Federal Reports

USDA OIG assessed whether dog breeders corrected previous noncompliances and whether the USDA's Animal and Plant Health Inspection Service carried out enforcement actions for substantiated Animal Welfare Act violations.

Kevin Leonard, a Tennessee resident, was sentenced on January 31, 2025, in U.S. District Court, Southern District of California, for health care fraud. Leonard was sentenced to 5 years of probation and ordered to forfeit $234,000. Leonard was a patient broker who unlawfully brokered patients to clinical treatment facilities owned and operated by Paragon Recovery LLC. In exchange, Leonard and others received kickback payments. The scheme resulted in the inflated fraudulent billing of insurance providers, including Amtrak’s.
 

In addition, Casimiro Bojorquez, a California resident, pleaded guilty on January 14, 2025, to conspiracy related to the health care fraud scheme. Our investigation found that Bojorquez and others conspired to solicit, offer, and receive illegal remunerations for referrals to clinical treatment facilities owned and operated by Paragon Recovery. Amtrak’s insurance providers were billed approximately $1,152,000 by facilities owned and operated by Paragon Recovery over the course of the scheme.

Bojorquez and two other codefendants will be sentenced at a future date.

In May 2024, we conducted on-site, unannounced inspections at five U.S. Customs and Border Protection (CBP) facilities in the Tucson area, specifically four U.S. Border Patrol (Border Patrol) facilities and one Office of Field Operations port of entry. At the time of our on-site inspections, Border Patrol held 1,381 detainees in custody in the Tucson Coordination Center, Tucson Soft-sided Facility, Nogales Processing Facility, and Ajo station. In all four facilities, we found Border Patrol held detainees longer than specified in the National Standards on Transport, Escort, Detention, and Search, which generally limits detention to 72 hours. Overall, Border Patrol met other applicable standards to provide or make available amenities such as food, water, and medical care to detainees. However, we found Border Patrol did not follow standard procedures for managing detainee property in one holding facility, instances where agents did not document welfare checks for detainees with medical conditions, holding cells that were over capacity, and insufficient medical staffing. In addition, we found data integrity issues with information in Border Patrol’s electronic system of record, e3.

Amtrak uses operational technology (OT) systems to manage equipment that controls train operations, such as communications and dispatching. Disruptions to these systems resulting from a disaster—whether caused by human or technical error, natural disasters, cybersecurity attacks, or physical attacks—could cause train delays and cancellations, revenue losses, and safety risks. Accordingly, our objective was to assess the company’s disaster recovery practices for its OT systems. Given the sensitive nature of the report’s information, we summarized the results in this public version of the report. Our assessment of the company’s disaster recovery practices for its OT systems resulted in three recommendations. Company executives agreed with our recommendations and described ongoing and planned actions to address them.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess confidential complaints alleging a veteran was going to be discharged from the Housing and Urban Development VA Supportive Housing (HUD-VASH) program and “should not have been,” and that other veterans were discharged from HUD-VASH “for no reason.” The OIG also evaluated access to primary care for veterans enrolled in HUD-VASH who remain unhoused.

The OIG did not substantiate that the veteran, nor other veterans, were discharged from the HUD-VASH program “for no reason.” However, deficiencies existed with the veteran’s case management, including treatment plan and discharge documentation. The OIG determined similar deficiencies occurred in the case management of other veterans discharged from HUD-VASH. Additionally, the electronic health records of many unhoused HUD-VASH veterans, who did not have scheduled primary care appointments, demonstrated the absence of treatment plans and assignments to primary care teams.

Deficiencies in case management and failures in supervisory oversight resulted in missed opportunities for improved case management for HUD-VASH veterans. The OIG is concerned that the absence of treatment plans, as well as primary care assignments, could affect HUD-VASH case management staff’s ability to coordinate veteran-centered care and may contribute to deficient facilitation of clinical services for this vulnerable population.

The OIG made five recommendations to the Facility Director related to completion and oversight of HUD-VASH documentation, HUD-VASH discharges, and assignment to primary care teams for unhoused HUD-VASH veterans.

The VA Office of Inspector General (OIG) reviewed a hotline complaint from January 2023 alleging that the Atlanta VA medical center’s call center was not answering calls and scheduling appointments within the expected time frame due to staffing shortages.

The OIG substantiated the allegations that the call center did not meet Veterans Health Administration (VHA) abandonment rate and timeliness standards because the call center did not have enough staff answering calls during the review period, which can lead to delays in scheduling appointments, potentially increase wait times, and decrease access to care. During the review period, the call center did not meet VHA’s call center standards, with 30 percent (rather than 5 percent) of the callers abandoning their calls, and only 22 percent (rather than 80 percent) of answered calls picked up within 30 seconds. Based on VHA’s recommended call center staffing model, the OIG estimated the call center needed 53 staff to answer the 135,600 calls received during the review period; the call center averaged 29 staff.

Other factors contributed to the call center’s inability to meet the performance standards. Call center supervisors focused on reviewing daily performance reports and real-time data provided through the call center dashboard, but they did not review cumulative data that could improve staff monitoring to ensure adequate phone coverage throughout the day and help address substandard handle times. Call center staff raised concerns during the review about possible problems in the management of the specialty care clinic telephone lines and mental health queue, which may also need to be addressed by facility leaders.

The OIG made three recommendations to the Veterans Integrated Service Network director and one recommendation to the facility director to assess the staffing and operations of the contact center and specialty care queues at the facility.

The Department of Homeland Security has taken steps to develop guidance and establish oversight for artificial intelligence (AI) use, but more action is needed to ensure DHS governs and manages AI use appropriately. DHS issued AI-specific guidance, appointed a Chief AI Officer, and established multiple working groups and its AI Task Force to help guide the Department’s AI efforts. However, more action is needed to ensure DHS has appropriate governance for responsible and secure use of AI.