizing a new
COVID-19 response strategy amid challenges
as missions support implementation of
host-country plans. USAID OIG also found
that additional oversight may be needed to
mitigate the risk of fraud, waste, and abuse for
USAID’s contribution to the Vaccine Alliance,
which totaled $4 billion. USAID OIG made two
recommendations to the USAID Bureau for
Global Health to mitigate current and future
risks of contributions to Vaccine Alliance.
OVERSIGHT REPORTS

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USDA OIG, COVID-19—Oversight of the
Emergency Food Assistance Program-Interim
Report, 27801-0001-21(1), August 25, 2021
The objective of USDA OIG’s ongoing inspection
was to evaluate the Food and Nutrition Service’s
oversight of the Emergency Food Assistance
Program, which provides Federally purchased
commodities to States and Territories to
distribute to recipient agencies serving low-
income households and individuals. USDA OIG
concluded the Food and Nutrition Service did
not formally evaluate potential impacts of the
COVID-19 pandemic on the Emergency Food
Assistance Program distribution. The Food
and Nutrition Service had not established
a formalized enterprise risk management
process, so there was no assurance that the
Food and Nutrition Service periodically reviewed
and documented its response to the impact of
changing conditions on the safe and effective
distribution of food assistance to States.
Department of the Interior (DOI) OIG, The
Bureau of Land Management’s COVID-19
Response at Recreation Management Areas,
2020-CR-063, June 15, 2021
DOI OIG identified various ways in which the
Bureau of Land Management’s actions could
have been improved regarding its response
to COVID-19. In particular, the Bureau of
Land Management’s State and field offices
reported problems with receiving timely and
complete guidance and communication from
the Bureau of Land Management headquarters.
Further, Bureau of Land Management officials
stated that public messaging regarding
COVID-19, such as news releases and safety
information, was not always timely because
of delayed approvals from the Bureau of Land
Management headquarters. In addition, many
Bureau of Land Management offices reported
increased numbers of visitors to recreation
management areas, along with harmful
consequences including damage to restrooms,
garbage dumping, driving and camping in
unauthorized areas, and general vandalism.
TIGTA, Assessment of the Effects of the
Coronavirus Pandemic on Customer Service
Operations, 2021-46-029, April 22, 2021
This audit was initiated to provide selected
information related to the impact of COVID-19
on the IRS’s Customer Service operations.
The overall objective of this review was
to assess the impact of COVID-19 on IRS
customer service operations and evaluate
the development of the IRS’s comprehensive
customer service strategy. TIGTA found that
in an effort to restore service to taxpayers as
quickly as possible, the IRS accelerated the
implementation of several customer service
options it had been testing and expanded the
use of existing technologies and capabilities.
However, the IRS’s ability to assist taxpayers
continues to be affected by COVID-19.
Social Security Administration (SSA) OIG, The
Social Security Administration’s Telephone
Services During June 2020, A-05-20-50998,
April 7, 2021
In June 2020, SSA’s field offices and national
800-number received 30% more calls than
June 2019, with field offices receiving most
of the additional calls. SSA altered operations
because of the COVID-19 pandemic to continue
serving the public through its telephone
operations. In general, SSA’s telephone services
performance during June 2020 was similar
to 13 customer service call centers SSA OIG
reviewed from 10 other Federal agencies, as
compared to June 2019, but SSA’s performance
seemed to fare better during COVID-19 than
industry call centers.
OVERSIGHT REPORTS

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Appendix A
Acronym List
Acronym
Meaning
BOP
Federal Bureau of Prisons
CARES Act
Coronavirus Aid, Relief, and Economic Security Act
CDC
Centers for Disease Control and Prevention
CMS
Centers for Medicare & Medicaid Services
COVID-19
novel coronavirus disease 2019
CPA
certified public accountant
CRF
Coronavirus Relief Fund
DHS
Department of Homeland Security
DoD
Department of Defense
DOI
Department of the Interior
DOJ
Department of Justice
DOL
Department of Labor
ED
Department of Education
EIDL
Economic Injury Disaster Loan
EPA
Environmental Protection Agency
HHS
Department of Health and Human Services
HUD
Department of Housing and Urban Development
IG
Inspector General
IRS
Internal Revenue Service
IT
information technology
NSF
National Science Foundation
OIG
Office of Inspector General
OMB
Office of Management and Budget
OPM
Office of Personnel Management
PACE
Pandemic Analytics Center of Excellence
PPE
personal protective equipment
PPP
Paycheck Protection Program
PRAC
Pandemic Response Accountability Committee
SBA
Small Business Administration
SIGPR
Special Inspector General for Pandemic Recovery
SIGTARP
Special Inspector General for Trouble Asset Relief Program
SSA
Social Security Administration
State
Department of State
Treasury
Department of the Treasury
TIGTA
Treasury Inspector General for Tax Administration
USAID
U.S. Agency for International Development
USPS
United States Postal Service
VA
Department of Veterans Affairs
VHA
Veterans Health Administration

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Appendix B
Pandemic-Related Reports by Office of Inspector General
Offices of Inspectors General (OIGs) issued a total of 119 reports between April 1, 2021, and
September 30, 2021, related to the COVID-19 pandemic response. The following information
provides a list and summary of each of those reports.
U.S. Agency for International Development (USAID) OIG
U.S. COVID-19 Vaccine Contributions: USAID Should Consider Enhancing Oversight to Mitigate
Risk of Fraud, Waste, and Abuse, E-000-21-002-M, September 1, 2021
USAID, a key player in U.S. international efforts to respond to the COVID-19 pandemic and
address its secondary impacts, administers U.S. government contributions to the Vaccine
Alliance and develops strategies to respond to the pandemic. USAID OIG reviewed the status
of USAID’s effort to develop and implement a COVID-19 vaccine strategy as of May 31, 2021
and found that USAID is finalizing a COVID-19 response strategy amid challenges as missions
support implementation of host-country plans. USAID OIG also found that additional oversight
may be needed to mitigate the risk of fraud, waste, and abuse for USAID’s contribution to the
Vaccine Alliance, which totaled $4 billion. USAID OIG made two recommendations to the USAID
Bureau for Global Health to mitigate current and future risks of contributions to Vaccine Alliance.
Recommendations: 2
COVID-19 Information Brief #3, June 9, 2021
This brief provides information on USAID’s response to the COVID-19 pandemic and associated
challenges, as well as related oversight plans and activities. Information about the pandemic
response of the other three foreign assistance agencies USAID OIG oversees – the Millennium
Challenge Corporation, U.S. African Development Foundation, and Inter‐American Foundation
– is also included. USAID OIG prepared this informational brief to increase stakeholder
knowledge and public transparency regarding these efforts. USAID OIG reported on activities
from the start of the pandemic through March 31, 2021, but emphasized activities since
December 1, 2020, when the reporting period for the previous brief ended.
USAID Adapted To Continue Program Monitoring During COVID-19, But the Effectiveness of
These Efforts Is Still To Be Determined, 9-000-21-007-P, May 21, 2021
Officials from USAID’s Bureaus for Africa, Asia, Latin America and the Caribbean, and the Middle
East, and selected missions—USAID/Burma, USAID/Egypt, USAID/Haiti, and USAID/Nigeria—
cited challenges to program monitoring efforts, including movement restrictions and technology
challenges. These restrictions limited staffs’ ability to conduct in person site visits, limited
in-person verification of data from implementers, and kept staff from engaging directly with

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beneficiaries. However, missions continued some monitoring of foreign assistance programs
through adapted approaches. USAID provided monitoring policy flexibilities related to remote
monitoring, remote site visits, and deadlines for data quality assessments, as well as guidance
designed to help missions.
U.S. Consumer Product Safety Commission OIG
Results of the OIG Survey on Returning to the Workplace, 21-O-06, May 27, 2021
On February 23, 2021, the U.S. Consumer Product Safety Commission OIG launched a survey
to gauge employee concerns about a potential return to their regularly assigned duty stations
after teleworking during the COVID-19 pandemic. At the time of the survey, infection rates
were decreasing while vaccination rates were increasing. The U.S. Consumer Product Safety
Commission OIG wanted to understand employee concerns regarding vaccinations, returning
to a regularly assigned duty station, messaging from management regarding returning to a
regularly assigned duty station, and views on employee schedule preferences once the agency
returned to more in-person work.
U.S. Department of Agriculture (USDA) OIG
COVID-19—Business and Industry Guaranteed Loan Modifications in Response to the
Pandemic, 34801-0001-23, September 27, 2021
On May 22, 2020, USDA announced the Business & Industry Coronavirus Aid, Relief, and
Economic Security (CARES) Act Guaranteed Loan Program to provide working capital loans to
businesses of any size and industry in rural areas of the country. USDA OIG found that the Rural
Business-Cooperative Service used the existing Business & Industry Guaranteed Loan Program
structure for approving and servicing guaranteed loans to immediately implement and track the
new Business & Industry CARES Act Guaranteed Loan Program. and made modifications to help
guaranteed lenders with existing borrowers experiencing cash flow issues.
COVID-19—Oversight of the Emergency Food Assistance Program-Interim Report, 27801-0001-
21(1), August 25, 2021
The objective of USDA OIG’s ongoing inspection was to evaluate the Food and Nutrition
Service’s oversight of the Emergency Food Assistance Program, which provides Federally
purchased commodities to States and Territories to distribute to recipient agencies serving
low-income households and individuals. USDA OIG concluded the Food and Nutrition Service
did not formally evaluate potential impacts of the COVID-19 pandemic on the Emergency
Food Assistance Program distribution. The Food and Nutrition Service had not established a
formalized enterprise risk management process, so there was no assurance that the Food and
Nutrition Service periodically reviewed and documented its response to the impact of changing
conditions on the safe and effective distribution of food assistance to States.
Recommendations: 2
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COVID-19—Supplemental Nutrition Assistance Program Online Purchasing in Response to the
Coronavirus Disease 2019, 27801-0003-22, August 25, 2021
USDA OIG reviewed the Food and Nutrition Service’s process for approving states and retailers
through June 2020 and analyzed Supplemental Nutrition Assistance Program Online Purchasing
Pilot data for online transactions through December 2020. Between March and December
2020, the total value of online Supplemental Nutrition Assistance Program purchases
transactions increased from over $18.9 million to more than $1.5 billion cumulatively. USDA
OIG found that the Food and Nutrition Service had not updated its risk assessment of the
Supplemental Nutrition Assistance Program Online Purchasing Pilot since its creation in 2014,
leaving it susceptible to fraud and abuse—particularly as the Food and Nutrition Service rapidly
expanded the pilot between March and December 2020. USDA OIG found that the Food and
Nutrition Service did not establish controls to effectively monitor, evaluate, or document how
participating retailers protect Supplemental Nutrition Assistance Program participants’ online
personal information.
Recommendations: 3
Survey of Food Safety and Inspection Service Inspectors’ Perceptions of COVID-19 Safety in the
Work Environment, 21-001-01, June 2, 2021
USDA OIG conducted a pulse survey of Food Safety and Inspection Service inspectors to obtain
information about how Food Safety Inspection Service frontline inspectors perceive COVID-19
safety in their work environments. The optional survey was emailed to inspectors and contained
52 questions concerning the impact COVID-19 illness had on operations and preserved safety
of inspector’s work environments. USDA OIG found that of the 2,773 responses, 41% reported
feeling safe at work, a decrease form 58% reporting they felt safe prior to the pandemic. Of the
inspectors that felt unsafe at work, 72% cited COVID-19 as the cause of feeling unsafe. USDA
OIG found that 45% of respondents felt their establishment did not inform them when they
came into contact with workers confirmed to have COVID-19.
U.S. Department of Commerce OIG
NIST Was Effective in Implementing the Requirements for Awarding Funds Under the CARES
Act, OIG-21-032-I, August 5, 2021
The U.S. Department of Commerce OIG’s objective was to determine whether National Institute
of Standards and Technology had been complying with the requirements of the CARES Act.
Specifically, the U.S. Department of Commerce OIG determined (1) what steps National Institute
of Standards and Technology took to implement and comply with the CARES Act, (2) challenges
National Institute of Standards and Technology faced during implementation, and (3) National
Institute of Standards and Technology’s status in the processing of applications and awarding
funds under the CARES Act. Overall, U.S. Department of Commerce OIG found that National
Institute of Standards and Technology implemented and followed the requirements of the
CARES Act and applicable grant award policies and procedures. National Institute of Standards
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and Technology also implemented measures to mitigate challenges resulting from an increased
workload and a forced transition to a virtual work environment prompted by the COVID-19
pandemic and is on track to fully obligate and expend all CARES Act funds before September 30,
2021.
NOAA Fisheries Implemented the Requirements for Awarding Funds Under the CARES Act but
Faces Challenges with the Pace of Funds Disbursement to Fishery Participants, OIG-21-028-I,
June 9, 2021
The Department of Commerce OIG evaluated the National Oceanic and Atmospheric
Administration’s National Marine Fisheries Service planed for the implementation of the
CARES Act funding. The Department of Commerce OIG’s objective was to determine whether
the National Oceanic and Atmospheric Administration complied with the requirements of the
CARES Act. Specifically, the Department of Commerce OIG determined (1) what steps the
National Oceanic and Atmospheric Administration took in implementing the requirements for
awarding funds, (2) challenges the National Oceanic and Atmospheric Administration faced
during implementation, and (3) the National Oceanic and Atmospheric Administration’s current
status in processing applications and award funds under the CARES Act. The Department of
Commerce OIG found that the National Marine Fisheries Service followed the requirements for
implementing the CARES Act. The National Marine Fisheries Service has put in place measures
to mitigate challenges resulting from the review and approval process during COVID-19 and is on
track to obligate all CARES Act funds before September 30, 2021. However, the National Marine
Fisheries Service still faces challenges with the pace at which funds are being disbursed to
fishery participants.
U.S. Department of Defense (DoD) OIG
Management Advisory Memorandum Regarding the Weaknesses Over TRICARE Payments for
the Administration of COVID-19 Vaccines, DODIG-2021-122, September 10, 2021
The purpose of this memorandum was to inform DoD leadership of potential internal control
weaknesses identified regarding TRICARE payments for the administration of COVID-19 vaccines
administered to TRICARE beneficiaries from December 2020 through April 2021 and to
document DoD OIG recommendations to Defense Health Agency officials. DoD OIG announced
the “Research on Potential Topics in the Military Health System for Future Audit Projects”
(Project No. D2021-D000AW-0007.000) on October 1, 2020, to evaluate potential audit topics
and high-risk areas by gathering and analyzing data, making inquiries, and conducting general
research on the DoD Military Health System. During the research project, DoD OIG analyzed
TRICARE claims payments paid to health care providers for administering COVID-19 vaccines
to TRICARE beneficiaries and identified potential internal control weaknesses related to paying
more than once for administering the same dose of COVID-19 vaccines, applying cost shares
for the administration of COVID-19 vaccines, and paying providers to administer vaccines in a
manner that did not meet Centers for Disease Control and Prevention requirements.
Recommendations: 1
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Audit of Department of Defense Education Activity Controls Related to the Spread of
Coronavirus Disease—2019, DODIG-2021-128, September 24, 2021
DoD OIG found that DoD Education Activity developed and implemented controls in accordance
with the Centers for Disease Control and Prevention and DoD guidance related to the spread
of COVID-19. Specifically, DoD Education Activity issued COVID-19 operational guidelines and
the 15 individual DoD Education Activity schools DoD OIG reviewed provided staff, students,
and parents with information and training on effective hygiene, social distancing, cleaning, and
identifying the signs of COVID-19 to reduce the risk of COVID-19 spread for students, teachers,
and staff members.
Special Report: The Missile Defense Agency’s Access to Information Technology and
Communications During the Coronavirus Disease–2019 Pandemic, DODIG-2021-113, August
13, 2021
This special report provides a subset of the results of the survey conducted to support Report
No. DODIG-2021-065, “Evaluation of Access to Department of Defense Information Technology
and Communications During the Coronavirus Disease–2019 Pandemic,” dated March 30, 2021.
The March report provided consolidated information for the entire DoD. This special report
provides a subset of that information directly related to the Missile Defense Agency.
Special Report: The Defense Logistics Agency’s Access to Information Technology and
Communications During the Coronavirus Disease–2019 Pandemic, DODIG-2021-112, August
12, 2021
This special report provides a subset of the results of the survey conducted to support Report
No. DODIG-2021-065, “Evaluation of Access to Department of Defense Information Technology
and Communications During the Coronavirus Disease–2019 Pandemic,” dated March 30, 2021.
The March report provided consolidated information for the entire DoD. This special report
provides a subset of that information directly related to the Defense Logistics Agency.
Audit of U.S. Army Corps of Engineers Quality Assurance Over Contracts for the Conversion of
Facilities to Alternative Care Sites in Response to the Coronavirus Disease–2019 Pandemic,
DODIG-2021-101, July 16, 2021
The DoD OIG determined that U.S. Army Corps of Engineers contracting officers conducted
appropriate quality assurance and contract administration actions for the 35 contracts
and contract actions, valued at $686.6 million, used for alternative care site conversions.
An alternate care site is a facility converted for healthcare use during a public health emergency,
to reduce the burden on hospitals and other permanent healthcare facilities. As a result,
U.S. Army Corps of Engineers personnel were ensured that controls were in place to conduct
quality assurance and contract administration because they had personnel available during
the conversions to oversee contractors, coordinate changes in site conditions and Government
requirements with the contractors, and ensure contract files contained the necessary
documents. Furthermore, U.S. Army Corps of Engineers personnel were able to complete the
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conversions of facilities to alternative care sites and determine that the Government obtained
the services established by the contract terms. U.S. Army Corps of Engineers personnel
completed actions after the conversions to document contractor performance enabling
contracting personnel to assess past performance of these contractors during future potential
contracting opportunities.
Audit of the Reimbursement for Department of Defense Mission Assignments for Coronavirus
Disease–2019 Pandemic Response in the U.S. Northern Command Area of Responsibility,
DODIG-2021-091, June 9, 2021
The DoD OIG determined that DoD tasked-unit personnel did not submit timely requests for
partial or final reimbursement from the Federal Emergency Management Agency for mission
assignment support. As of July 31, 2020, DoD Components reported $221.6 million in incurred
reimbursable costs for 11 of the 12 COVID-19 pandemic response mission assignments
reviewed, but had not submitted timely reimbursement requests for those costs. If DoD tasked-
unit personnel submitted timely and supported reimbursement requests, then the DoD could
have used the $221.6 million reimbursed by the Federal Emergency Management Agency
to support DoD operations. Because of the DoD’s untimely requests for reimbursement, the
Federal Emergency Management Agency could not accurately report disaster relief funding to
Congress or bill states for their shared portion of the mission assignment costs.
Recommendations: 3
Audit of the DoD Coronavirus Aid, Relief, and Economic Security Act Awards to the Defense
Industrial Base, DODIG-2021-081, May 20, 2021
The DoD OIG determined that the DoD awarded CARES Act funding to sustain or increase the
Defense Industrial Base in accordance with Federal regulations and Defense Production Act
authorities for the six awards that were reviewed. In addition, DoD officials complied with the
Federal Acquisition Regulation and the Code of Federal Regulations when awarding CARES
Act funding to existing contracts and new technology investment agreements. As a result, the
six Defense Industrial Base companies that the DoD OIG reviewed will receive $206.8 million
in CARES Act funding to help them overcome the financial distress caused by the COVID-19
pandemic and sustain critical national defense.
Audit of the U.S. Army Corps of Engineers Use of Undefinitized Contract Actions for the
Conversion of Alternate Care Sites in Response to the Coronavirus Disease–2019 Pandemic,
DODIG-2021-074, April 7, 2021
The DoD OIG determined that U.S. Army Corps of Engineers contracting officers were not
operating in a normal contracting environment due to the urgent nature of the COVID–19
pandemic response, and therefore awarded 30 undefinitized contract actions to start the
conversion of facilities to Alternative Care Sites in accordance with the CARES Act. U.S. Army
Corps of Engineers contracting officers shortened the amount of time required to complete
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Alternative Care Sites conversion by awarding the contract actions as undefinitized contract
actions to allow contractors to begin conversion immediately and subsequently negotiate
contract costs. However, U.S. Army Corps of Engineers contracting officers only definitized two of
the 30 total undefinitized contract actions, valued at about $9.5 million, within the definitization
schedules included in the contract actions. For the other 28 undefinitized contract actions,
with a not to exceed amount of about $474.4 million at the time of award, U.S. Army Corps of
Engineers contracting officers definitized the award from one to 26 days after the definitization
dates established in the contract actions. Additionally, U.S. Army Corps of Engineers contracting
officers determined the price was fair and reasonable for the 30 contract actions awarded;
however, contracting officers did not follow DoD acquisition regulations related to adjusting the
potential contractor profit to reflect the definitization status of the award. As a result, U.S. Army
Corps of Engineers officials may have paid more for Alternative Care Sites conversion by not
complying with Defense Federal Acquisition Regulation Supplement requirements concerning
profit and the cost risk to the Government.
Recommendations: 1
U.S. Department of Homeland Security (DHS) OIG
FLETC’s Actions to Respond to and Manage COVID-19 at Its Glynco Training Center, OIG-21-73,
September 30, 2021
DHS OIG’s objective was to determine actions the Glynco training center has taken to prevent
and mitigate the spread of COVID-19 among staff and students. DHS OIG reviewed Federal
Law Enforcement Training Center’s policies and procedures to prevent and mitigate the spread
of COVID-19, and assessed measures such as screening and testing, social distancing, and
contract tracing and quarantining. DHS OIG interviewed Federal Law Enforcement Training
Center officials, DHS component personnel working at the center, and a sample of students
who attended classes between October 2020 and April 2021. DHS OIG also reviewed housing
records for a sample of 20 DHS students who attended training at Federal Law Enforcement
Training Center between October 2020 and April 2021. DHS OIG judgmentally selected the
sample from a list of 3,489 DHS students, including 12 students who were in isolation during
their training, as well as students spread across the timeframe of the sample.
Recommendations: 1
Lessons Learned from FEMA’s Initial Response to COVID-19, OIG-21-64, September 23, 2021
The objective of this audit was to determine how effectively the Federal Emergency Management
Agency supported and coordinated Federal efforts to distribute personal protective equipment
(PPE) and ventilators in response to the COVID-19 outbreak. To accomplish the objectives
of the audit, including the assessment of internal controls, DHS OIG reviewed applicable
Federal laws and regulations and Federal Emergency Management Agency’s policies and
procedures, focusing on COVID-19 response activities. DHS OIG interviewed Federal Emergency
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Management Agency officials at the National Response Coordination Center and within all
10 Federal Emergency Management Agency regions, and Department of Health and Human
Services (HHS) officials to gain an understanding of Federal Emergency Management Agency’s
activities and decision-making processes from January 27, 2020 through April 19, 2020, for
PPE and ventilator distribution. DHS OIG also developed a survey that was distributed to 444
stakeholders, to which there were 105 responses, to obtain stakeholder perspectives on the
Federal Emergency Management Agency’s response activities prior to and after it assumed the
lead federal agency role. DHS OIG used examples from the survey responses to illustrate the
potential effects of the issues identified. DHS OIG assessed the reliability of computer-based
data by obtained an understanding of the Federal Emergency Management Agency’s controls
over data in WebEOC and conducting limited testing to trace data to source documents and
identify missing or invalid data elements. DHS OIG found the data was inaccurate, insufficient,
and incomplete and therefore was unreliable. The team issued a recommendation to improve
the accuracy, completeness, and reliability of the system.
Recommendations: 3
Violations of ICE Detention Standards at Otay Mesa Detention Center, OIG-21-61, September
14, 2021.
DHS OIG initiated this inspection at Congress’ direction. Prior to conducting an unannounced
inspection, DHS OIG reviewed and analyzed concerns raised by immigrant rights groups and
complaints to the DHS OIG Hotline about conditions for detainees in the U.S. Immigration and
Customs Enforcement custody. DHS OIG generally limited its scope to the 2011 Performance-
Based National Detention Standards for health, safety, medical care, mental health care,
grievances, classification and searches, use of segregation, use of force, language access, and
staff training. DHS OIG also conducted a limited review of facility compliance with COVID-19
requirements. DHS OIG conducted the inspection remotely, given the inherent risks associated
with on-site inspections during the COVID-19 pandemic. DHS OIG focused on elements of these
standards that could be observed and evaluated remotely.
Recommendations: 7
DHS Needs to Enhance Its COVID-19 Response at the Southwest Border, OIG-21-60, September
10, 2021
The objective of this review was to determine to what extent DHS has implemented COVID-19
measures for migrants at the southwest border. To achieve its objective, DHS OIG obtained,
reviewed, and analyzed key DHS and DHS component information and documentation,
including: (1) policies and procedures for migrant COVID-19 screenings, testing, and
detainment/quarantine; (2) records/systems maintained, accessed, and shared by DHS/
components related to COVID-19 screening, testing, and isolating; and (3) DHS and DHS
component data on migrants released into the United States, including those tested for
COVID-19. Additionally, DHS OIG incorporated a referral it received during this review from
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the Office of Special Counsel outlining concerns regarding a lack of testing and quarantining
migrants for COVID-19, and subsequent employee notifications regarding potential exposure
into its review process. DHS OIG interviewed officials from DHS’ Office of the Immigration
Detention Ombudsman and the DHS Chief Medical Officer in the Countering Weapons of Mass
Destruction Office. DHS OIG also interviewed officials from U.S. Customs and Border Protection,
U.S. Immigration and Customs Enforcement, and the Federal Emergency Management Agency.
DHS OIG also obtained and analyzed information related to the Department’s COVID-19
response from the Office of the Executive Secretary and the Office of Strategy, Policy and Plans.
Due to the COVID-19 pandemic, DHS OIG conducted all steps via telephone, email, or video
communication. Although the team did not physically travel for meetings or site visits, DHS
believe these restrictions did not impair its ability to gather sufficient evidence to support its
conclusions.
Recommendations: 2
ICE’s Management of COVID-19 in Its Detention Facilities Provides Lessons Learned for Future
Pandemic Responses, OIG-21-58, September 9, 2021
The U.S. Immigration and Customs Enforcement has taken various actions to prevent the
pandemic’s spread among detainees and staff at their detention facilities. The DHS OIG
remotely inspected nine facilities, taking measures including maintaining adequate supplies
of personal protective equipment (PPE) such as face masks, enhanced cleaning, and proper
screening for new detainees and staff. The DHS OIG found other areas in which detention
facilities struggled to properly manage the health and safety of detainees, for example,
observing instances where staff and detainees did not consistently wear face masks or socially
distance. In addition, the DHS OIG noted some facilities did not consistently manage medical
sick calls and did not regularly communicate COVID-19 test results to detainees. Although the
DHS OIG found that the U.S. Immigration and Customs Enforcement was able to decrease the
detainee population to help mitigate the spread of COVID-19, information on detainee transfers
was limited. The DHS OIG also found that testing of both detainees and staff was insufficient,
and that U.S. Immigration and Customs Enforcement headquarters did not generally provide
effective oversight of their detention facilities during the pandemic. The DHS OIG recommended
the U.S. Immigration and Customs Enforcement resolve these issues to ensure it can meet the
challenges of not only the COVID-19 pandemic, but future pandemics as well.
Recommendations: 6
CBP Needs to Strengthen Its Oversight and Policy to Better Care for Migrants Needing Medical
Attention, OIG-21-48, July 20, 2021
The U.S. Customs and Border Protection needs better oversight and policy to adequately
safeguard migrants experiencing medical emergencies or illnesses along the southwest
border. According to the U.S. Customs and Border Protection’s policies, once an individual is in
custody, the U.S. Customs and Border Protection agents and officers are required to conduct
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health interviews and “regular and frequent” welfare checks to identify individuals who may
be experiencing serious medical conditions. However, the U.S. Customs and Border Protection
could not always demonstrate staff conducted required medical screenings or consistent
welfare checks for all 98 individuals whose medical cases were reviewed.
Recommendations: 3
Violations of ICE Detention Standards at Adams County Correctional Center, OIG-21-46, July
14, 2021
During an unannounced inspection of Adams County Correctional Center in Natchez,
Mississippi, DHS OIG identified violations of U.S. Immigration and Customs Enforcement
detention standards that threatened the health, safety, and rights of detainees. Although Adams
generally provided sufficient medical care, DHS OIG identified one case in which the medical
unit examined a sick detainee but did not send the detainee to the hospital for urgent medical
treatment, and the detainee died. DHS OIG also found the medical unit did not document
outcomes of detainee sick calls or ensure proper review and follow-up of detainee test results.
Recommendations: 7
Violations of Detention Standards at Pulaski County Jail, OIG-21-32, April 29, 2021
During an unannounced inspection of Pulaski County Jail, DHS OIG identified violations of
U.S. Immigration and Customs Enforcement detention standards that threatened the health,
safety, and rights of detainees. In addressing COVID-19, Pulaski did not consistently enforce
precautions including use of facial coverings and social distancing, which may have contributed
to repeated COVID-19 transmissions at the facility. Pulaski did not meet standards for
classification, medical care, segregation, or detainee communication. DHS OIG also found that
the facility was not consistently providing required oversight for detainees in segregation by
conducting routine wellness checks. Finally, DHS OIG found deficiencies in staff communication
practices with detainees. Specifically, U.S. Immigration and Customs Enforcement did
not specify times for staff to visit detainees and could not provide documentation that it
completed facility visits with detainees during the pandemic. DHS OIG found that Pulaski
generally complied with the U.S. Immigration and Customs Enforcement detention standard
for grievances. DHS OIG made five recommendations to ensure the Chicago Enforcement
and Removal Operations Field Office overseeing Pulaski addresses identified issues and
ensures facility compliance with relevant detention standards. U.S. Immigration and Customs
Enforcement concurred with all five recommendations.
Recommendations: 5
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U.S. Department of the Interior (DOI) OIG
The Bureau of Land Management’s COVID-19 Response at Recreation Management Areas,
2020-CR-063, June 15, 2021
The U.S. Department of the Interior OIG identified various ways in which the Bureau of Land
Management’s actions could have been improved regarding its response to COVID-19. In
particular, the Bureau of Land Management’s State and field offices reported problems
with receiving timely and complete guidance and communication from the Bureau of Land
Management headquarters. Further, Bureau of Land Management officials stated that public
messaging regarding COVID-19, such as news releases and safety information, was not always
timely because of delayed approvals from the Bureau of Land Management headquarters. In
addition, many Bureau of Land Management offices reported increased numbers of visitors
to recreation management areas, along with harmful consequences including damage
to restrooms, garbage dumping, driving and camping in unauthorized areas, and general
vandalism.
U.S. Department of Justice (DOJ) OIG
Review of the Office of Justice Programs’ Administration of CARES Act Funding, 21-130,
August 30, 2021
DOJ OIG reviewed the Office of Justice Programs’ administration of CARES Act funding to assess
the Office of Justice Programs’ efforts to (1) distribute Coronavirus Emergency Supplemental
Funding awards in a timely and efficient manner, and (2) review pre-awarded activities to
determine if Coronavirus Emergency Supplemental Funding awards were made in accordance
with applicable laws, regulations, and other guidelines. The Office of Justice Programs was
allocated $850 million (84% of total DOJ appropriations from the CARES Act) to award
Coronavirus Emergency Supplemental Funding grants for the purposes of preventing, preparing
for, and responding to the COVID-19 pandemic. The DOJ OIG found that the Office of Justice
Programs acted quickly to distribute Coronavirus Emergency Supplemental Funding  and that
most recipient spending reviewed appeared allowable under the terms and conditions of the
awards. However, the DOJ OIG noted that as of March 31, 2021, nearly a year after the first
award was made, Coronavirus Emergency Supplemental Funding recipients reported spending
or obligating just 40%of the total amount awarded. The DOJ OIG found that some Office of
Justice Program staff reported that they did not receive training on the Coronavirus Emergency
Supplemental Funding program or were dissatisfied with the training they received. Some
award managers reported that Coronavirus Emergency Supplemental Funding performance
reports do not contain the information necessary to effectively oversee Coronavirus Emergency
Supplemental Funding awards.
Recommendations: 3
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Staff Perceptions of the Federal Bureau of Prison’s Management of the Coronavirus Disease
2019 Pandemic: A Follow-Up Survey of BOP Staff, 21-126, September 28, 2021
DOJ OIG released an interactive dashboard with results of a follow-up anonymous online survey
that the DOJ OIG conducted in February 2021, in which DOJ OIG received 6,578 responses out
of almost 35,000 Federal Bureau of Prisons institution staff. While most survey respondents
rated their institution’s response to the pandemic as “effective” or “somewhat effective,”
respondents also reported that the pandemic has had negative effects on staff. The DOJ OIG
found that opportunities for improvement remain.
Limited-Scope Review of the Executive Office for Immigration Review’s Response to the
Coronavirus Disease 2019 Pandemic, 21-063, April 22, 2021
The DOJ OIG examined the Executive Office for Immigration Review’s response to the pandemic
and its efforts to mitigate risk. The DOJ OIG found that the Executive Office for Immigration
Review suspended certain hearings, but it continued to hear detained cases and upheld
deadlines for many immigration cases. This, combined with the Executive Office for Immigration
Review’s historical reliance on paper filings, as well as a lack of equipment, limited its ability to
adopt remote options for filing and court appearances promptly or universally. The Executive
Office for Immigration Review increased telework, promoted social distancing, and provided
personal protective equipment to staff. However, the Executive Office for Immigration Review
did not apply these changes evenly and initial communication related to the pandemic was
sometimes unclear, inconsistent, and untimely.
Recommendations: 9
U.S. Department of Labor (DOL) OIG
COVID-19: The Pandemic Highlighted the Need to Strengthen Wage and Hour Division’s
Enforcement Controls, 19-21-008-15-001, September 30, 2021
DOL OIG found that controls implemented by the Wage and Hour Division for enforcing Families
First Coronavirus Response Act paid leave compliance could be strengthened. The Wage and
Hour Division relied on incoming complaints to enforce Families First Coronavirus Response Act
paid leave, but did not require staff to document all incoming complaints and did not implement
additional complaint handling controls specific to the Families First Coronavirus Response Act.
The Wage and Hour Division could not ensure the agency took proper action on all Families
First Coronavirus Response Act complaints. Additionally, the Wage and Hour Division did not
ensure Families First Coronavirus Response Act complainants received the leave payments they
were owed and did not have a method for analyzing trends regarding conciliation outcomes or
a conciliation performance measure to determine if the Wage and Hour Division was meeting
agency objectives. As a result, the Wage and Hour Division could not determine how effective
the agency was at securing Families First Coronavirus Response Act payments for workers
when using conciliations. Lastly, DOL OIG found that the Wage and Hour Division continued to
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experience enforcement challenges such as increasing the amount of remote investigations and
limiting direct investigations of other labor laws, such as the Fair Labor Standards Act, due to
COVID-19 restrictions.
Recommendations: 5
COVID-19: Pandemic Causes Delays in FECA Claims Adjudication, 19-21-007-04-431,
September 23, 2021
DOL OIG found the COVID-19 pandemic had a negative impact on Federal Employee’s
Compensation Program’s ability to timely adjudicate claims. Timeliness of adjudicated claims
declined by 15% during the audit period. DOL OIG found the decline to be primarily driven
by COVID-19 claims, which took longer to adjudicate than other claims. While the Federal
Employee’s Compensation Program was able to improve the timeliness of adjudicating COVID-19
claims throughout the audit period, 46% of COVID-19 claims remained open as of March 31,
2021.
Recommendations: 1
The U.S. Department of Labor Complied with The Payment Integrity Information Act for FY
2020, but Reported Unemployment Insurance Information Did Not Represent Total Program
Year Expenses, 22-21-007-13-001, August 6, 2021
DOL’s reported Unemployment Insurance (UI) improper payment rate of 9.17% was compliant
with Payment Integrity Information Act of 2019; however, it was not representative of total
unemployment expenses for program year 2020. This occurred for the following reasons: (1)
DOL excluded CARES Act unemployment insurance programs because these programs were
not in existence for more than 12 months, and (2) DOL received direction from the Office
of Management and Budget (OMB) to utilize the results from the first three quarters of the
program year. This allowed state workforce agencies to suspend work on improper payment
sampling to reduce the burden on program resources. The DOL OIG’s initial pandemic audit and
investigation work indicate UI program improper payments, including fraudulent payments, is
likely higher than 10%.
Recommendations: 1
Alert Memorandum: The Employment and Training Administration Does Not Require the
National Association of State Workforce Agencies to Report Suspected Unemployment
Insurance Fraud Data to the Office of Inspector General or the Employment and Training
Administration, 19-21-006-03-315, July 1, 2021
DOL OIG found the Employment and Training Administration did not require the National
Association of State Workforce agencies and its Integrity Data Hub to share suspected UI
fraud data with the Employment and Training Administration or the DOL OIG as required by the
DOL Manual Series Chapter 8. In response to a draft of this memorandum, the Employment
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and Training Administration committed to corrective action to become compliant with the
Inspector General Act that authorizes the DOL OIG to have access to all materials related to DOL
programs.
Recommendations: 2
Alert Memorandum: The Employment and Training Administration Needs to Issue Guidance
to Ensure State Workforce Agencies Provide Requested Unemployment Insurance Data to the
Office of Inspector General, 19-21-005-03-315, June 16, 2021
DOL’s interpretation of federal regulations and the Employment and Training Administration’s
subsequent guidance to state workforce agencies limit the state workforce agencies’ mandatory
sharing of UI information in only those circumstances where DOL OIG is conducting an
investigation into a particular instance of suspected UI fraud. This is contrary to the Inspector
General Act, which authorizes DOL OIG to obtain UI information for all purposes (e.g. audit
and investigative) to prevent and detect fraud, waste, and abuse within the UI program. These
disclosure limitations have prevented DOL OIG from obtaining critical UI claim and wage data
needed to conduct timely investigative and audit work and fulfill our oversight responsibilities.
Recommendations: 5
COVID-19: States Struggled to Implement Cares Act Unemployment Insurance Programs, 19-
21-004-03-315, May 28, 2021
DOL OIG concluded that DOL and the states struggled to implement three key CARES Act UI
programs. DOL’s guidance and oversight did not ensure states implemented the programs and
paid benefits properly; performed required and recommended improper payment detection
and recovery activities; and reported accurate and complete program activities. DOL OIG found
the lack of adherence to required and recommended reporting occurred primarily because
(1) states’ information technology systems were not modernized, (2) staffing resources were
insufficient to manage the increased number of new claims, and (3) state officials felt guidance
from the Employment and Training Administration was untimely and unclear. As of January 2,
2021, if improper payment rates where to continue at 10%, OIG DOL estimated that a total of
$87.3 billion in UI benefits could be paid improperly by the conclusion of the program.
Recommendations: 4
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U.S. Department of Education (ED) OIG
Remington College’s Use of Higher Education Emergency Relief Fund Student Aid and
Institutional Grants, ED-OIG/A20CA0017, September 28, 2021
ED OIG found that Remington College generally used the Student Aid portion of its Higher
Education Emergency Relief Fund funds for allowable and intended purposes but did not
always use the Institutional portion of its funds in accordance with Federal requirements.
Additionally, Remington College did not minimize the time between drawing down and spending
its Institutional funds nor deposit excess Higher Education Emergency Relief Fund funds
(Student Aid and Institutional) in an interest-bearing account. ED OIG also determined that the
information in Remington College’s required Higher Education Emergency Relief Fund reports
posted on its website was generally accurate, complete, and timely.
Recommendations: 8
Lincoln College of Technology’s Use of Higher Education Emergency Relief Fund Student Aid
and Institutional Grants, ED-OIG/A20CA0016, September 24, 2021
ED OIG found that the Lincoln College of Technology generally used the Student Aid portion of its
Higher Education Emergency Relief Fund funds for allowable and intended purposes. However,
the Lincoln College of Technology did not adequately document eligibility determinations for
a small number of students who received emergency financial aid grants. ED OIG also found
that the Lincoln College of Technology did not always use the Institutional portion of its funds
in accordance with Federal requirements. Additionally, the Lincoln College of Technology did
not minimize the time between drawing down and spending its Student Aid and Institutional
funds nor deposit excess Higher Education Emergency Relief Fund funds in an interest-bearing
account. ED OIG also determined that the information in the Lincoln College of Technology’s
required Higher Education Emergency Relief Fund reports posted on its website was generally
accurate, complete, and timely.
Recommendations: 5
Inconsistent Grantee and Subgrantee Reporting of Education Stabilization Fund Subprograms
in the Federal Audit Clearinghouse, F21NF0037, August 26, 2021
The purpose of this flash report was to share ED OIG’s observations concerning grantees and
subgrantees inconsistently reporting audit data on ED’s subprograms, or unique components
of a program, to the Federal Audit Clearinghouse, the designated repository of single audit
data. ED OIG found that grantees and subgrantees were not consistently reporting expenditures
of Education Stabilization Fund subprogram awards in the Federal Audit Clearinghouse.
Specifically, when entering federal award information into the Data Collection Form, grantees
and subgrantees either (1) did not identify which Education Stabilization Fund subprogram their
expenditures were awarded under or (2) used widespread variations of subprogram identifying
information to identify which subprogram their expenditures were awarded under.
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Federal Student Aid’s Suspension of Involuntary Collection in Response to the Coronavirus
Pandemic, I20NY0010, June 15, 2021
The objective of this review was to evaluate the results of Federal Student Aid’s process for
suspending involuntary collection and refunding payments involuntarily collected on defaulted
Department-held loans in response to the Coronavirus pandemic. ED OIG found that Federal
Student Aid suspended administrative wage garnishments and the U.S. Department of the
Treasury (Treasury) offsets for over 96% of the borrowers that Federal Student Aid collected
payments for within 90 days of March 13, 2020, the start of the suspension period. However, as
of October 23, 2020, ED OIG found that Federal Student Aid continued to receive administrative
wage garnishments for 1,930 borrowers. ED OIG also found that Federal Student Aid refunded
most administrative wage garnishments and Treasury offsets collected from March 13, 2020,
through September 30, 2020, and issued refunds for $576.65 million (99%) of the $582.48
million collected for the same period. Federal Student Aid also refunded 1,063,984 of the
1,094,507 administrative wage garnishments and 221,436 of the 244,080 Treasury offsets
within 60 days from the date the payments were received. However, ED OIG found that Federal
Student Aid did not reprocess refunds for $21.25 million of the $576.65 million Federal Student
Aid refunded that were subsequently returned to Treasury and did not refund $5.83 million (1%)
of the $582.48 million wage garnishments and Treasury offsets collected. Finally, ED OIG found
that Federal Student Aid did not develop procedures to obtain and track the U.S. Department of
Justice’s progress on suspending involuntary collections and refunding payments involuntarily
collected on defaulted Department-held loans from March 13, 2020, through September 30,
2020.
Recommendations: 3
Significant Recommendations: 3
Risk of Closed Institutions of Higher Education Receiving Higher Education Emergency Relief
Fund Grants, I21SIU00841, May 14, 2021
The purpose of this report was to share ED OIG observations concerning institutions of higher
education that ceased to provide educational instruction in all programs of study (closed) and
received or had access to coronavirus response and relief aid through the Higher Education
Emergency Relief Fund. ED OIG found that 17 institutions of higher education that closed on or
before December 31, 2020, applied for and were awarded a total of $4,912,675 of the Higher
Education Emergency Relief Fund grants by the Office of Postsecondary Education. Fourteen of
the 17 institutions of higher education drew down Higher Education Emergency Relief funds,
and 3 did not draw down any of their awards. Of the 14 institutions of higher education that
drew down their Higher Education Emergency Relief Fund awards, 8 made drawdowns after the
institution closure date listed in the Postsecondary Education Participants System. The total of
these post-closure drawdowns was $1,261,329. In addition, 1 of the 14 closed institutions of
higher education that drew down funds made a draw of $364,715 one day before closing.
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U.S. Department of Health and Human Services (HHS) OIG
Six of Eight Home Health Agency Providers Had Infection Control Policies and Procedures
That Complied With CMS Requirements and Followed CMS COVID-19 Guidance To Safeguard
Medicare Beneficiaries, Caregivers, and Staff During the COVID-19 Pandemic, A-01-20-00508,
September 24, 2021
The objective of this report was to determine whether eight selected home health agencies had
infection control policies and procedures that complied with Centers for Medicare & Medicaid
Services (CMS) requirements and followed its guidance to safeguard home health agency
staff, Medicare beneficiaries, and caregivers during the COVID-19 pandemic. HHS OIG found
that six of the eight selected home health agency providers had infection control policies and
procedures. However, one home health agency provider did not comply with CMS requirements
or follow CMS’ COVID-19 guidance. In addition, this provider and another home health agency
provider’s COVID-19 screening protocols for patients were not consistent with CMS guidance,
increasing the risk of infection for patients and staff.
Recommendations: 1
Indian Health Service Use of Critical Care Response Teams Has Helped To Meet Facility Needs
During the COVID-19 Pandemic, OEI-06-20-00700, September 17, 2021
The objective of this review was to assess Indian Health Service’s use of the Critical Care
Response Teams to support Indian Health Service and Tribal health care facilities’ responding to
the COVID-19 pandemic. The Critical Care Response Team consisted of a critical care physician,
one or two critical care nurses, and a respiratory therapist. The team provided on average two-
weeks of hands-on training, strengthening staff skills and capacity to handle surges of COVID-19
patients. While the program is a positive step in the Indian Health Service’s efforts to promptly
respond to the immediate needs of facilities, HHS OIG concluded the Critical Care Response
model could be further leveraged to support broader care improvement efforts.
Recommendations: 3
CMS’s COVID-19 Data Included Required Information From the Vast Majority of Nursing
Homes, but CMS Could Take Actions To Improve Completeness and Accuracy of the Data, A-09-
20-02005, September 3, 2021
The objective of this audit was to determine whether the CMS’s COVID-19 data for nursing
homes were complete and accurate. HHS OIG found that CMS’s COVID-19 data for nursing
homes included the required information from the vast majority of nursing homes; however, the
data were not complete or accurate for some facilities. For about 5% of nursing homes, the data
did not include all COVID-19 information nursing homes were required to report and/or were not
complete or accurate after CMS performed its quality assurance checks.
Recommendations: 6
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Medicare Beneficiaries Hospitalized With COVID-19 Experienced a Wide Range of Serious,
Complex Conditions, OEI-02-20-00410, August 30, 2021
This report describes the complex care needs of beneficiaries hospitalized with COVID-19.
It focuses on surges in COVID-19 hospitalizations in six localities and builds upon prior HHS
OIG work that describes the extent to which hospitals have been strained by COVID-19. As HHS
OIG noted in the 2021 report about hospital experiences during the pandemic, hospitals have
been operating in “survival mode” for an extended period of time. They have also experienced
difficulty balancing the complex and resource-intensive care needed for COVID-19 patients
with efforts to resume routine hospital care. HHS OIG found that beneficiaries diagnosed with
COVID-19 were also treated for a variety of other conditions (e.g., acute kidney failure), and
Black, Hispanic, and older beneficiaries were disproportionately hospitalized with COVID-19
relative to the Medicare population in the analyzed localities.
States’ Backlogs of Standard Surveys of Nursing Homes Grew Substantially During the
COVID-19 Pandemic, OEI-01-20-00431, July 27, 2021
This addendum updates HHS OIG’s analysis from a prior report (OEI-01-20-00430), which found
that state survey agencies faced backlogs of standard surveys of nursing homes early in the
COVID-19 pandemic, with 8 percent of nursing homes having gone at least 16 months without
a standard survey as of June 2020. This update from that the state survey agencies’ backlogs
of standard nursing home surveys have grown substantially, even after August 2020 when CMS
lifted its suspension of those surveys (which it had suspended due to the COVID-19 pandemic).
Nationally, 71 percent of nursing homes had gone at least 16 months without a standard survey
as of May 31, 2021. The rising backlogs add urgency to our existing recommendation that
CMS clarify expectations and provide guidance to state survey agencies on completing these
important surveys.
CMS’s Controls Related to Hospital Preparedness for an Emerging Infectious Disease
Were Well-Designed and Implemented but Its Authority Is Not Sufficient for It To Ensure
Preparedness at Accredited Hospitals, A-02-21-01003, June 28, 2021
HHS OIG assessed whether CMS designed and implemented effective internal controls related
to hospital preparedness for emerging infectious diseases such as COVID-19. CMS’s controls
were well-designed and implemented to achieve its control objective and respond to risks, but
CMS’s authority is not sufficient for it to ensure preparedness for emerging infectious diseases
including COVID-19 at 4,200 accredited hospitals.
Recommendations: 2
COVID-19 Had a Devastating Impact on Medicare Beneficiaries in Nursing Homes During 2020,
OEI-02-20-00490, June 22, 2021
This data snapshot provides objective, standardized data based on Medicare claims for all
Medicare beneficiaries in nursing homes throughout the country. Nursing home residents
have been particularly affected by the disease, as they are predominately elderly, tend to have
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underlying conditions, and live in close quarters. This snapshot is part of an HHS OIG initiative
focusing on COVID-19 and nursing homes.
U.S. Department of Housing and Urban Development (HUD) OIG
COVID-19 Forbearance Data in HUD’s Single Family Default Monitoring System Generally
Agreed With Information Maintained by Loan Servicers, 2021-KC-0005, August 16, 2021
HUD OIG audited lender reporting of COVID-19 forbearances for Federal Housing Administration-
insured loans in the Single Family Default Monitoring System. HUD OIG compared default
reporting data from Single Family Default Monitoring System to loan data provided by five
sampled servicing lenders that serviced a third of the FHA single-family portfolio. HUD OIG
audit objective was to determine whether COVID-19 forbearance data available in the Single
Family Default Monitoring System were consistent with the information maintained by loan
servicers. HUD OIG found that COVID-19 forbearance data available in the Single Family Default
Monitoring System were generally consistent with the information maintained by the loan
servicers reviewed.
Limited Review of HUD’s Office of Chief Procurement Officer Pandemic-Related Procurement
Accommodations and Challenges, 2021-FW-0801, July 14, 2021
HUD OIG conducted a limited review of the HUD’S Office of the Chief Procurement Officer’s
administration of five procurement activities under the CARES Act. The CARES Act and related
OMB memorandums gave HUD flexibility in modifying existing contracts and required rapid
delivery of CARES Act funds. The HUD OIG objective was to determine what HUD had done
to accommodate contractors’ pandemic-related issues while ensuring that HUD met its
business objectives. In addition, HUD OIG objective included determining what challenges HUD
encountered in procuring and administering its contracts during the pandemic. Based upon a
limited review of five COVID-19-related contract transactions and HUD OIG’s understanding of
the pre-pandemic controls and policies that HUD had in place, HUD was adequately prepared
before the pandemic to accommodate contractors’ pandemic-related issues while ensuring that
HUD met its business objectives. Because HUD was adequately prepared, it did not encounter
substantial challenges in procuring and administering its contracts. HUD used its existing
policies, procedures, and systems to modify contracts to allow contractor accommodations.
Promoting a Homeless Waitlist Preference at Multifamily-Assisted Rental Unit Properties,
2021-KC-0802, June 17, 2021
HUD OIG prepared this memorandum to provide the Office of Housing at the U.S. Department
of Housing and Urban Development (HUD) information regarding the opportunity to promote
a homeless waitlist preference at Multifamily Housing rental assistance properties. HUD has
an opportunity to revisit the promotion and marketing of its homeless waitlist preference and
the importance of partnering with a homeless service provider. Additionally, HUD can take this
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opportunity to make any changes to the program or adopt additional incentives to increase the
likelihood of owner and agent participation. Lastly, HUD should also consider updating its public
website to make it more likely that someone with limited resources and knowledge of its site can
successfully identify Multifamily Housing rental assistance properties in his or her area.
HUD’s Use of, Accounting for, and Reporting on CARES Act Funding, 2021-OE-0006, April 26,
2021
The objective of this report was to assess HUD’s use, accounting, and reporting of CARES Act
funding. As of March 31, 2021, HUD had dispersed $3.4 billion and obligated $7.4 billion of its
$12.4 billion in CARES Act funds, leaving $1.6 billion unobligated. If HUD is unable to obligate
funds properly, HUD could have balances canceled and returned to the General Fund when the
expired accounts close. HUD used disaster emergency fund codes to track the status of each
program’s CARES Act funding. HUD passed on the responsibility to prevent the duplication of
benefits to Community Development Block Grant-CARES Act grantees. While HUD met portions
of its PRAC quarterly reporting requirement on behalf of covered recipients, HUD’s process
did not support reporting quarterly on the estimated number of jobs created or retained or on
subrecipient data, as required for covered recipients in the CARES Act. HUD OIG found that
unclear reporting requirements and the required reporting schedule pose challenges to HUD’s
quarterly reporting to the PRAC.
U.S. Department of State (State) OIG
Review of the Effects of the COVID-19 Pandemic on the International Exchange Programs of
the Bureau of Educational and Cultural Affairs, ISP-I-21-25, May 28, 2021
State OIG conducted this review to assess how the Bureau of Educational and Cultural Affairs
responded from March 2020 through January 2021 to the risk management challenges
associated with the COVID-19 pandemic’s impact on its exchange programs. Specifically,
State OIG reviewed the Bureau of Educational and Cultural Affairs immediate crisis response,
including the repatriation of thousands of exchange program participants; the effects of the
crisis on the Bureau of Educational and Cultural Affairs’ budget and grants administration; and
the effects of the crisis on exchange program operations. State OIG found that the Bureau of
Educational and Cultural Affairs’ extensive experience in responding to previous country-specific
emergencies, including the need to evacuate and repatriate exchange program participants,
helped prepare it to respond to the COVID-19 pandemic.
Inspection of the Bureau of Overseas Buildings Operations’ Office of Safety, Health, and
Environmental Management, ISP-21-21- April 26, 2021
State OIG inspected the Office of Safety, Health, and Environmental Management, which is
located under the Directorate of Operations, in the Bureau of Overseas Buildings Operations.
State OIG found that the Office of Safety, Health, and Environmental Management made
progress in reducing safety risks to Department of State employees and family members. In
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addition, the Office of Safety, Health, and Environment Management served as a member of
the Department’s COVID-19 working group and developed a mitigation toolkit that provided the
most up to date COVID-19 information to overseas posts. The office also designated a separate
working group to review COVID-19 pandemic plans for the Department’s construction contacts
so that construction projects were ready to restart safely.
Recommendations: 11
U.S. Department of the Treasury (Treasury) OIG
Termination Memorandum – Audit of Air Carrier Worker Support Certifications – West Air, Inc.
(Redacted), OIG-CA-21-028, September 10, 2021
The CARES Act requires that financial assistance to passenger and cargo air carriers and
respective contractors be used for the continuation of payments of employees’ wages, salaries,
and benefits. Passenger and air cargo carriers, that do not report salaries and benefits to the
Department of Transportation, referred to as non-241 air carriers, and contractors requesting
financial assistance are required to certify to Treasury via “sworn” financial statements, or other
appropriate data, wages, salaries, benefits, and other compensation amounts for the period
of April 1, 2019, through September 30, 2019. The CARES Act assigned the Treasury OIG with
responsibility to audit the certifications required to be submitted. The objective of Treasury OIG’s
West Air audit was to assess the accuracy, completeness, and sufficiency of West Air’s “sworn”
financial statements or other data used to certify the wages, salaries, benefits, and other
compensation amounts submitted to and approved by Treasury. On February 23, 2021, West Air
returned all $2,974,054 of its award to Treasury. West Air officials informed Treasury OIG that
their business industry was not negatively impacted by COVID-19, and therefore had no need
for Payroll Support Program funding. Because West Air returned its full awardable amount of
$2,974,054 under the Payroll Support Program, Treasury OIG terminated the audit.
American Rescue Plan - Application of Lessons Learned From the Coronavirus Relief Fund, OIG,
CA-21-020, May 17, 2021
The CARES Act assigned Treasury OIG with responsibility for monitoring and oversight of the
receipt, disbursement, and use of Coronavirus Relief Fund (CRF) monies. Through their CRF
monitoring and oversight work to date, they have identified certain lessons learned with respect
to the implementation and administration of the CRF program to include (1) the need for clear
and timely guidance, (2) the need for agreements with terms and conditions, (3) balancing data
reporting & transparency and recipient burden, (4) outreach, and (5) the need for performance
measures. Treasury OIG believes that these lessons learned are valuable for management’s
consideration in implementing the American Rescue Plan Act programs.
Recommendations: 7
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U.S. Department of Veteran Affairs (VA) OIG
Failure to Mitigate Risk of and Manage a COVID-19 Outbreak at a Community Living Center at
VA Illiana Health Care System in Danville, Illinois, 21-00553-285, September 28, 2021
VA OIG conducted an inspection at the VA Illiana Health Care System in Danville, Illinois, to
determine the validity of allegations, specific to COVID-19 and the Community Living Center of
failure to observe infection control practices; failure to minimize risk of exposure to COVID-19;
inconsistent ongoing testing; and failure to notify residents, families, and staff of positive test
results. During the inspection, VA OIG identified concerns related to leaders’ post-outbreak
actions. VA OIG substantiated a failure to observe general infection control practices. Leaders
failed to minimize the risk of exposure to COVID-19. Leaders did not respond adequately to a
staff exposure, have a plan for the transfer and isolation of residents, implement recommended
infection control measures when performing aerosol generating procedures, and continued to
hold group therapies. VA OIG identified actions taken by leaders following the Community Living
Center outbreak lacked input from frontline staff to identify corrective actions and opportunities
for improvement.
Recommendations: 15
Care Concerns and the Impact of COVID-19 on a Patient at the Fayetteville VA Coastal Health
Care System in North Carolina, 21-01304-275, September 27, 2021
The VA OIG conducted a healthcare inspection at the Fayetteville VA Coastal Health Care System
in North Carolina to assess concerns related to the quality, coordination, and timeliness of care;
and the impact of COVID-19 on a patient with unintentional weight loss who was later diagnosed
with oral cancer and died at another VA medical center. VA OIG substantiated that the primary
care provider and dietitians did not provide quality care to the patient. Dietitians conducted
incomplete nutritional assessments given the patient’s declining nutrition status and may have
contributed to a delay in diagnosis. VA OIG determined that the patient’s Patient Aligned Care
Team nurse and dietitians failed to coordinate care by not communicating the family’s request
for a face-to-face appointment and the patient’s declining nutritional status to the primary care
provider. VA OIG concluded that COVID-19 impacted the care provided by dietitians because of
the use of telephone visits, which did not allow dietitians to visually assess the patient’s physical
characteristics caused by a declining nutritional status.
Recommendations: 6
Significant Recommendations: 1
Deficiencies in COVID-19 Screening and Facility Response for a Patient Who Died at the
Michael E. DeBakey VA Medical Center in Houston, Texas, 20-03635-217, August 18, 2021
The VA OIG conducted a healthcare inspection regarding allegations of incompletely screening
for COVID-19 and treatment of a patient with serious mental illness who presented for same-day
care at the Michael E. DeBakey VA Medical Center (facility). VA OIG substantiated that facility
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staff did not complete the patient’s COVID-19 temperature screening. VA OIG substantiated that
facility staff failed to medically manage the patient with COVID-19 symptoms; sent the patient
to the drive-through testing area without medical evaluation; and did not isolate the patient,
complete a plan of care, or follow policy for transporting patients suspected to have COVID-19.
The vulnerable patient disappeared while in the facility’s care, was found off-site four days
later experiencing a medical emergency, taken back to the facility, and died the following day.
VA OIG determined that the Mental Health Intensive Case Management team failed to address
documentation discrepancies related to the patient’s surrogate and educate the family on
COVID-19 visitor policy and screening processes. VA OIG identified the facility’s noncompliance
with the missing patient policy, and facility leaders’ failure to report an adverse event and to
ensure a timely review of the patient’s episode of care. VA OIG identified that facility leaders did
not timely or accurately disclose to the patient’s family the medical mismanagement that led
to the patient’s adverse clinical outcome. VA OIG concluded the failure to screen, isolate, and
evaluate the patient resulted in potential COVID-19 exposure to staff, patients, and the public
when the patient moved through facility grounds.
Recommendations: 9
Opportunities Exist to Improve Management of Noninstitutional Care through the Veteran-
Directed Care Program, 20-02828-174, August 4, 2021
The Veteran-Directed Care program, one of Veterans Health Administration’s (VHA’s) 12
noninstitutional care programs, provides veterans with a budget to hire caregivers and purchase
the goods and services that will best meet their care needs and allow them to remain in their
homes longer. In Fiscal Year 2020, the program more than doubled, reaching  about 4,400
veterans and Veteran-Directed Care program expenditures increased from $3.3 billion in
Fiscal Year 2020 to about $3.5 billion in Fiscal Year 2021. VA OIG found that VHA provided
Veteran-Directed Care services to veterans that addressed their care needs. However, due to
weaknesses in program management, VHA lacked assurance that veterans in the program
were being monitored properly, provider agencies were paid correctly, and taxpayer dollars were
properly spent. In addition, VA OIG identified opportunities for VHA to improve Veteran-Directed
Care policies and funding to ensure medical facilities effectively implement and manage the
program to help veterans stay in their homes.
Recommendations: 2
Comprehensive Healthcare Inspection of Facilities’ COVID-19 Pandemic Readiness and
Response in Veterans Integrated Service Network 19, 21-01699-175, July 7, 2021
This VA OIG Comprehensive Healthcare Inspection Program report provides a focused evaluation
of Veterans Integrated Service Network (VISN) 19 facilities’ COVID-19 pandemic readiness
and response. This evaluation focused on emergency preparedness; supplies, equipment, and
infrastructure; staffing; access to care; community living center patient care and operations;
facility staff feedback; and VA and VISN 19 vaccination efforts. VA OIG has aggregated findings
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on COVID-19 preparedness and responsiveness from routine inspections to ensure prompt
dissemination of information given the quickly changing landscape as infection rates and
demands on facilities continually shift. Findings of inspected medical facilities are grouped
by VISN, which are regional offices that provide oversight of medical centers in their area.
This report, the second in a series, describes findings on COVID-19 practices from healthcare
inspections performed within VISN 19 during the weeks of November 30 and December 7,
2020. It also provides a more recent snapshot of the pandemic’s demands on these facilities’
operations based on data compiled as of April 2021. Interviews and survey results provide
additional context on lessons learned and perceptions of both preparedness and response.
This report also provides data that illustrates the tremendous COVID-19-related demands
on VA healthcare services. It describes leader and staff experiences, assessments, shared
sentiments, and best practices to help improve operations and clinical care during public health
crises. At the time of the inspections, the VHA and the VISN were experiencing the highest
number of cases since the beginning of the pandemic and had valuable information to share
about their experiences.
Deficiencies in Emergency Preparedness for Veterans Health Administration Telemental Health
Care at VA Clinic Locations Prior to the Pandemic, 19-09808-171, June 24, 2021
The VA OIG staff interviewed Veterans Health Administration leaders from the Office
of Connected Care and the Office of Mental Health and Suicide Prevention to gain an
understanding of national expectations and telehealth emergency practices within telemental
health care. VA OIG concluded that delays in intervention may have occurred during telehealth
emergencies as a result of (1) Missing telehealth emergency plans and procedures, (2)
Emergency procedures not specific to telehealth care or the patient-clinic location, (3) Lack of a
process for annual updates to telehealth emergency procedures, (4) Undefined telehealth staff
roles and responsibilities for telehealth emergency plans, (5) Missing or insufficient emergency
contact information for relevant telehealth staff, and (6) Lack of a process to verify and
communicate emergency contact information among telehealth staff. VA OIG also concluded
that missed opportunities for patient safety and a general lack of awareness for vulnerabilities
may have occurred without a consistent process for patient safety event reporting that identifies
the telehealth setting.
Recommendations: 5
Medical/Surgical Prime Vendor Contract Emergency Supply Strategies Available Before the
COVID-19 Pandemic, 20-03075-138, June 14, 2021
VA medical facilities’ demand for PPE increased dramatically during the COVID-19 pandemic.
VA OIG reviewed how the VHA ensured the Medical/Surgical Prime Vendor-Next Generation
program and its prime vendors met contract requirements by offering medical facilities a no-cost
option to develop advance-order supply lists tailored to catastrophic events and contingency
plans. VA OIG also assessed whether facilities took advantage of those options and strategies
and relied on the contracts to obtain PPE during the pandemic. All four Medical/Surgical Prime
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Vendor-Next Generation prime vendors developed contingency plans that included the advance-
order list. Three of the four vendors also offered options to purchase and store medical supplies
in advance. Though the prime vendors fulfilled their contract requirements, VA OIG found
none of 16 medical facilities assessed took advantage of those emergency strategies before
the pandemic. Most facility leaders did not know those plans existed. Most medical facilities
reported maintaining their own contingency stocks, which were at risk of quickly depleting.
That risk increased when prime vendors were unable to fulfill orders, leading staff to purchase
medical supplies on the open market where VHA’s data showed they paid higher prices. By not
asking prime vendors to provide services established in contingency plans, VA medical facilities
missed opportunities to receive certain needed medical supplies. VA can apply lessons learned
during the pandemic by continuing to refine its contract requirements for prime vendors to
address catastrophes.
Recommendations: 2
Review of VHA’s Financial Oversight of COVID-19 Supplemental Funds, 20-02967-121, June
10, 2021
In response to the CARES Act, the VA OIG reviewed the VHA tracking and reporting of COVID
19 supplemental funding from legislation for pandemic relief. VA met monthly reporting
requirements to OMB and Congress on supplemental fund obligations and expenditures. VA
also submitted required weekly obligations and expenditures from supplemental funding to
OMB by program activity. Of approximately $17.3 billion in medical care supplemental funds, VA
reported it had obligated about $7.11 billion and had spent about $5.67 billion by December
29, 2020. VA OIG noted three concerns where VA’s reporting was not complete and accurate:
(1) Obligations were at risk of not being included in VA’s reports; (2) VA initially delayed the
reporting of reimbursable obligated amounts for two months; and (3) VA’s reports contained
negative dollar amounts in data fields that should have only positive amounts, which misstated
VA’s overall reported obligations. Those concerns indicate weaknesses in how VA and VHA
internal controls are structured to meet reporting requirements. Despite the risks identified,
VA performed only a limited review at the summary fund level of its COVID 19 obligations and
expenditures before reporting. A review of summary funds is not detailed enough to identify
potential anomalies and ensure reliability of externally reported information. OMB’s guidance
required VA to report on obligations and expenditures classified by the type of items or services
purchased. VA OIG concluded that the three identified variances affected the quality of reporting
given the inherent risks due to outdated financial information technology infrastructure.
Recommendations: 2
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Use and Oversight of the Emergency Caches Were Limited during the First Wave of the
COVID-19 Pandemic, 20-03326-124, June 9, 2021
VA OIG assessed how effectively VA managed its emergency caches during the first wave of
the COVID-19 pandemic in early 2020. These caches contain a standard supply of drugs and
medical supplies, including some PPE, for use during a public health emergency. The review
team found that use and oversight of the emergency caches were limited. Only 9 of 144 medical
facilities activated their emergency caches during the review period (February through June
2020). Among the reasons they were not used included medical facility directors reporting
supplies were not needed or caches lacked sufficient quantity for meeting pandemic demands.
The VHA also changed the process for mobilizing caches during the pandemic, but without
clearly communicating it to medical facility directors. The review team also identified problems
with cache maintenance and monitoring. Most caches contained some expired or missing
PPE, diminishing their ability to support pandemic preparedness. Expired or incomplete cache
inventories can also compromise facilities’ ability to respond to other local emergencies, such as
hurricanes or wildfires. Furthermore, VHA had incomplete documentation on cache activations,
making it difficult to know which caches would need to be restocked. Finally, medical facility
leaders were not always able to accurately report if their facility’s cache was activated during the
pandemic.
Recommendations: 3
Inadequate Resident Supervision and Documentation of an Ophthalmology Procedure at the
Oklahoma City VA Health Care System in Oklahoma, 20-03886-141, May 18, 2021
VA OIG conducted an inspection in response to allegations related to ophthalmology resident
supervision and quality of care by an attending ophthalmologist (subject ophthalmologist) at
the Oklahoma City VA Health Care System in Oklahoma. VA OIG substantiated that the subject
ophthalmologist failed to provide adequate resident supervision and entered inaccurate
documentation related to supervision for a single patient case. The ophthalmology residents
were unable to reach the subject ophthalmologist when the patient experienced a complication
during an eye injection procedure. The residents reached another attending ophthalmologist
who examined the patient and assisted the residents. The subject ophthalmologist was
assigned to supervise residents in the clinic and did not arrange a hand-off for attending
coverage when away from the clinic. VA OIG found that a note in the patient’s electronic health
record that documented supervision by the subject ophthalmologist was incorrect because the
subject ophthalmologist did not directly participate in and was not present during the care of the
patient. The subject ophthalmologist used a standard template and acknowledged the note was
incorrect due to a failure to read and edit the note before signing it. The VA OIG and an external
ophthalmologist conducted a review of 20 patients and determined the subject ophthalmologist
provided acceptable quality of care and appropriate documentation. Aside from the single
patient case, VA OIG did not identify other failures to supervise residents or inaccurate
documentation of resident supervision by the subject ophthalmologist.
Recommendations: 3
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Inconsistent Documentation and Management of COVID-19 Vaccinations for Community Living
Center Residents, 21-00913-91, April 14, 2021
While reviewing the VHA’s plans to document receipt and distribution of the COVID-19 vaccine,
the VA OIG determined that VHA facilities did not consistently document the COVID 19
vaccination status of veterans living in VA’s Community Living Centers. VA OIG determined that
VHA could not know at a national level whether the vaccine was offered to some residents at
Community Living Centers, and if so, what their status was. Because Community Living Center
residents are in the highest COVID-19 vaccine priority group, they should be offered the vaccine,
when possible, before other groups of veterans. With vaccine supplies limited, VHA should know
which Community Living Center residents still need to be vaccinated. VA OIG found VHA has
made important strides in distributing vaccines to Community Living Center residents but can
move toward more comprehensive and consistent data collection to guide ongoing actions and
protect this vulnerable population. Doing so would include making sure all Community Living
Centers routinely track refusals and contraindications in a consistent manner. Guidance should
be clear that all communications should be consistently documented in accordance with VHA
processes. Similarly, clear guidance and consistent oversight should help ensure Community
Living Centers are properly tracking veterans who fall in the 23% of Community Living Center
residents missing information needed to determine their vaccination status. It was not possible
by January 2021 to establish which of the 1,899 veterans in this cohort had been offered the
vaccine.
Review of Community-Based Outpatient Clinics Closed Due to the COVID-19 Pandemic, 20-
03002-108, April 6, 2021
VA OIG reviewed community-based outpatient clinic closures that occurred due to the COVID 19
pandemic to evaluate the impact on patient care. VA OIG virtually interviewed VHA staff at 140
facilities that oversaw the 1,031 community-based outpatient clinics that were operational prior
to the World Health Organization’s pandemic declaration. Of these community-based outpatient
clinic, 173 were closed to face-to-face visits on or after February 1, 2020. Reasons for closure
fell into four categories including (a) safety of patients and staff, (b) need for consolidation of
resources, (c) lack of staff and PPE, and (d) small size of community-based outpatient clinic
or proximity to other community-based outpatient clinics or facilities. Clinicians of closed
community-based outpatient clinics triaged patients care needs and provided care options.
The four most reported options used were telephone visit, VA Video Connect, rescheduled
appointment for a later date, or an outpatient visit at the parent facility. Based on survey
responses and interviews with facility leaders, VA OIG concluded that, generally, patient care
needs were not interrupted. Other responses identified challenges encountered implementing
virtual care and mitigating risk of patient and staff exposure to COVID-19, including problems
with bandwidth and technical issues when using VA Video Connect at rural sites and limitations
in housekeeping resources.
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U.S. Environmental Protection Agency (EPA) OIG
Pandemic Highlights Need for Additional Tribal Drinking Water Assistance and Oversight in
EPA Regions 9 and 10, 21-E-0254, September 27, 2021
EPA OIG found that the COVID-19 pandemic negatively impacted the oversight and assistance
that Regions 9 and 10 provide to the tribal drinking water systems under their purview, as well
as the capacity of these systems to provide safe drinking water. The pandemic also underscored
the limitations of both EPA resources and tribal drinking water system resiliency. As a result,
tribal drinking water systems may be unable to operate safely and comply with drinking water
regulations. Access to safe and clean water is critical at all times, but even more so during
pandemic situations.
Recommendations: 10
EPA Effectively Planned for Future Remote Access Needs but Should Disconnect Unneeded
Services in Timely Manner, 21-P-0241, September 20, 2021
EPA OIG found that the EPA effectively planned a long-term solution to address remote
access concerns while transitioning to the U.S. General Services Administration’s
Enterprise Infrastructure Solutions contract. Specifically, in its solicitation for network and
telecommunications services under the Enterprise Infrastructure Solutions contract, the EPA
included a requirement that the selected vendor provide remote access solutions to support
12,500 concurrent remote users, with the capability to expand to 20,000 concurrent remote
users. This range of concurrent remote users should meet the EPA’s future workforce needs,
since it exceeds the EPA’s fiscal year 2020 workforce by almost 6,000 users.
EPA’s National Vehicle and Fuel Emissions Laboratory Has Taken Steps to Mitigate Impact of
Coronavirus Pandemic on Mobile Source Emission Compliance, 21-E-0158, June 7, 2021
EPA OIG examined how the COVID-19 pandemic impacted laboratory operations and testing
at the EPA’s Office of Transportation and Air Quality’s National Vehicle and Fuel Emissions
Laboratory and how those impacts affected mobile source emissions compliance. With
an annual target of 2,600 tests, the laboratory conducted 670 total tests in 2020, a large
reduction from the 2,267 tests completed in 2019 on light-duty vehicles, engines, and fuels.
The Office of Transportation and Air Quality identified the greatest challenges to supporting
the compliance programs during the COVID-19 pandemic were their inability to conduct
testing at National Vehicle and Fuel Emissions Laboratory due to closures and the inability of
staff to travel for inspections and audits. The Office of Transportation and Air Quality worked
with manufacturers to find flexibilities available under existing authority to address the
unprecedented situation caused by the pandemic. The National Vehicle and Fuel Emissions
Laboratory was able to prioritize testing of groups that could more likely cause excess emissions
or experience in-use emissions problems and employed alternative approaches to overseeing
compliance like conducting certification testing and laboratory audits virtually instead of in
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person. EPA OIG found that while the COVID-19 pandemic affected National Vehicle and Fuel
Emissions Laboratory operations, the laboratory took measures to mitigate these impacts on its
compliance programs.
EPA Did Not Conduct Agencywide Risk Assessment of CARES Act Appropriations, Increasing
Risk of Fraud, Waste, Abuse, and Mismanagement, 21-E-0128, May 4, 2021
EPA OIG initiated an evaluation of the EPA’s internal controls for the emergency supplemental
appropriations provided to the EPA in the CARES Act. The objectives of this evaluation were to
document and assess the internal controls that the EPA implemented to mitigate risks of fraud,
waste, abuse, and mismanagement over the CARES Act appropriations. EPA OIG’s evaluation
determined that the Agency did not fully comply with federal laws, OMB Circular A-123, and
the Government Accountability Office Green Book. Specifically, the Office of the Chief Financial
Officer, which is responsible for agencywide Emergency Risk Management and internal controls,
did not have processes to develop, communicate, and mitigate any entity-level risks through
implementation of internal controls related to the CARES Act supplemental appropriations.
Recommendations: 2
EPA Needs to Improve Processes for Updating Guidance, Monitoring Corrective Actions, and
Managing Remote Access for External Users, 21-E-0124, April 16, 2021
During the annual evaluation of the EPA’s compliance with the Federal Information Systems
Management Act, EPA OIG reviewed EPA’s compliance with the “Identity and Access
Management” domain, which is relevant to EPA’s COVID-19 readiness, meaning it related to the
Agency’s ability to respond to IT threats and vulnerabilities and maintain IT operations during
the coronavirus pandemic. EPA OIG found weaknesses in the agency’s management of user
identity and access including allowing external users access to the web application directory
system without documented approval or verification that the users needed access to the system
to do their jobs, and a lack of monitoring to identify privileged user access for unusual or
unauthorized activity.
Recommendations: 5
U.S. Farm Credit Administration OIG
Survey of Farm Credit Administration Employees on COVID-19, I-21-02, June 9, 2021
The Farm Credit Administration OIG produced an inspection report on their survey of Farm Credit
Administration employees of the safety measures and other actions implemented by Farm
Credit Administrations in response to COVID-19. The survey results showed that employees
believed the Farm Credit Administration took positive actions to implement safety measures and
other actions in response to COVID-19. The survey showed that most employees were working
remotely since the COVID-19 operating changes, and they felt that they have been able to fully
perform all work responsibilities in the remote environment.
Recommendations: 1
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U.S. General Services Administration OIG
PBS Did Not Always Follow CDC and Internal Guidance to Limit the Risk of COVID-19 Exposure,
A201018/P/4/R21005, August 26, 2021
The General Services Administration found that their Public Buildings Service did not always
take appropriate action to limit the risk of exposure to COVID-19 in its owned and leased
facilities. They also found that the Public Buildings Service did not always receive or provide
timely notice of positive COVID-19 incidents in accordance with the Public Buildings Service’s
notification process. As a result, the Public Buildings Service could not take appropriate action
to clean and disinfect affected space. Further, building occupants, contractors, and visitors may
have unknowingly passed through space contaminated by individuals infected with COVID-19,
and been at increased risk of exposure to and transmission of the disease.
Federal Reserve Board & Consumer Financial Protection Bureau OIG
Results of Analytical Testing of the Board’s Publicly Reported Data for the Secondary Market
Corporate Credit Facility, July 14, 2021
In response to the economic effects of the COVID-19 pandemic, the Federal Reserve Board
established several emergency lending programs and facilities to provide loans to employers,
certain businesses, and communities across the country. The Federal Reserve Board
established two facilities to support credit to large employers: the Primary Market Corporate
Credit Facility for new bond and loan issuance and the Secondary Market Corporate Credit
Facility to provide liquidity for outstanding corporate bonds. The Federal Reserve Board
designed the Secondary Market Corporate Credit Facility to create a portfolio that tracked a
broad, diversified market index of U.S. corporate bonds. In February 2021, Federal Reserve
Board OIG announced an evaluation of third-party cybersecurity risk management processes
for vendors supporting the Main Street Lending Program and the Secondary Market Corporate
Credit Facility. During our planning work for this evaluation, Federal Reserve Board OIG identified
transactions that appeared to have been documented twice in each of the Secondary Market
Corporate Credit Facility transaction-specific disclosures published from January through
April 2021. In addition, Federal Reserve Board OIG identified instances in each of the publicly
reported transaction-specific disclosures published from January through April 2021 in
which transactions for partial bond redemptions were not clearly labeled and did not include
redemption amounts. After informing Federal Reserve Board and Federal Reserve Bank of
New York officials of these duplicate entries, they took immediate steps to strengthen internal
review processes to ensure that these transactions are appropriately recorded in the Secondary
Market Corporate Credit Facility public disclosure data. The Federal Reserve Board OIG offered
two items for management’s immediate consideration. Our final report for this evaluation may
include recommendations related to these issues
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Results of Analytical Testing of the Board’s Publicly Reported Data for the Main Street Lending
Program, April 14, 2021
In response to the economic effects of the COVID-19 pandemic, the Federal Reserve Board
established several emergency lending programs and facilities to provide loans to employers,
certain businesses, and communities across the country. The Federal Reserve Board
established the Main Street Lending Program to support lending to small and medium-sized
for-profit businesses and nonprofit organizations that were unable to access the PPP or that
required additional financial support after receiving a PPP loan. The Main Street Lending
Program ended on January 8, 2021. In February 2021, Federal Reserve Board OIG announced
an evaluation of third-party cybersecurity risk management processes for vendors supporting
the Main Street Lending Program and the Secondary Market Corporate Credit Facility. During
our planning work for this evaluation, Federal Reserve Board OIG checked the accuracy and
completeness of specific demographic data to identify invalid city-state combinations. Federal
Reserve Board OIG also determined the accuracy of specific Main Street Lending Program
transaction disclosure data. The Federal Reserve Board OIG identified several inaccurate
city and state data points affecting a limited number of published loan transactions for the
Main Street Lending Program. After informing Federal Reserve Board and System officials of
these inaccuracies, they took immediate steps to address them and to update the Board’s
public reporting. The Federal Reserve Board OIG’s final report for this evaluation may include
recommendations related to the issues described in this memorandum.
U.S. National Railroad Passenger Corporation (Amtrak) Office OIG
GOVERNANCE: Amtrak Continues to Demonstrate Good Stewardship of Pandemic Relief Funds,
OIG-MAR-2021-009, May 12, 2021
Amtrak continued to demonstrate good stewardship of federal funds provided to prevent,
prepare for, and respond to the pandemic. Amtrak has been accurately reporting on how it is
using funds from the Coronavirus Response and Relief Supplemental Appropriations Act of
2021 to help states and commuter rail operators meet their obligations to Amtrak. Amtrak
OIG identified two opportunities for Amtrak to be more transparent about its spending plans
and workforce status to provide its oversight agencies and Congress better insight into how
the company is using funds to address pandemic needs. Because Amtrak continues to receive
and will likely require additional federal assistance as it recovers from the pandemic, Amtrak
can help reassure Congress and other stakeholders it is using these funds as intended by
communicating thoroughly and transparently to stakeholders.
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U.S. National Science Foundation (NSF) OIG
Capstone Report: Observations on the OMB COVID-19 Flexibilities, 21-6-003, August 3, 2021
In response to the COVID-19 pandemic, OMB issued, and various federal agencies (including
the NSF) implemented, three memoranda providing temporary administrative flexibilities for
federal financial assistance awards. NSF OIG engaged a certified public accountant (CPA) firm
to conduct 10 audits of award recipients’ implementation of the COVID-19 flexibilities. Although
the certified public accountant firm found that NSF award recipients generally complied with
relevant guidance, the report identifies three common themes observed during the course
of the ten COVID-19 flexibility audits: (1) recipients were not always able to implement the
flexibilities due to insufficient time and/or guidance; (2) recipients were hesitant to use the
flexibilities based on available guidance and federal funding sources; and (3) recipients did not
consistently track or monitor their use of the flexibilities, as they were not required to.
Performance Audit of the Implementation of OMB COVID-19 Flexibilities – University of
Michigan, 21-1-018, August 2, 2021
The NSF OIG engaged a CPA firm to conduct a performance audit of the implementation of
OMB COVID-19 flexibilities at the University of Michigan for the period March 1 to September
30, 2020. The auditors tested more than $1 million of the $61.8 million of costs incurred
on NSF awards. The objective of the audit was to determine if University of Michigan used
the administrative COVID-19 flexibilities authorized by OMB and, if so, whether University of
Michigan complied with the associated guidelines.
Significant Recommendations: 3
Performance Audit of the Implementation of OMB COVID-19 Flexibilities – University of Central
Florida, 21-1-015, May 27, 2012
The NSF OIG engaged a CPA firm to conduct a performance audit of the implementation of OMB
COVID-19 flexibilities at the University of Central Florida for the period March 1 to September
30, 2020. The auditors tested approximately $380,000 of the more than $14.8 million of costs
claimed to NSF. The audit objective was to determine if University of Central Florida used the
administrative COVID-19 flexibilities authorized by OMB and, if so, whether University of Central
Florida complied with the associated guidelines.
Recommendations: 7
Significant Recommendations: 7
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Performance Audit of the Implementation of OMB COVID-19 Flexibilities – California Institute
of Technology, 21-1-014, May 26, 2021
The NSF OIG engaged a CPA firm to conduct a performance audit of the implementation of
OMB COVID-19 flexibilities at the California Institute of Technology for the period March 1 to
September 30, 2020. The auditors tested approximately $170,000 of the more than $54.9
million of costs claimed to NSF. The objective of the audit was to determine if California Institute
of Technology used the administrative COVID-19 flexibilities authorized by OMB and, if so,
whether California Institute of Technology complied with the associated guidelines.
Significant Recommendations: 11
Performance Audit of the Implementation of OMB COVID-19 Flexibilities - University of
Wisconsin–Madison, 21-1-013, May 25, 2021
The NSF OIG engaged a CPA firm to conduct a performance audit of the implementation of
OMB COVID-19 flexibilities at the University of Wisconsin–Madison for the period March 1 to
September 30, 2020. The auditors tested approximately $188,000 of the more than $55
million of costs claimed to NSF. The objective of the audit was to determine if University of
Wisconsin–Madison used the administrative COVID-19 flexibilities authorized by OMB and, if so,
whether University of Wisconsin–Madison complied with the associated guidelines.
Significant Recommendations: 8
Performance Audit of the Implementation of OMB COVID-19 Flexibilities - Florida State
University, 21-1-012, May 25, 2021
The NSF OIG engaged a CPA firm to conduct a performance audit of the implementation of OMB
COVID-19 flexibilities at Florida State University for the period March 1 to September 30, 2020.
The auditors tested approximately $725,000 of the more than $30.8 million of costs claimed
to NSF. The audit objective was to determine if Florida State University used the administrative
COVID-19 flexibilities authorized by OMB and, if so, whether Florida State University complied
with the associated guidelines.
Significant Recommendations: 8
Performance Audit of the Implementation of OMB COVID-19 Flexibilities – Florida International
University, 21-1-011, May 19, 2021
The NSF OIG engaged a CPA firm to conduct a performance audit of the implementation of OMB
COVID-19 flexibilities at Florida International University for the period March 1 to September
30, 2020. The auditors tested approximately $208,000 of the more than $12.4 million of costs
claimed to NSF. The audit objective was to determine if Florida International University used the
administrative COVID-19 flexibilities authorized by OMB and, if so, whether Florida International
University complied with the associated guidelines.
Significant Recommendations: 9
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Performance Audit of the Implementation of OMB COVID-19 Flexibilities – State University of
New York at Stony Brook, 21-1-010, May 18, 2021
The NSF OIG engaged a CPA firm to conduct a performance audit of the implementation of OMB
COVID-19 flexibilities at the State University of New York at Stony Brook for the period March 1 to
September 30, 2020. The auditors tested approximately $611,000 of the more than $21 million
of costs claimed to NSF. The objective of the audit was to determine if State University of New
York at Stony Brook used the administrative COVID-19 flexibilities authorized by OMB and, if so,
whether State University of New York at Stony Brook complied with the associated guidelines.
Significant Recommendations: 10
Performance Audit of the Implementation of OMB COVID-19 Flexibilities - University of New
Mexico, 21-1-009, May 13, 2021
The NSF OIG engaged a CPA firm to conduct a performance audit of the implementation of OMB
COVID-19 flexibilities at the University of New Mexico for the period March 1 to September 30,
2020. The auditors tested approximately $187,000 of the more than $15.6 million of costs
claimed to NSF. The audit objective was to determine if the University of New Mexico used the
administrative COVID-19 flexibilities authorized by OMB and, if so, whether the University of New
Mexico complied with the associated guidelines.
Recommendations: 9
Significant Recommendations: 9
U.S. Office of Personnel Management (OPM) OIG
Evaluation of OPM’s Response to the COVID-19 Pandemic, 4K-FS-00-20-042, May 6, 2021
In May 2020, OPM issued a Returning to OPM Facilities Preparedness Guide to assist managers
with the transition to reopen its offices during the COVID-19 pandemic. The Guide did not
specifically identify when employees would return to the office but provided a framework to
support OPM supervisors with guidelines and planning considerations for evaluating the needs
of employees as OPM returns from a maximum telework operating status. During OPM OIG’s
evaluation, they determined that: (1) Improvements were needed for processing COVID-19
incidents; (2) OPM management did not require workers to wear face coverings; and (3) OPM
needed to implement additional signage for entering, social distancing, and routine cleaning
and disinfecting at the Theodore Roosevelt Federal Building.
Recommendations: 6
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Pandemic Response Accountability Committee (PRAC)
Observations: Fiscal Year 2020 COVID-19 Federal Contracting, P-21-04, August 4, 2021
The PRAC’s objective was to review pandemic-related federal contracts and identify first-time
contractors and contracts awarded without competitive bidding. PRAC found that first-time
federal contractors received $4.4 billion worth of pandemic contracts in Fiscal Year 2020 and
that $128 million was de-obligated from contracts with first-time federal contractors during
the same period. Additionally, PRAC identified the four most common flexibilities identified to
justify limited competition were urgency, only one source, simplified acquisition procedures, and
authorized by statute. Of these, PRAC found that 11% of non-competitive contracts used the
“only one responsible source” authority, which is defined to be used when supplies and services
are available from only one source in certain conditions. A limited sample revealed that 10 of
14 contracts either shouldn’t have selected that authority or had data entry errors within the
Federal Procurement Data System.
Key Insights: COVID-19 in Correctional and Detention Facilities, PRAC-2021-03, May 21, 2021
Correctional and detention facilities present unique challenges in preventing and controlling
the spread of COVID-19. When compared to the general population, a disproportionate number
of COVID-19 outbreaks and deaths occur in jails, prisons, and detention facilities across
the country. Considering the increased risk presented by these congregate settings, several
Offices of Inspectors General published reports on how federal agencies handled the COVID-19
pandemic in correctional and detention environments. This insights reports summarizes the
work completed by OIGs related to the steps federal agencies have taken to prevent the spread
and mitigate the impact of COVID-19 on their staff and the individuals housed in federal
correctional and detention facilities. Common issues identified include challenges of physical
layout, capacity, staffing, guidance, consistency in mitigation efforts across facility types, and
safe transport of inmates and detainees.
U.S. Peace Corps OIG
Management Implication Report: Peace Corps/Ukraine’s PEPFAR Food Voucher Program, IG-
21-02-SR, July 15, 2021
In March 2021, the Peace Corps/Ukraine director of management and operations and deputy
director of management and operations submitted a complaint to Peace Corps OIG about
concerns of fraud and mismanagement of the President’s Emergency Plan for AIDS Relief
Food Voucher Program. The Voucher program was initiated and expanded during a period of
time when all volunteers had been evacuated from Peace Corps/Ukraine due to COVID-19.
The complaint emphasized that Peace Corps/Ukraine had inaccurately reported data and food
voucher project results, mismanaged the approved project plan, and lacked sufficient oversight
over the voucher program. The purpose of this Management Implication Report, which does not
make a recommendation, is to summarize information concerning this complaint and actions
taken by Peace Corps OIG in response to the complaint.
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U.S. Small Business Administration (SBA) OIG
The Small Business Administration’s Implementation of Recommended Controls and the
Economic Aid Act, August 12, 2021 21-19
SBA implemented or initiated action on all SBA OIG recommendations to strengthen internal
controls related to the Paycheck Protection Program (PPP). The Economic Aid Act continued
assistance under the PPP for small businesses financially affected by the ongoing coronavirus
pandemic. SBA OIG found SBA implemented the PPP in accordance with the Economic Aid
Act with two exceptions. SBA did not 1) require an assessment of affiliation for faith-based
organizations which contradicts its internal control procedures and 2) issue guidance regarding
farm credit system institutions to ensure requirements were met. SBA OIG recommended SBA
assess affiliation for faith-based organizations to ensure only eligible faith-based organizations
receive the applicable PPP loans.
Recommendations: 1
Significant Recommendations: 1
Evaluation of SBA’s Coronavirus Reconstitution Plan, 21-18, July 12, 2021
SBA OIG found that SBA established its May 2020 COVID-19 Reconstitution Plan in accordance
with applicable federal guidance. SBA OIG identified issues with the implementation of the
reconstitution plan that should be addressed to help the agency safeguard its employees from
contracting and spreading COVID-19 in the workplace. SBA OIG found the agency did not follow
occupancy procedures for advancing or reverting phases at its Washington, DC headquarters.
SBA also did not implement exposure tracking protocols to ensure it consistently traced
COVID-19 cases. SBA OIG found the agency did not consistently notify its staff of presumed or
confirmed COVID-19 cases in the sampling SBA OIG analyzed. SBA did not consistently contact
potentially exposed personnel and ensure employees completed 14-day quarantine periods. SBA
replaced the reconstitution plan with its new COVID-19 Workplace Safety Plan in February 2021.
SBA made one recommendation for SBA to enforce the requirements of its new workplace safety
plan by consistently applying procedures for occupancy and exposure tracking and to accurately
record and maintain supporting documentation for all reported COVID-19 cases.
Recommendations: 1
Significant Recommendations: 1
SBA’s Handling of Identity Theft in the COVID-19 Economic Injury Disaster Loan Program, 21-
15, May 6, 2021
SBA OIG issued this evaluation report to notify SBA officials of significant matters regarding its
handling of complaints of identity theft COVID-19 Economic Injury Disaster Loan program. SBA
OIG recommend the Administrator to direct the Associate Administrator for the Office of Disaster
Assistance, the Chief Financial Officer for the Office of Performance Management and Chief
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Financial Officer, and the Associate Administrator for the Office of Capital Access to: (1) Develop
a process to maintain and track all identity theft complaints; (2) Develop a process to provide
status updates to each complainant alleging identity theft; and (3) Complete and formalize a
process to restore identity theft victims to their condition prior to the fraud. The process should
include steps to stop the loan billing statements, prevent delinquency collections, release them
from loan liability and Uniform Commercial Code liens. SBA OIG also recommended that SBA
develop a process to remove any fraudulent loans and related Uniform Commercial Code filing
fees from its financial records, and review over 150,000 returned billing statements and resolve
any that involve identity theft, then refer fraudulent loans to OIG.
Recommendations: 5
Significant Recommendations: 5
Management Alert Serious Concerns About SBA’s Control Environment and the Tracking of
Performance Results in the Shuttered Venue Operators Grant Program, 21-13, April 7, 2021
SBA OIG issued this Management Alert regarding serious concerns with the control environment
and the tracking of performance results in the Shuttered Venue Operators Grant program
requiring immediate attention and action. SBA should take immediate action to reduce or
eliminate risks by strengthening existing controls and implementing internal controls to address
potential misuse of federal funds. Strong controls will ensure the Shuttered Venue Operators
Grant program can effectively help eligible small business owners and entities that have
suffered economic injury because of the COVID-19 pandemic. To address serious concerns and
potential deficiencies in internal controls of the Shuttered Venue Operators Grant program, SBA
OIG suggests the SBA Administrator: (1) Reassess the audit risk plan to identify vulnerabilities,
commensurate with the expected volume of applications and average award amount, to
strengthen internal controls and reduce risk of misuse of federal funds; (2) Clearly establish 2
CFR 200 criteria for the program to ensure compliance during the implementation and oversight
phases; (3) Implement required performance measures to determine the impact of program
funds; and (4) Ensure sufficient resources are available to implement and oversee the Shuttered
Venue Operators Grant program.
U.S. Postal Service (USPS) OIG
U.S. Postal Service Protection Against External Cyberattacks, 20-277-R21, August 31,2021
USPS OIG’s objective was to determine if the Postal Service has an effective security posture
to protect its Information Technology Infrastructure from external cyberattacks and prevent
unauthorized access to restricted data. USPS OIG found that the Postal Service generally has an
effective security posture and security awareness program to protect its IT infrastructure from
external cyberattacks.
Recommendations: 4

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COVID-19 Leave Administration. 20-032-R21, June 16, 2021
USPS OIG’s objective was to assess the Postal Service’s management of its employees’ use of
COVID-19 leave under the Families First Coronavirus Response Act. Although the Families First
Coronavirus Response Act expired on December 31, 2020, the Postal Service continued to allow
liberal leave usage for employees who had a sickness related to COVID‑19. On March 11, 2021,
ARPA was signed into law. Effective March 12, 2021, and continuing through September 30,
2021, ARPA provides employees with up to 600 hours of paid leave. The OPM issued guidance
on using the new leave authority on April 29, 2021.
Recommendations: 4
U.S. Postal Inspection Service Pandemic Response to Mail Fraud and Mail Theft, 20-305-R21,
May 20, 2021
USPS OIG’s objective was to assess the Postal Inspection Service’s response to mail fraud and
mail theft during the COVID-19 pandemic. Overall, USPS OIG found that the Postal Inspection
Service took appropriate action to respond to mail fraud and mail theft during the COVID-19
pandemic. For example, the Mail Fraud Program employees participated in federal task forces
to investigate and disrupt COVID-19 related scams. Postal inspectors also coordinated with law
enforcement agencies when Economic Impact Payment checks were mailed to help prevent mail
theft.
Recommendations: 2
Customer Perceptions of the U.S. Postal Service During the COVID-19 Pandemic, RISC-
WP-21-002. April 9, 2021
USPS OIG conducted a nationally representative survey to understand the ways the COVID 19
pandemic may have altered customer perceptions of the Postal Service and their habits around
mail and other postal-related activities. USPS OIG found that Americans continued to hold
favorable views of the Postal Service during the pandemic, underscoring the important role
USPS plays for the nation. USPS OIG survey results provide information on changes in customer
behavior and expectations, and careful monitoring of emerging trends will allow the Postal
Service to continue to prepare for new and growing demands moving forward.
U.S. Social Security Administration (SSA) OIG
Interim Report: The Social Security Administration’s Processing of Mail and Enumeration
Services During the COVID-19 Pandemic, A-08-21-51036; A-15-21-51015, July 29, 2021
This interim report presents preliminary findings related to two SSA OIG reviews, A-08-21-51036
& A-15-21-51015. The objectives of these audits are to evaluate SSA’s management of mail and
controls over its processing of Social Security card applications during the COVID-19 pandemic.

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Safety of Social Security Administration Employees and Visitors Since March 2020, A-15-20-
51001, June 16, 2021
On March 17, 2020, the SSA Commissioner announced the closure of field offices and
redirected customers to online and telephone service channels. Although offices have been
closed to the general public since that date, SSA continues providing limited in-person services
by appointment only. SSA reported that a limited number of authorized employees, mostly
managers, enter field offices to perform mission-critical work that cannot be done remotely,
such as opening mail, sending documents to remote workers that require SSA’s action, and
facilitating the return of documents to the public.
The Social Security Administration’s Telephone Services During June 2020, A-05-20-50998,
April 7, 2021
In June 2020, SSA’s field offices and national 800-number received 30% more calls than June
2019, with field offices receiving most of the additional calls. SSA altered operations because
of the COVID-19 pandemic to continue serving the public through its telephone operations. In
general, SSA’s telephone services performance during June 2020 was similar to 13 customer
service call centers SSA OIG reviewed from 10 other Federal agencies, as compared to June
2019, but SSA’s performance seemed to fare better during COVID-19 than industry call centers.
U.S. Special Inspector General for Pandemic Recovery (SIGPR)
Direct Loan Program Survey Results, SIGPR-A-21-003, September 23, 2021
SIGPR is currently examining the Department of Treasury’s administration of the Direct Loan
Program. As part of its examination, SIGPR surveyed both approved and non-approved loan
applicants to gain an understanding of how all applicants viewed the program. The purpose of
the report was to provide the results of SIGPR’s survey of approved and non-approved Direct
Loan Program applicants.
Addendum - Alert Memorandum: Caribbean Sun Airlines, Inc. Has Not Responded to the
Department of the Treasury’s Notice of Non-Compliance with the U.S. Treasury Aviation Loan
and Guarantee Agreement, SIGPR-A-21-002, September 21, 2021
On September 8, 2021, SIGPR issued an alert memorandum stating that Caribbean Sun
Airlines, Inc. had not complied with Treasury’s Notice of Non-Compliance. On September 13,
2021, SIGPR received a copy of Caribbean Sun Airlines, Inc.’s response which was provided to
Treasury’s Program Manager for Aviation Loans and forwarded to SIGPR.
Recommendations: 1

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Alert Memorandum: Caribbean Sun Airlines, Inc. Has Not Responded to the Department of
the Treasury’s Notice of Non-Compliance with the U.S. Treasury Aviation Loan and Guarantee
Agreement, SIGPR-A-21-002, September 8, 2021
On December 7, 2020, Caribbean Sun Airlines, Inc. obtained a loan from Treasury under
Section 4003 of the CARES Act for $6,768,749. On March 25, 2021, SIGPR issued a survey to
Caribbean Sun Airlines, Inc. but did not receive a response. On August 2, 2021, SIGPR issued an
Alert Memorandum, notifying Treasury that Caribbean Sun Airlines, Inc. was non-responsive. On
August 3, 2021, Treasury issued a Notice of Non-compliance, requiring Caribbean Sun Airlines,
Inc. to respond to our survey within 30 days. Pursuant to Treasury’s Notice of Non-compliance,
issued on August 3, 2021, Caribbean Sun Airlines, Inc. had until September 2, 2021, to respond
to SIGPR’s survey. As stated in Treasury’s notice of non-compliance, failure to respond to
SIGPR’s survey by September 2, 2021, would constitute an “Event of Default” under Section
7.01(d) of the Agreement. An event of default would allow Treasury to pursue remedies under
the Agreement, including declaring the loan immediately due and payable in whole or in part.
Recommendations: 1
Alert Memorandum: Caribbean Sun Airlines, Inc. Has Not Responded to SIGPR’s Direct Loan
Program Survey, SIGPR-A-21-1, August 12, 2021
The purpose of this memorandum was to notify Treasury that Caribbean Sun Airlines, Inc. had
not responded to SIGPR’s Direct Loan Program survey. Accordingly, SIGPR recommended that
Treasury should take immediate action to address this matter.
Recommendation: 1
Implementation Review: Loan Agreements Need to Provide for Appropriate Access to the
Special Inspector General for Pandemic Recovery, July 28, 2020, I-21-001, May 19, 2021
On July 28, 2020, SIGPR recommended that Treasury expressly include SIGPR in the list
of entities entitled to “timely and unrestricted access” to information from the borrower
in all loan agreements under section 4003 of the CARES Act. On July 30, 2020, Treasury
agreed to implement the change in future loan agreements. In the implementation review,
SIGPR’s objective was to determine whether corrective actions were taken to address the
recommendation. SIGPR reviewed the subsequent loan agreements under CARES Act section
4003(b)(1-3) and found that Treasury had taken appropriate corrective action to address the
recommendation.

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U.S. Special Inspector General for Trouble Asset Relief Program (SIGTARP)
Treasury Has Been Effective at Shifting the Hardest Hit Fund To Assist Homeowners Suffering
Pandemic-Related Hardships, Efforts That Could Be Further Enhanced, 21-001, June 10, 2021
This evaluation report assessed Treasury’s effectiveness in shifting the Hardest Hit Fund to
help homeowners suffering from unemployment, a loss of income, or other hardships related
to the pandemic. SIGTARP recommended on April 8, 2020, that Treasury take urgent action to
put to better use all remaining unspent Hardest Hit Funds and funds estimated to be unspent in
the Home Affordable Mortgage Program for Hardest Hit Fund’s traditional form of assistance—
unemployment mortgage assistance. SGTARP recommended that Treasury shift $118 million
of recovered funds to open Hardest Hit Fund programs that, in addition to the available $331
million, would provide a total of $449 million. Treasury did not implement SIGTARP’s April 2020
recommendations, but instead applied the $118 million to the Home Affordable Mortgage
Program accounts even though Home Affordable Mortgage Program was no longer open to new
applicants. State agencies in Hardest Hit Fund also sought Treasury approval to ramp back up
unemployment mortgage assistance. SIGTARP found that Treasury has been effective in shifting
the Hardest Hit Fund to help homeowners suffering from unemployment, a loss of income, or
other hardships related to the pandemic.
Recommendations: 7
U.S. Treasury Inspector General for Tax Administration (TIGTA)
People First Initiative Actions Helped Taxpayers During the Pandemic; However, Many
Taxpayers Received Inaccurate Collection Notices, 2021-36-060, September 16, 2021
During the start of COVID-19, the Internal Revenue Service (IRS) was impacted in many ways.
IRS sites closed for months, thus postponing everyday operations such as mailing notices and
receiving and processing correspondence from taxpayers. During this time, the IRS had to
act and make decisions as to how to proceed, and some of the decisions potentially caused
confusion and undue burden to numerous taxpayers who received erroneous Collection notices.
Upon reopening its print sites, the IRS decided to issue millions of notices to taxpayers that had
generated during the shutdown, many with erroneous notice dates and payment due dates.
TIGTA’s review of these notices identified that the IRS issued 89,338 premature Notices and
Demand for tax that were generated for 87,542 individual taxpayers who filed Tax Year 2019
tax returns before the COVID-19 filing date extension of July 15, 2020. The notices showed
that balances were owed even though the taxes were not actually due because of the filing
extension.
Recommendations: 1

Semiannual Report to Congress  |  APRIL 1, 2021–SEPTEMBER 30, 2021
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APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

HOLDING
WRONGDOERS
ACCOUNTABLE
INSIGHTS THROUGH
OVERSIGHT
REPORTS
Steps Were Taken to Protect Employee Health and Safety, but Additional Efforts Are Needed to
Ensure Compliance With Federal Guidelines During Pandemics, 2021-16-073, September 16,
2021
This audit was initiated to evaluate the actions the IRS has taken to execute its Pandemic
Incident Management Plan and protect the health and safety of its employees during the
COVID-19 pandemic. Overall, the IRS completed necessary actions related to the requirements
outlined in its Pandemic Incident Management Plan and continues to take steps to ensure the
health and safety of its employees. In addition, the IRS leveraged data related to employee
infection and transmission rates, employee telework eligibility and status, and facility status to
allow for informed decision-making during the pandemic.
Recommendations: 1
Inspection of Health and Safety Measures at Select IRS Taxpayer Assistance Centers During
the COVID-19 Pandemic, 2021-IER004, September 13, 2021
In April 2021, TIGTA conducted unannounced health and safety inspections of 20 judgmentally
selected IRS Tax Assistance Centers. Overall, the IRS generally implemented health and
safety measures to help protect individuals (both IRS employees and taxpayers) at the 20 Tax
Assistance Centers.
Effects of the COVID-19 Pandemic on Business Tax Return Processing Operations, 2021-16-
073, September 2, 2021
The closure of Tax Processing Centers created a significant backlog of business tax returns,
correspondence, and other types of business taxpayer-related work that needed to be
processed. Some penalties were inappropriately assessed due to delays in processing payments
or tax forms. In addition, systemic payment processing limitations caused further delays in
processing payments. Redirecting more payments to the lockbox sites could facilitate reducing
the backlog.
Recommendations: 2
Inspection of Health and Safety Measures at Select IRS Facilities During the COVID-19
Pandemic, 2021-IE-R003, July 26, 2021
In March 2021, TIGTA conducted unannounced health and safety inspections of nine
judgmentally selected IRS facilities. Overall, the IRS generally implemented health and safety
measures to help protect individuals at the nine facilities.

Semiannual Report to Congress  |  APRIL 1, 2021–SEPTEMBER 30, 2021
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APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

HOLDING
WRONGDOERS
ACCOUNTABLE
INSIGHTS THROUGH
OVERSIGHT
REPORTS
Taxpayers Were Notified About the CARES Act Retirement Plan Provisions; However, Additional
Actions Could Be Taken to Identify Potential Noncompliance, 2021-16-044, July 20, 2021
The IRS took a number of steps to oversee the retirement-related provisions of the CARES Act,
including educating taxpayers and the development of high-level compliance plans to enforce
taxpayer compliance with the provisions. For example, the IRS informed taxpayers about the
CARES Act retirement provisions. This included creating and distributing various news releases,
notices, and a tax tip to educate taxpayers of the new retirement provisions. Additionally,
management developed compliance plans for Sections 2202 and 2203 to assess the impact
on examination activities and outline the steps necessary to efficiently encourage and enforce
taxpayer compliance. The Section 2202 Compliance Plan identified risks associated with
taxpayer eligibility for and reporting of early distributions and recommended training examiners
and monitoring examination work for taxpayer compliance to determine if additional study is
warranted. The Section 2203 Compliance Plan did not identify any risks associated with the
waiver of Required Minimum Distributions, but management took steps to notify examiners
about the provision.
Recommendations: 2
Implementation of Tax Year 2020 Employer Tax Credits Enacted in Response to the COVID-19
Pandemic, 2021-46-043, July 9, 2021
TIGTA’s review identified that the expediency required to implement this much-needed relief to
employers did not allow for the development of the complex systemic verifications, including
pre-refund controls (e.g., electronic business rules). As such, the IRS established procedures to
manually review and process Forms 7200. TIGTA’s review of 9,459 advance payment requests
received as of June 4, 2020, determined that the IRS accurately processed most of these
requests. TIGTA identified processing errors on 17 total Forms 7200 with incorrect credits
totaling $83,806. The errors included forms processed more than once; forms involving a
government entity, which does not qualify; and forms that claimed an amount over the allowable
threshold. The IRS was able to initiate actions to ensure that the taxpayers’ accounts reflect the
correct amount of employer tax credits.
Assessment of Processes to Verify Tentative Carryback Refund Eligibility, 2021-46-035, June 2,
2021
TIGTA’s review found that subsequent to enactment of the CARES Act, the IRS immediately took
steps in an effort to readily provide assistance to taxpayers in obtaining refunds associated
with CARES Act tentative refund applications. However, some tentative refund applications were
erroneously processed after the filing deadline. In addition, some tentative refund applications,
including some associated with identity theft tax accounts, were not sent for required fraud
review.
Recommendations: 5

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APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

HOLDING
WRONGDOERS
ACCOUNTABLE
INSIGHTS THROUGH
OVERSIGHT
REPORTS
Implementation of Economic Impact Payments, 2021-46-034, May 24, 2021
This report presents the results of TIGTA’s review to assess the IRS Economic Impact Payment
outreach and assistance to individuals, accuracy of the computation of the payment, and
adequacy of controls to prevent ineligible individuals from receiving a payment. TIGTA found
that as of May 21, 2020, the IRS correctly computed 98% of the 157 million issued Economic
Impact Payments. However, as of July 16, 2020, the IRS had issued over 4.4 million Economic
Impact Payments totaling nearly $5.5 billion to potentially ineligible individuals. These payments
included payments made to deceased individuals, potentially nonqualified dependents,
nonresidents, individuals in U.S. Territories (who have also received payments from the
Territories), and individuals with filing status changes. As of October 1, 2020, individuals that
received payments but were ineligible voluntarily returned 65,447 payments totaling more than
$80 million.
Recommendations: 2
Interim Report - Status of Coronavirus Response Funding, 2021-16-026, May 5, 2021
This audit is one in a series of audits being conducted by TIGTA as part of our oversight role of
the IRS’s response to the coronavirus pandemic, including implementation of the applicable
CARES Act provisions. TIGTA’s overall objective was to evaluate controls implemented by the IRS
to ensure that the $765.7 million in appropriated funds received for its coronavirus response is
adequately tracked and used only for the intended purpose. As of September 30, 2020, the IRS
spent $438.5 million of the $765.7 million in appropriated funds it received for its coronavirus
response, with $327.2 million still available for use. TIGTA found that the IRS provided an
initial spend plan to Congress, as required, describing its planned use of the $765.7 million
in coronavirus funding. The IRS did not, however, provide Congress a quarterly report of its
coronavirus response funding expenditures through June 30, 2020, as required. The IRS stated
that ongoing discussions with the Department of the Treasury over what information should be
included in the spending report caused the delay in its quarterly reporting.
Assessment of the Effects of the Coronavirus Pandemic on Customer Service Operations,
2021-46-029, April 22, 2021
This audit was initiated to provide selected information related to the impact of COVID-19 on
the IRS’s Customer Service operations. The overall objective of this review was to assess the
impact of COVID-19 on IRS customer service operations and evaluate the development of
the IRS’s comprehensive customer service strategy. TIGTA found that in an effort to restore
service to taxpayers as quickly as possible, the IRS accelerated the implementation of several
customer service options it had been testing and expanded the use of existing technologies and
capabilities. However, the IRS’s ability to assist taxpayers continues to be affected by COVID-19.
Recommendations: 4

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APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

HOLDING
WRONGDOERS
ACCOUNTABLE
INSIGHTS THROUGH
OVERSIGHT
REPORTS
Appendix C: Hotline Data
Since inception, the Pandemic Response Accountability Committee received most of its
hotline complaints through its electronic complaint form. The PRAC’s hotline provides an
avenue for concerned citizens to report potential fraud, waste, abuse, and mismanagement
related to the pandemic response, including the CARES Act and other related legislation.
During the reporting period, we received 1,529 hotline tips, of which 310 were filed for
information or not actionable. The remaining 1,184 were deemed potentially actionable for
fraud, waste, abuse, or mismanagement. From these, the PRAC forwarded 1,219 allegations
to 11 different Offices of Inspection General for review and appropriate action.
1,529
hotline
tips
1,184
potential
actions
310 not
actionable
1,219
allegations

Semiannual Report to Congress  |  APRIL 1, 2021–SEPTEMBER 30, 2021
83
APPENDICES
HIGHLIGHTS
BACKGROUND
ACCOMPLISHMENTS

HOLDING
WRONGDOERS
ACCOUNTABLE
INSIGHTS THROUGH
OVERSIGHT
REPORTS
PRAC Point of Contact:
Lisa Reijula
Associate Director of Outreach and Engagement
Lisa.Reijula@cigie.gov
Visit our website at:
PandemicOversight.gov
Follow us on social media:
            @COVID_Oversight
Report Fraud, waste, abuse, or misconduct:
To report allegations of fraud, waste, abuse, or misconduct regarding pandemic
relief funds or programs please go to the PRAC website at
PandemicOversight.gov.
A Committee of the
Council of the Inspectors General
on Integrity and Efficiency

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