Dhs OIG 23 34 Fema Did Not Effectively Manage The Distribution Of Covid 19 Medical Supplies An
Summary
FEMA Did Not Effectively Manage the Distribution of COVID-19 Medical Supplies and Equipment, report OIG-23-34 of the Department of Homeland Security Office of Inspector General, dated July 19, 2023 and addressed by Inspector General Joseph V. Cuffari to FEMA Administrator Deanne Criswell. The report finds that FEMA did not use its Logistics Supply Chain Management System to track about 30 percent of the critical medical resources shipped and did not maintain delivery receipt documentation for about a third of the shipments reviewed. It reports that FEMA facilitated distribution of 885,608,984 items, including gloves, respirators, masks, gowns, testing supplies, face shields and ventilators, from January 22, 2020 to January 26, 2022. The report makes three recommendations, with which FEMA concurred, and includes appendices on methodology, FEMA's response, contributors and distribution.
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FEMA Did Not Effectively
Manage the Distribution
of COVID-19 Medical
Supplies and Equipment
July 19, 2023
OIG-23-34
OFFICE OF INSPECTOR GENERAL
Department of Homeland Security
Washington, DC 20528 / www.oig.dhs.gov
July 19, 2023
MEMORANDUM FOR: The Honorable Deanne Criswell
Administrator
Federal Emergency Management Agency
FROM: Joseph V. Cuffari, Ph.D.
Inspector General
SUBJECT: FEMA Did Not Effectively Manage the Distribution of
COVID-19 Medical Supplies and Equipment
For your action is our final report, FEMA Did Not Effectively Manage the
Distribution of COVID-19 Medical Supplies and Equipment. We incorporated the
formal comments provided by your office.
The report contains three recommendations aimed at improving the
management of the Federal Emergency Management Agency’s (FEMA)
distribution process in response to future disasters. Your office concurred with
all three recommendations. Based on the information provided in your response
to the draft report, we consider all three recommendations open and resolved.
Once your office has fully implemented the recommendations, please submit a
formal closeout letter to us within 30 days so that we may close the
recommendations. The memorandum should be accompanied by evidence of
completion of agreed-upon corrective actions.
Please send your response or closure request to OIGAuditsFollowup@oig.dhs.gov.
Consistent with our responsibility under the Inspector General Act of 1978, as
amended, we will provide copies of our report to congressional committees with
oversight and appropriation responsibility over the Department of Homeland
Security. We will post the report on our website for public dissemination.
Please call me with any questions, or your staff may contact Kristen Bernard,
Acting Deputy Inspector General for Audits, at (202) 981-6000.
Attachment
www.oig.dhs.gov
DHS OIG HIGHLIGHTS
FEMA Did Not Effectively Manage the Distribution
of COVID-19 Medical Supplies and Equipment
July 19, 2023 What We Found
Although the Federal Emergency Management Agency (FEMA)
Why We Did worked with its strategic partners to deliver critical medical
supplies and equipment in response to COVID-19, FEMA did
This Audit not effectively manage the distribution process. Specifically,
FEMA did not use the Logistics Supply Chain Management
On March 19, 2020, System (LSCMS), its system of record for managing the
FEMA was tasked with distribution process, to track about 30 percent of the critical
leading the Federal medical resources shipped, as required. Instead, FEMA used
response to combat the other tracking mechanisms, such as the Web Emergency
COVID-19 pandemic. Operations Center resource request system and spreadsheets,
FEMA was responsible that did not share information with LSCMS. In addition, FEMA
for coordinating the did not maintain delivery receipt documentation for about a
distribution of personal third of the shipments we reviewed. This occurred because
protective equipment, FEMA was under pressure to expedite the delivery of critical
ventilators, and medical medical resources and did not follow established business
supplies to state, local, practices. As a result, FEMA did not have full visibility into the
tribal, and territorial resources shipped and received, hindering its ability to make
governments. We informed decisions. Also, without delivery receipt documents,
conducted this audit to FEMA could not ensure it delivered billions of dollars of the
determine to what extent right resources, to the right place, at the right time.
FEMA managed and
distributed medical Since the COVID-19 pandemic began, FEMA evaluated its early
supplies and equipment response efforts and developed a Logistics Resource Tracker to
in response to COVID-19. help the National Response Coordination Center centrally track
the distribution of resources. Although the new automated tool
What We enhanced FEMA’s visibility into the resources shipped and
received, the tool did not always have accurate data. Without
Recommend accurate data, FEMA cannot ensure it has quality information
to make informed allocation decisions about where to send
resources, how to evaluate performance, and how to address
We made three risk in future disaster response operations.
recommendations to
improve FEMA’s future
response operations. FEMA’s Response
For Further Information: FEMA concurred with all three recommendations. Appendix B
Contact our Office of Public Affairs
at (202) 981-6000, or email us at
contains FEMA’s management response in its entirety.
DHS-
OIG.OfficePublicAffairs@oig.dhs.gov.
www.oig.dhs.gov OIG-23-34
OFFICE OF INSPECTOR GENERAL
Department of Homeland Security
Table of Contents
Background .................................................................................................... 1
Results of Audit .............................................................................................. 5
FEMA Delivered COVID-19 Medical Resources But Did Not Effectively
Manage the Distribution Process............................................................ 5
NRCC Developed an Automated Tool to Help Centrally Track COVID-19
Medical Resources, But Data in the Tool Was Not Always Accurate ........ 8
FEMA Did Not Consistently Maintain Delivery Receipt Documentation
for COVID-19 Medical Resource Shipments ......................................... 11
Conclusion.................................................................................................... 15
Recommendations ......................................................................................... 15
Management Comments and OIG Analysis .................................................... 16
Appendixes
Appendix A: Objective, Scope, and Methodology ................................. 19
Appendix B: FEMA Response to the Draft Report ................................. 22
Appendix C: Office of Audits Major Contributors to This Report ........... 27
Appendix D: Report Distribution .......................................................... 28
Abbreviations
FEMA Federal Emergency Management Agency
HHS U.S. Department of Health and Human Services
LMD Logistics Management Directorate
LSCMS Logistics Supply Chain Management System
NRCC National Response Coordination Center
PPE personal protective equipment
RRCC Regional Response Coordination Center
SLTT state, local, tribal, and territorial
WebEOC Web Emergency Operations Center
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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security
Background
In March 2020, the World Health Organization characterized the COVID-19
outbreak as a pandemic and the President declared a nationwide emergency. 1
On March 19, 2020, the Federal Emergency Management Agency (FEMA) was
tasked with leading the Federal response efforts among the U.S. Department of
Health and Human Services (HHS) and other agencies. FEMA was responsible
for reviewing resource requests, making sourcing and allocation decisions, and
coordinating the distribution of critical medical resources from across the
Federal Government, private sector, and other strategic partners to state, local,
tribal, and territorial (SLTT) governments. Critical medical resources included
personal protective equipment (PPE) such as face shields, surgical/procedural
masks, respirators, coveralls/gowns, and gloves, as well as ventilators and
COVID-19 testing supplies.
To coordinate the Federal response efforts, FEMA activated its National Response
Coordination Center (NRCC) 2 and 10 Regional Response Coordination Centers
(RRCCs). With HHS, FEMA also established the Unified Coordination Group.
These entities had the following responsibilities:
• NRCC was FEMA’s primary operations management center and focal
point for national resource coordination located at FEMA headquarters.
• RRCCs were multi-agency centers FEMA operated in each of its
10 regional offices as the focal points for regional resource coordination.
• The Unified Coordination Group made operational decisions and
provided input to the White House Coronavirus Task Force. The group
consisted of the FEMA Administrator, the HHS Assistant Secretary for
Preparedness and Response, the HHS Assistant Secretary for Health, and
an HHS Centers for Disease Control and Prevention representative.
Through the NRCC and RRCCs, FEMA worked with HHS and other strategic
partners to facilitate the distribution of nearly 886 million critical medical
resources 3 worth billions of dollars 4 to SLTT governments from January 22,
2020, through January 26, 2022, in response to the COVID-19 pandemic.
1 Proclamation on Declaring a National Emergency Concerning the Novel Coronavirus Disease
(COVID-19) Outbreak, March 13, 2020.
2 FEMA activated the NRCC from March 19, 2020, through June 23, 2021, for COVID-19. After
a 1-month deactivation, FEMA reactivated the NRCC from July 26, 2021, through July 22, 2022.
3 This figure excludes medical resources transported from foreign manufacturers to the United
States using Project Airbridge flights. We audited FEMA’s oversight of Project Airbridge under
a separate engagement.
4 FEMA could not provide an exact dollar amount associated with the value of these resources.
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Table 1 provides a breakdown of the distribution data by resource category, as
reported by FEMA.
Table 1. FEMA-reported Critical Medical Resources
Distributed in Response to COVID-19, January 22,
2020 – January 26, 2022
Resource Category Number of Items
Gloves 395,003,223
Respirators 267,628,358
Surgical/Procedural Masks 76,961,995
Coveralls/Gowns 65,990,234
COVID-19 Testing Supplies 53,101,535
Face Shields 26,902,226
Ventilators 21,413
Total 885,608,984
Source: Department of Homeland Security Office of Inspector
General analysis of NRCC data
Within FEMA’s Office of Response and Recovery, the Logistics Management
Directorate (LMD) provides guidance, standards, execution, and governance of
logistics operations. LMD’s mission is to deliver the right resources, at the right
place, at the right time, to support SLTT governments.
According to FEMA’s guidance, 5 the distribution process during a disaster
response begins when SLTT governments submit resource requests to their
respective RRCC. Then, RRCCs manually enter the resource requests into
FEMA’s Web Emergency Operations Center (WebEOC) Crisis Management
System, 6 the system of record for managing resource requests. When RRCCs
cannot fulfill resource requests or there are competing requests for scarce
resources, RRCCs will forward these requests in WebEOC to the NRCC for
adjudication and approval. Once the request is approved, RRCCs and the NRCC
acquire local or national resources, respectively, from FEMA’s strategic partners
across the Federal Government and private sector. 7 When the resources are
acquired, the NRCC and RRCCs manually enter and approve transportation
5 FEMA Resource Support Section Resource Request and Fulfillment Process Guide, February 12, 2016.
6 Within FEMA’s Office of Response and Recovery, the Response Directorate’s Operations
Division manages the implementation of WebEOC.
7 To acquire the necessary resources, FEMA uses various sourcing methods such as contracts,
purchase cards, mission assignments, interagency agreements, and donations.
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orders in the Logistics Supply Chain Management System (LSCMS). 8 According
to the FEMA Transportation Management Guide, LSCMS is FEMA’s system of
record for requesting and tracking the movement of commodities, supplies, and
equipment from FEMA’s distribution centers, private vendors, or other strategic
partners, typically through FEMA-manned incident support bases or Federal
staging areas, 9 to the final disaster locations. 10 LSCMS provides in-transit visibility
of shipments with the use of satellite transponders attached to trailers moving
resources. Figure 1 provides a simplified overview of FEMA’s distribution process.
Figure 1. Simplified Overview of FEMA’s Distribution Process
Source: DHS OIG analysis of FEMA guidance
In the last 3 years, we have issued three audit reports related to FEMA’s
management of its distribution process in response to major disasters
including Hurricanes Irma and Maria, as well as COVID-19. Specifically:
8 FEMA’s Logistics Systems Division within LMD manages the implementation of LSCMS,
including training, user accounts, reporting, and system modernization.
9 While functionally the same, incident support bases are overseen by NRCC staff at FEMA
headquarters, while Federal staging areas are overseen by RRCC or joint field office staff in the
FEMA region.
10 Final disaster locations include state-managed/operated staging areas or points of
distribution where resources are conveyed directly to survivors.
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• In September 2020, we reported 11 FEMA mismanaged the commodity
distribution process in response to Hurricanes Irma and Maria. FEMA
lost visibility of about 38 percent of its shipments to Puerto Rico, did not
use Global Positioning System transponders to track shipments, allowed
its contractor to break inventory seals, and did not require documented
proof of deliveries. We made five recommendations to improve FEMA’s
disaster response operations.
• In September 2021, we reported 12 on FEMA’s coordination efforts with
HHS and other Federal agencies to facilitate the shipment of PPE and
ventilators. Due to weaknesses in FEMA’s WebEOC resource request
system and allocation processes, we concluded FEMA faced challenges
ensuring stakeholder requests were accurately adjudicated and allocation
decisions were properly informed. We made three recommendations to
improve FEMA’s current and future operations.
• In February 2023, we reported 13 on FEMA’s oversight of Project Airbridge,
which was designed to mitigate perceived shortfalls in medical supply
distributors’ inventories of PPE and facilitate the delivery of critical PPE to
locations where it was most needed. Although airlift initiatives move items
quickly, we concluded Project Airbridge may not have been necessary
because distributors’ supply chains had significant PPE inventories.
Additionally, FEMA did not ensure all distributors delivered 50 percent of
Airbridge PPE to designated healthcare facilities in prioritized locations.
We made two recommendations to improve FEMA’s management and
oversight of future public/private partnerships.
Based on our prior audit work, we excluded FEMA’s resource request process
from the scope of this audit, such as adjudicating stakeholder requests and
making allocation decisions for limited PPE supplies. We also excluded air
shipments relative to FEMA’s oversight of Project Airbridge. The objective of
this audit was to determine to what extent FEMA managed and distributed
medical supplies and equipment in response to COVID-19. During this audit,
we focused on FEMA’s procedures for tracking the movement of medical
supplies and equipment to SLTT governments, as well as FEMA’s procedures
for maintaining supporting documentation to confirm delivery and receipt of
COVID-19 shipments.
11 FEMA Mismanaged the Commodity Distribution Process in Response to Hurricanes Irma and
Maria, OIG-20-76, September 25, 2020.
12 Lessons Learned from FEMA’s Initial Response to COVID-19, OIG-21-64, September 21, 2021.
13 FEMA Did Not Provide Sufficient Oversight of Project Airbridge, OIG-23-14, February 7, 2023.
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Department of Homeland Security
Results of Audit
Although FEMA worked with its strategic partners to deliver critical medical
supplies and equipment in response to COVID-19, FEMA did not effectively
manage the distribution process. Specifically, FEMA did not use LSCMS, its
system of record for managing the distribution process, to track about 30 percent
of the critical medical resources shipped, as required. Instead, FEMA used other
tracking mechanisms, such as the WebEOC resource request system and
spreadsheets, that did not share information with LSCMS. In addition, FEMA
did not maintain delivery receipt documentation for about a third of the
shipments we reviewed. This occurred because FEMA was under pressure to
expedite the delivery of critical medical resources and did not follow established
business practices. As a result, FEMA did not have full visibility into the
resources shipped and received, hindering its ability to make informed decisions.
Also, without delivery receipt documents, FEMA could not ensure it delivered
billions of dollars of the right resources, to the right place, at the right time.
Since the COVID-19 pandemic began, FEMA evaluated its early response efforts
and developed a Logistics Resource Tracker to help the NRCC centrally track the
distribution of resources. Although the new automated tool enhanced FEMA’s
visibility into the resources shipped and received, the tool did not always have
accurate data. Without accurate data, FEMA cannot ensure it has quality
information to make informed allocation decisions about where to send
resources, how to evaluate performance, and how to address risk in future
disaster response operations.
FEMA Delivered COVID-19 Medical Resources But Did Not
Effectively Manage the Distribution Process
According to FEMA’s guidance, 14 the NRCC and RRCCs are required to use
LSCMS as the system of record for managing the distribution process, including
tracking the movement of FEMA-owned commodities, supplies, and equipment,
as well as those sourced by FEMA from partners across the Federal Government
and private sector to fulfill SLTT requests. LSCMS provides in-transit visibility
of shipments with the use of satellite transponders attached to trailers and
containers moving resources from FEMA’s distribution centers, Federal staging
areas, and incident support bases to the final disaster locations. This capability
allows FEMA leadership to make supply chain decisions related to the
fulfillment of resource requests and the movement of those resources during
disaster response operations.
14 FEMA Transportation Management Guide, March 2019.
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OFFICE OF INSPECTOR GENERAL
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Despite spending more than $400 million to develop and maintain LSCMS, the
NRCC did not always use the system of record to track the critical medical
resources distributed in response to COVID-19. Based on NRCC data from
January 2020 through January 2022, we found NRCC officials used other
mechanisms instead of LSCMS to track about 30 percent of the nearly 886 million
critical medical items shipped. Table 2 describes the other mechanisms the NRCC
used to track the critical medical resources distributed during COVID-19.
Table 2. Other NRCC Mechanisms Used to Track Critical Medical
Resources Distributed During COVID-19, January 2020 to January 2022
NRCC Tracking
Description
Mechanism
FEMA’s system of record for managing resource requests. Officials tracked
WebEOC shipments and entered status updates in the comments section of the
resource request form.
Spreadsheets for tracking shipments under FEMA contracts with a major
commercial parcel shipment carrier. Officials entered the carrier’s tracking
Small Parcel Trackers
numbers on the spreadsheet and checked the carrier’s website for shipment
updates.
Spreadsheets for tracking both domestic and international donations from
Donation Trackers across the Federal Government, private sector, and non-governmental
organizations.
Spreadsheets for tracking shipments out of HHS’ Strategic National Stockpile,
HHS Trackers a multibillion dollar inventory of drugs, vaccines, supplies, and other medical
countermeasures.
Source: DHS OIG analysis of NRCC data
Additionally, we found the RRCCs did not always use LSCMS, as required.
FEMA officials from 9 of the 10 RRCCs said they did not always use LSCMS to
track local shipments of COVID-19 resources within their regions. As with the
NRCC, RRCC officials used other mechanisms such as hardcopy paper forms,
spreadsheets, and WebEOC rather than LSCMS to track the local shipments.
For example, from April 2020 through June 2021, one RRCC received about
16.1 million medical items at its regional staging area, but the RRCC only used
LSCMS to distribute about 635,000 of these items from its regional staging
area to the final SLTT destinations. For the approximately 15.5 million items
remaining, the RRCC used hardcopy paper forms and WebEOC to track the
local shipments to the final SLTT destinations. We could not determine the
magnitude of local shipments within FEMA’s regions managed outside of
LSCMS because RRCCs either did not have consolidated data in an automated
format or had local shipment data mingled with LSCMS data.
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Further, we found none of the other tracking mechanisms used by the NRCC
and the RRCCs shared information with LSCMS. For instance, in the example
discussed above, the RRCC manually entered shipment details such as the
dates and quantities of medical resources shipped and received by the SLTT
governments in the WebEOC Comments section. However, WebEOC does not
automatically share information with LSCMS, as required by law. 15 A FEMA
official also said the WebEOC comments could not be downloaded in a
consolidated format for further analysis. FEMA has faced longstanding
challenges with personnel using systems that do not share information, adhoc
spreadsheets, and manual methods to carry out disaster response operations.
In our May 2008 report 16 and September 2014 report, 17 we found FEMA relied
on paper forms and spreadsheets to gather information on shipments by its
partners. In our September 2020 report on FEMA’s response to Hurricanes
Irma and Maria, 18 we found personnel manually tracked shipments until they
could enter data into LSCMS. Such actions adversely affected data accuracy,
causing confusion among staff about available assets and stock, and wasting
time during critical response operations.
NRCC and RRCC officials did not always use LSCMS to manage their distribution
processes because FEMA has conflicting guidance that is open to different
interpretations. Specifically, according to the FEMA Resource Support Section
Resource Request and Fulfillment Process Guide, both WebEOC and LSCMS are
used for requesting, tracking, and delivering resources in support of a response
operation. This guide identifies WebEOC as the system of record for the entire
resource request and fulfillment process to track resource requests and their
associated resources. However, the FEMA Transportation Management Guide
requires the NRCC and RRCCs to use LSCMS as the system of record for
managing the distribution process. Some RRCC officials said they did not believe
they were limited to using only LSCMS. Other RRCC officials thought they only
had to use LSCMS to track resources transferring from the NRCC’s control to the
RRCC’s control, or to track resources requiring transportation assistance from
FEMA headquarters. Officials from one RRCC noted that, in addition to LSCMS,
they liked the flexibility of using other mechanisms as resource tracking tools
throughout the ever-changing and fast-paced COVID-19 response.
15 The Post-Katrina Emergency Management Reform Act of 2006, Pub. L. No. 109-295, § 640(a)(1),
instructed FEMA to ensure its information technology systems are, to the extent practicable,
fully compatible and can share and access information, as appropriate, from each other.
16 Logistics Information Systems Need to Be Strengthened at the Federal Emergency Management
Agency, OIG-08-60, May 28, 2008.
17 FEMA’s Logistics Supply Chain Management System May Not Be Effective During a Catastrophic
Disaster, OIG-14-151, September 22, 2014.
18 FEMA Mismanaged the Commodity Distribution Process in Response to Hurricanes Irma and
Maria, OIG-20-76, September 25, 2020.
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We also attributed this condition to the unprecedented nature, complexity, and
magnitude of FEMA’s response to COVID-19, and the pressure FEMA faced to
expedite delivery of critical medical resources. The scale of FEMA’s efforts to
coordinate the Federal Government’s response to COVID-19 was unprecedented.
COVID-19 was the first national pandemic response led by FEMA. It was also
the first time in U.S. history the President declared a nationwide emergency and
authorized major disaster declarations for all states and territories for the same
incident. Table 3 illustrates the unprecedented nature of FEMA’s response to
COVID-19 by providing the average number of states and territories, receiving
facilities, product types, and shipments completed for COVID-19 and non-
COVID-19 disasters from May 2017 through May 2021.
Table 3. Unprecedented Nature of FEMA’s Response to COVID-19,
May 2017 to May 2021
Average Number per Disaster Incident
States and Receiving Product Shipments
Disaster Incident Territories Facilities Types Completed
Non–COVID-19 4 16 43 4,396
COVID-19 56 870 455 54,896
Source: DHS OIG analysis of LSCMS data
NRCC Developed an Automated Tool to Help Centrally Track
COVID-19 Medical Resources, But Data in the Tool Was Not
Always Accurate
Since the COVID-19 pandemic began, FEMA evaluated its early response
operations from January 2020 through September 2020. During its review,
FEMA found the NRCC did not have a centralized system for tracking the
distribution of resources, which affected its visibility into shipments and the
estimated delivery dates for SLTT governments. 19 In response, FEMA developed
a Logistics Resource Tracker to help the NRCC centrally track the distribution
of resources. The automated tool was designed to enhance FEMA’s situational
awareness and inform decision making by aggregating, visualizing, and sharing
information on resource requests and distribution data. To aggregate the data,
FEMA staff uploaded and standardized distribution data from various source
input reports including reports generated from LSCMS and manual spreadsheet
trackers used by the NRCC.
19 Pandemic Response to Coronavirus Disease 2019 (COVID-19): Initial Assessment Report,
January 2021.
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Although the new automated tool enhanced FEMA’s visibility into the resources
shipped and received by consolidating distribution data from the various
source input reports, FEMA could improve the accuracy of the information in
the tool. We analyzed the source input reports and resulting output aggregation
report from the NRCC’s automated tool, representing critical medical resources
distributed from January 22, 2020, through January 26, 2022. When
comparing the input reports to the final output report to determine if the tool
accurately identified medical resource shipments to SLTT governments, we
identified the following discrepancies:
• The Facility Type field was blank or marked as “Other” for 51 percent of
the 11,034 shipment records. The NRCC did not always include this
field when manually creating spreadsheets outside of LSCMS, or FEMA
selected “Other” when creating facilities in LSCMS. This issue hindered
FEMA’s ability to determine if resources were shipped to FEMA locations
or SLTT locations. As of November 2022, FEMA’s Logistics Systems
Division confirmed about 10 percent of the active facilities in LSCMS
were created using the “Other” Facility Type. FEMA plans to review these
facilities for data accuracy and determine if internal system controls,
training, or job aids should be implemented to improve data accuracy in
the future.
• The NRCC incorrectly removed records for resource shipments to SLTT
governments from the automated tool because it concluded that certain
facilities were an intermediate location 20 and not the final destination.
For instance, the NRCC removed shipment records totaling more than
7.5 million PPE items that FEMA delivered from March 2020 through
April 2021 to a state staging area facility because, in December 2020, the
facility also had outbound shipment records of about 400,000 PPE items
returned to a FEMA distribution center. In this example, the quantity of
PPE items distributed to the SLTT governments was understated in the
NRCC’s tool by about 7.1 million.
• The NRCC incorrectly removed shipment records from the automated tool
that FEMA entered in LSCMS as transportation-only orders. FEMA uses
this type of order to track resources, such as donations, that are not
usually part of its logistics supply chain. For example, the NRCC
removed a shipment of 143,000 donated PPE items that FEMA delivered
in June 2021 to a state staging area facility. LMD did not include an
20 A shipment represents the movement of resources from a point of origin to a final
destination, which may include one or more intermediate locations. The NRCC defined
intermediate locations as facilities with both inbound and outbound shipments.
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accurate description and quantity on the source LSCMS report provided
to the NRCC. Specifically, the LSCMS report identified the Item
Description as “Transportation Power” or “Transportation Trailer” and
had a received quantity of zero. 21
We could not determine the exact magnitude for all issues because the NRCC
did not maintain an audit trail of shipment records removed during its
aggregation process, including a justification for why records were removed.
According to an NRCC official, the aggregation process involved steps to
remove, among others, duplicate records and records for distributions to non-
SLTT locations. Without an audit trail to verify data accuracy, neither FEMA
nor we could ensure the accuracy of the information.
Additionally, an NRCC official stated the automated tool did not include data
on local shipments of resources in regions that RRCC personnel tracked outside
of LSCMS. As discussed, RRCC personnel sometimes used WebEOC rather
than LSCMS to track local shipments to final destinations. Details related to
local shipments such as quantities shipped and received were often reported in
the Comments section of requests in WebEOC, but FEMA could not download
and provide this data to the NRCC for aggregation in the automated tool.
These data inaccuracies were due to FEMA not developing and communicating
a comprehensive plan for data management to ensure officials consistently
collected, processed, and analyzed distribution data. The NRCC and RRCCs
used systems (i.e., LSCMS and WebEOC) that did not share information and
manual spreadsheets to collect key information and did not always apply the
same standards for data collection. Although the NRCC’s aggregation process
helped to standardize the distribution data, a FEMA official stated the
automated tool was not intended to correct inaccurate information or establish
standards for data entry across different platforms.
According to a FEMA official, in October 2022, the NRCC was using the new
automated tool in its normal business process for non–COVID-related disasters.
FEMA must address these data management challenges to ensure it has
accurate information to make informed allocation decisions about where to
send resources, how to evaluate performance, and how to address risk in
future disaster response operations.
21 In LSCMS, FEMA entered “2 pallets of gloves” in the Notes field on the distribution order and
shipment record, as well as in the Additional Shipping Information field on the bill of lading. We
could only verify the quantity of PPE items received based on handwritten notes annotated on
the signed bill of lading that FEMA uploaded as an attachment to WebEOC.
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FEMA Did Not Consistently Maintain Delivery Receipt
Documentation for COVID-19 Medical Resource Shipments
According to FEMA’s guidance, 22 when shipments arrive, FEMA logistics
personnel must collect supporting documentation to confirm delivery and
receipt of shipments in LSCMS. This documentation includes signed bills of
lading, 23 signed packing slips, 24 or other receipt paperwork. Before entering
shipments as received in LSCMS, FEMA must verify the documents collected
accurately describe the type and quantity of resources being transported, the
destination facility, and other relevant details. If there is a discrepancy between
the documentation and LSCMS, FEMA must physically count shipments and
update the system to reflect the accurate data. FEMA must also maintain the
signed receipt documentation as part of the disaster file.
Despite these requirements, our review of a statistical sample of 106 records
representing COVID-19 medical resources distributed from January 22, 2020,
through January 26, 2022, 25 showed FEMA did not consistently maintain
delivery and receipt documentation for the shipments. We selected our sample
from the population of distribution records listed on the different tracking
reports the NRCC used to manage the COVID-19 response. Table 4 provides a
breakdown of our sample by the type of NRCC tracking report.
Table 4. Sampled Records by Type of NRCC Tracking Report
Type of NRCC Tracking Number of Percent of Total
Report Sampled Records Sampled Records
LSCMS Trackers 77 73%
Small Parcel Trackers 17 16%
HHS Trackers 10 9%
Donation Trackers 2 2%
Total 106 100%
Source: DHS OIG analysis of sampled NRCC records
22 FEMA Staging Field Operations, National Incident Support Base/Federal Staging Area
Standard Operating Procedure, May 20, 2021, and LSCMS standard operating procedures.
23 A bill of lading is a contract between FEMA and a commercial carrier detailing the type,
quantity, and destination of the goods being transported. It serves as a receipt of goods and
documentary evidence of title, and must be signed by the carrier, shipper, and receiver.
24 A packing slip is a document generated by LSCMS containing all information pertinent to a
shipment, including a description of the inventory and the quantity of that inventory, pick-up
and delivery facilities, notes, and other information.
25 We selected our statistical sample from a population of 14,392 records using a confidence
level of 90 percent, a population proportion of 50 percent, and a sampling error rate of
8 percent.
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We requested required supporting documentation including signed bills of
lading, signed packing slips, and other receipt paperwork such as third-party
delivery confirmations from parcel shipment carriers. 26 FEMA could not provide
supporting documentation for 36 of 106 (34 percent) sampled records reviewed
confirming delivery and receipt of the shipments. 27 Table 5 provides a summary
of our analysis with a breakdown by the type of NRCC tracking report.
Table 5. Analysis of Sample Documents by Type of NRCC Tracking Report
Number of Percent of
Type of NRCC Tracking Documents Documents Not
Sampled Documents Not
Report Available Available
Records Available
LSCMS Trackers 77 64 13 17%
Small Parcel Trackers 17 4 13 76%
HHS Trackers 10 1 9 90%
Donation Trackers 2 1 1 50%
Total 106 70 36 34%
Source: DHS OIG analysis of sampled NRCC records
Additionally, when signed bills of lading, signed packing slips, and other receipt
paperwork were available, the documentation did not always have sufficient
information related to the resources received at the final destination. Of the
70 sampled records that had supporting documentation, we found:
• 40 percent (28 of 70 records) did not identify the quantity of medical
supplies and equipment. In most cases, the documents identified the
number of pallets or associated weight of the shipments.
• 17 percent (12 of 70 records) did not identify both the type and quantity
of medical supplies and equipment.
Although FEMA manually entered these details on the NRCC’s tracking reports,
in LSCMS or WebEOC, we could not verify the accuracy of this information
because it was not supported by signed delivery receipt documentation.
26 Beginning March 23, 2020, a major commercial parcel shipment carrier modified its normal
operating procedures to maintain social distance protocols. The carrier allowed its drivers to
record the recipient’s last name in lieu of obtaining a signature directly from the recipient.
Therefore, we accepted third-party delivery confirmation documents in lieu of signed paperwork.
27 Based on the results of our statistical sample, we estimated, with 90 percent confidence, that
34 percent of all records in the population did not have supporting documentation to confirm
delivery and receipt; the lower-bound level of this estimate is 26 percent, and the upper-bound
limit is 42 percent.
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Further, when signed bills of lading, signed packing slips, and other receipt
paperwork were available to support the sampled records, FEMA did not
maintain the documentation in the same location. We found 27 of the 70
sampled records (39 percent) were located online in FEMA’s automated systems
(i.e., LSCMS or WebEOC). The remaining 43 records (61 percent) were located
offline. Specifically, NRCC officials provided us the documents from an offline
internal network drive at FEMA headquarters, while RRCC officials provided us
the documents from offline files at the FEMA region. In one instance, we
obtained support from offline files at HHS. Table 6 provides a summary of our
analysis of the documentation location for the sampled records.
Table 6. Analysis of Documentation Location for OIG Sample
Number of Sampled
Document Location Percent of Total
Records
Offline 43 61%
LSCMS 20 29%
WebEOC 7 10%
Total 70 100%
Source: DHS OIG analysis of sampled NRCC records
This occurred because FEMA was under pressure to expedite delivery of critical
medical resources in response to the COVID-19 pandemic and did not always
follow established business practices. Typically, FEMA establishes Federal
staging area and incident support base facilities during a disaster response to
maintain accountability for commodities, supplies, and equipment in FEMA’s
supply chain. These facilities have FEMA staff on site to receive shipments,
perform inventories, distribute shipments to final SLTT destinations, and collect
signed documentation from personnel receiving shipments at final SLTT
destinations. However, NRCC officials stated FEMA deviated from this normal
practice due to the unprecedented nature of the COVID-19 response. To
expedite shipments, FEMA and its strategic partners in other Federal agencies,
non-governmental organizations, and the private sector shipped resources
directly to SLTT locations with no FEMA personnel on site. Based on our
analysis of LSCMS data from January 2020 through May 2021, we estimate
FEMA and its partners distributed as much as 70 percent of all COVID-19
resources (i.e., medical and non-medical) directly to SLTT locations.
In these circumstances, FEMA’s guidance did not clearly describe the
distribution process and whether the NRCC, RRCCs, or FEMA’s partners were
responsible for ensuring supporting documentation was collected and
maintained. We also found FEMA had conflicting or unclear guidance for
collecting and maintaining signed delivery receipt documents. Specifically:
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• FEMA’s LSCMS standard operating procedures 28 stated personnel could
confirm delivery receipt by phone. If confirmed by phone, the guidance
required personnel to document the recipient’s name, organization, title,
and phone number in the LSCMS Notes field. However, the guidance did
not require personnel to follow up and obtain signed documentation.
• When acquiring transportation services from commercial carriers, FEMA’s
Standard Tender of Service guidance did not initially require carriers to
provide signed bills of lading for payment. In November 2020, FEMA
added this requirement with an effective start date of May 2021.
• FEMA’s guidance did not establish a single repository or a consistent
approach for maintaining documents. Although LSCMS has the capability
to upload hardcopy documents, FEMA’s guidance did not specifically
identify the location in which the documents should be maintained.
FEMA has taken actions to improve its policies and procedures for collecting
and maintaining delivery receipt documentation. As mentioned, FEMA updated
its Standard Tender of Service guidance by requiring commercial transportation
carriers to submit signed bills of lading for payment starting in May 2021. In
addition, FEMA established an automated integration between LSCMS and
tracking systems used by major commercial parcel shipment carriers. Instead
of FEMA having to manually track the status of parcel shipments on carrier
websites, 29 LSCMS can retrieve the tracking information automatically from
carrier systems and preserve it in LSCMS. As of October 2022, an official from
FEMA’s Logistics System Division stated FEMA completed the automated
integration with three major carriers.
Although these actions are positive steps, more work is needed to improve
FEMA’s process for collecting and maintaining delivery receipt documentation to
ensure it is better prepared for future disaster response operations. The
shipping and receiving process in LSCMS is essential for ensuring accountability
and maintaining an accurate inventory of resources in FEMA’s supply chain.
Without documentation, FEMA cannot ensure it accomplished its mission by
delivering billions of dollars of the right resources, to the right place, at the right
time to support SLTT governments in response to the COVID-19 pandemic.
28 On July 27, 2021, FEMA LMD retired the Logistics Systems Division’s LSCMS standard
operating procedures. However, the LSCMS standard operating procedures were effective for the
first 16 months of FEMA’s response to COVID-19.
29 Tracking information on shipments generally remains available on most carrier websites
from 90 days up to 120 days after delivery.
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Conclusion
In response to the COVID-19 pandemic, FEMA worked with its partners to
distribute critical medical resources but faced challenges tracking resource
movements and maintaining documentation to confirm delivery. Although
FEMA has taken some action to address these challenges, more guidance is
needed to improve future disaster operations by ensuring personnel use
LSCMS or an alternative integrated solution as the system of record to
maintain visibility of shipments, address data management challenges, and
maintain adequate documentation to confirm delivery. Without accurate
information, FEMA cannot ensure it is making informed decisions and
delivering the right resources, to the right place, at the right time.
Recommendations
Recommendation 1: We recommend the FEMA Administrator clarify existing
guidance and ensure FEMA personnel use the Logistics Supply Chain
Management System or an alternative integrated solution as the system of record
during disaster response operations to manage the distribution of FEMA-owned
commodities, supplies, and equipment as well as those sourced by FEMA from
partners across the Federal Government, non-governmental organizations, and
the private sector to fulfill state, local, tribal, and territorial requests.
Recommendation 2: We recommend the FEMA Administrator take action to
develop and improve the Logistics Management Directorate’s internal controls,
guidance, and system integration to obtain more accurate information that
enhances logistics decision making regarding the fulfillment of commodity
requests during disaster response operations. At a minimum, FEMA should:
a. develop internal controls to ensure appropriate information related to
facility types, intermediate locations, and transportation-only orders is
accurately reported in the Logistics Supply Chain Management System or
an alternative integrated solution;
b. update guidance and deliver training to ensure there is a clear audit trail
when aggregating distribution data on FEMA-owned commodities, supplies,
and equipment as well as those sourced by FEMA from partners across the
Federal Government, non-governmental organizations, and the private
sector to fulfill state, local, tribal, and territorial requests; and
c. improve integration between the Logistics Supply Chain Management
System and the Web Emergency Operations Center Crisis Management
System to ensure the systems are, to the extent practicable, compatible
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and share information as required by the Post-Katrina Emergency
Management Reform Act of 2006.
Recommendation 3: We recommend the FEMA Administrator issue guidance
and ensure a standardized process for collecting and maintaining documentation
to confirm delivery and receipt of FEMA-owned commodities, supplies, and
equipment, as well as those sourced by FEMA from partners across the Federal
Government, non-governmental organizations, and the private sector to fulfill
state, local, tribal, and territorial requests. At a minimum, the guidance and
standardized process should:
a. identify the required types of documentation to confirm delivery and
receipt such as signed bills of lading, packing slips, and other forms;
b. include controls to ensure the shipment documentation includes item
descriptions and the specific quantity of items delivered and received;
c. clarify the procedures for executing and documenting the delivery of
commodities, supplies, and equipment to locations where no FEMA
personnel are present to receive shipments; and
d. establish appropriate repositories for delivery and receipt documentation.
Management Comments and OIG Analysis
FEMA’s Associate Administrator of the Office of Policy and Program Analysis
provided written comments on a draft of this report. A copy of FEMA’s response
is in Appendix B. FEMA concurred with all three recommendations, which we
consider open and resolved. FEMA also submitted technical comments
separately, which we addressed as appropriate. FEMA’s response identified
three concerns with the report, as summarized below.
FEMA disagreed with our overall conclusion that the agency did not effectively
manage the distribution of COVID-19 medical supplies and equipment.
Specifically, FEMA disagreed that a lack of sufficient visibility into resources
shipped and received hindered its ability to make informed decisions. By
leveraging both new and existing tools to source and track resource requests,
FEMA said it was able to provide senior leaders with sufficient information to
make supply chain decisions to allocate resources in support of COVID-19
resource requests. We stand by our conclusion that, without accurate
information, FEMA cannot ensure it is making informed decisions and
delivering the right resources, to the right place, at the right time.
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Also, FEMA said our report does not discuss the important role of the Supply
Chain Task Force, formed under the Unified Coordination Group, to orchestrate
a comprehensive four-pronged strategy to: (1) preserve medical supplies,
(2) accelerate industrial manufacturing and distribution, (3) expand industry,
and (4) allocate resources to the right place at the right time. This report focused
on FEMA’s procedures for tracking the movement of medical supplies and
equipment to SLTT governments, as well as FEMA’s procedures for maintaining
supporting documentation to confirm delivery and receipt of COVID-19
shipments. We discussed parts of the Supply Chain Task Force’s role in more
detail in a separate report. 30 We also covered FEMA’s process for adjudicating
stakeholder requests and making allocation decisions in another report. 31
Additionally, in its technical and management comments, FEMA disputed that
it delayed our request for unfiltered data and system access to LSCMS. We
requested access to this information in July 2020 but did not receive direct,
read-only access to LSCMS until June 2021. Although FEMA provided us a
filtered extract of the LSCMS database in January 2021, we could not assert
whether the filtered extract was sufficiently complete and reliable for our audit
purposes until we received the complete, unfiltered extract in June 2021.
A summary of FEMA’s responses to the recommendations and our analysis
follows.
FEMA’s Response to Recommendation 1: Concur. FEMA’s Logistics
Management Directorate (LMD) will clarify existing guidance and training
associated with the management and distribution of FEMA-owned and FEMA-
sourced commodities, supplies, and equipment during response operations.
FEMA’s estimated completion date for these actions is December 31, 2024.
OIG’s Analysis of FEMA’s Comments: FEMA’s planned corrective actions are
responsive to the recommendation. The recommendation will remain open and
resolved until FEMA provides documentation showing the completion of these
corrective actions.
FEMA’s Response to Recommendation 2: Concur. FEMA LMD will take
action to improve internal controls, guidance, and system integration to obtain
more accurate information regarding commodity requests during disaster
operations. FEMA’s estimated completion date for these actions is December
31, 2024.
30 FEMA Did Not Provide Sufficient Oversight of Project Airbridge, OIG-23-14, February 7, 2023.
31 Lessons Learned from FEMA’s Initial Response to COVID-19, OIG-21-64, September 21, 2021.
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OIG’s Analysis of FEMA’s Comments: FEMA’s planned corrective actions are
responsive to the recommendation. The recommendation will remain open and
resolved until FEMA provides documentation showing the completion of these
corrective actions.
FEMA’s Response to Recommendation 3: Concur. FEMA LMD will issue
guidance and ensure a standardized process for collecting and maintaining
documentation to confirm delivery and receipt of FEMA-owned and FEMA-
sourced commodities, supplies, and equipment. Efforts to address this
recommendation will include multiple steps to determine the standardized
process for collecting and maintaining documentation, draft the updates,
ensure clearance of the new guidance, and distribute the information to FEMA
personnel. FEMA’s estimated completion date for these actions is December
31, 2024.
OIG’s Analysis of FEMA’s Comments: FEMA’s planned corrective actions are
responsive to the recommendation. The recommendation will remain open and
resolved until FEMA provides documentation showing the completion of these
corrective actions.
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Appendix A
Objective, Scope, and Methodology
The Department of Homeland Security Office of Inspector General was
established by the Homeland Security Act of 2002 (Public Law 107−296) by
amendment to the Inspector General Act of 1978.
Our audit objective was to determine to what extent FEMA managed and
distributed medical supplies and equipment in response to COVID-19.
To answer our objective, we:
• reviewed FEMA guidance to understand the criteria and internal controls
relative to managing the distribution process during a disaster response;
• obtained an understanding of FEMA’s supply chain management
process, including use of WebEOC and LSCMS;
• analyzed prior audit, assessment, and after-action reports to gain an
understanding of the findings, conclusions, and recommendations,
relative to FEMA’s distribution process during disaster responses;
• interviewed FEMA officials from the Office of Response and Recovery,
LMD, NRCC, and all 10 RRCCs as well as HHS officials from the Office of
the Assistant Secretary for Preparedness and Response to gain an
understanding of the distribution process for COVID-19;
• examined the distribution data in the different tracking reports the NRCC
used to manage COVID-19 from January 22, 2020, through January 26,
2022, to determine to what extent FEMA used LSCMS to track
movements;
• selected a statistical sample 32 of 106 records from the different tracking
reports the NRCC used to manage COVID-19 response, representing
shipments from January 22, 2020, through January 26, 2022; and
• traced 106 sampled records to signed bills of lading, signed packing slips,
and other receipt paperwork to assess the adequacy of documentation
FEMA maintained to confirm delivery and receipt of shipments.
32 We selected our statistical sample from a population of 14,392 records using a confidence
level of 90 percent, a population proportion of 50 percent, and a sampling error rate of
8 percent.
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We assessed the reliability of data from the different tracking reports the NRCC
used to manage COVID-19 including reports generated from LSCMS, and
separate spreadsheets manually created by the NRCC and HHS to track
Strategic National Stockpile shipments, small parcel shipments, and donation
shipments. To assess the reliability of data, we:
• compared an unfiltered extract from the LSCMS database to the different
COVID-19–related LSCMS reports provided by the NRCC;
• tested the completeness and accuracy of the item description, quantity,
and destination facility type by tracing the data to source documents for
a statistical sample of 106 records;
• conducted limited testing to trace other key data fields to source
documentation; and
• researched corroborating information from other data sources or data
fields to verify whether the computer-processed data was accurate.
We identified data reliability issues such as incomplete information about local
shipments, no source documentation to confirm delivery for about one-third of
our sampled records, and other data management challenges, which we
discussed in our report. We issued recommendations aimed at improving the
accuracy and completeness of the distribution data for future disaster responses.
Overall, while the data is not without errors, we determined the data was
sufficiently reliable for the purposes of this audit.
We also assessed internal controls relevant to the audit objective. This
included FEMA’s control environment, risk assessment, control activities,
information and communication, and monitoring controls. We designed our
audit procedures to include steps to mitigate risks identified. As described in
the Results of Audit section of this report, we identified weaknesses in FEMA’s
control environment, control activities, information and communication, and
monitoring controls. However, because we conducted a limited review of
internal controls relevant to the audit objective, other deficiencies may have
existed at the time of our audit.
We conducted this performance audit from July 2020 through April 2023
pursuant to the Inspector General Act of 1978, as amended, and according to
generally accepted government auditing standards. Those standards require
that we plan and perform the audit to obtain sufficient, appropriate evidence to
provide a reasonable basis for our findings and conclusions based upon our
audit objectives. We believe that the evidence obtained provides a reasonable
basis for our findings and conclusions based upon our audit objective.
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DHS OIG’s Access to DHS Information
As part of our audit, we requested direct, read-only access to LSCMS and an
unfiltered extract of the LSCMS database, which contains distribution data on
shipments of medical supplies and equipment in response to COVID-19.
However, DHS initially denied our request. After a 328-day delay, DHS agreed
and provided us with direct, read-only access to LSCMS as well as an
unfiltered extract of the LSCMS database containing distribution data on
COVID-19 medical supplies and equipment.
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Appendix B
FEMA Response to the Draft Report
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Appendix C
Office of Audits Major Contributors to This Report
Ruth Blevins, Director
Richard Harsche, Director
Nicholas Genitempo, Audit Manager
Armando Lastra, Audit Manager
Oluwabusayo Sobowale, Auditor
Lindsey Koch, Communications Analyst
Tai Cheung, Independent Report Referencer
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Appendix D
Report Distribution
Department of Homeland Security
Secretary
Deputy Secretary
Chief of Staff
Deputy Chiefs of Staff
General Counsel
Executive Secretary
Director, U.S. Government Accountability Office/OIG Liaison Office
Under Secretary, Office of Strategy, Policy, and Plans
Assistant Secretary for Office of Public Affairs
Assistant Secretary for Office of Legislative Affairs
FEMA Audit Liaison
Office of Management and Budget
Chief, Homeland Security Branch
DHS OIG Budget Examiner
Congress
Congressional Oversight and Appropriations Committees
www.oig.dhs.gov 28 OIG-23-34
Additional Information and Copies
To view this and any of our other reports, please visit our website at:
www.oig.dhs.gov.
For further information or questions, please contact Office of Inspector General
Public Affairs at: DHS-OIG.OfficePublicAffairs@oig.dhs.gov.
Follow us on Twitter at: @dhsoig.
OIG Hotline
To report fraud, waste, or abuse, visit our website at www.oig.dhs.gov and click
on the red "Hotline" box. If you cannot access our website, call our hotline at
(800) 323-8603, or write to us at:
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Office of Inspector General, Mail Stop 0305
Attention: Hotline
245 Murray Drive, SW
Washington, DC 20528-0305
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