Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review allegations regarding internal endocrine consult management, endocrine clinic utilization, and patient access to gender-affirming hormone therapy (GAHT) at the VA Fayetteville Coastal Healthcare System (system) in North Carolina. The OIG also reviewed leaders’ awareness of and response to these concerns.

The OIG substantiated that the chief of medicine (COM) did not effectively manage internal consults. Specifically, the COM did not communicate endocrine consult management process changes to key stakeholders, did not process consults according to Veterans Health Administration (VHA) timeliness requirements, canceled a large volume of consults without communicating to sending providers, converted face-to face consults to e-consults without providing a mechanism for sending providers to communicate concerns, and delayed implementation of a required service line agreement. 

The COM’s deficient management of endocrine consults negatively impacted endocrine clinic utilization and resulted in provider-created workarounds and patients not receiving timely endocrine appointments. From February through early October 2024, patient access to GAHT was delayed because of the COM’s actions, resulting in adverse clinical outcomes. The OIG found the COM’s interpersonal communication skills did not reflect the high reliability organization (HRO) values of clear communication and respect for others, and negatively affected system staff across multiple services.

The OIG made one recommendation to the Veterans Integrated Service Network Director to review the leadership performance of the COM, and six recommendations to the System Director related to reviewing the endocrine consult management process, reviewing patients affected by delayed endocrine consults, ensuring service line agreements are developed, confirming effective utilization of endocrine clinic appointments, ensuring there is a process for monitoring and tracking clinic profile modification requests, and evaluating communication gaps between leaders to comply with HRO goals.

In 2015, the Environmental Protection Agency issued the Coal Combustion Residuals (CCR) rule, which included requirements for addressing the risks from coal ash disposal.  The Tennessee Valley Authority (TVA) updated the program funding for its CCR management program in 2015 to address compliance with the CCR rule and in 2017 began developing a site-specific project to address coal ash at Gallatin Fossil Plant.  The Gallatin Ash Pond Complex Closure and Restoration (Gallatin Ash) project activities include (1) construction, operation, and closure of on-site lined landfills; (2) excavation and disposal of approximately 14 million cubic yards of CCR from Gallatin Fossil Plant; and (3) closure of the legacy ash site and coal yard, along with other site restoration work. 

The project was first approved for implementation by the Project Review Board in February 2018 with a total estimated project cost of approximately $899 million.  As of July 2024, the total estimated project cost had increased to approximately $1.64 billion, an increase of approximately 82 percent.  Because of the costs associated with this project, we assessed the management of project costs. 

We determined cost management for the Gallatin Ash project needed improvement related to the development of the project estimate and monitoring and tracking of project change requests (PCRs).  Specifically, the project estimate (1) did not include the complete scope of work and (2) was not developed using definitive costs as required.  As a result, the initial implementation project estimate was significantly understated.  Some PCRs submitted by contractors lacked adequate detail to determine if project cost increases were reasonable.  In addition, PCRs were not prepared for cost increases resulting from inaccurate project estimates. During the review, we also identified confidential contractor information that was shared by TVA project management with another contractor, creating reputational and liability risks for TVA.

Why We Did This Report

The U.S. Environmental Protection Agency Office of Inspector General has identified concerns regarding the installation and use of unauthorized software, specifically jiggler software, on EPA computers and networks. Commonly referred to as “mouse jigglers,” jiggler software simulates activity on a laptop, preventing the laptop from entering sleep mode and locking out its user. After running network scans in two EPA regions in November and December 2024, the Agency discovered 120 employees and contractors using jiggler software.

Summary of Findings

Our investigation found that jiggler software could bypass the Agency’s Windows Installer settings, that some of the EPA’s information technology specialists believed they were exempt from the policy, and that other EPA employees and contractors installed the software without authorization. Furthermore, we discovered inconsistencies in how quickly the regional offices acted to remove the jiggler software after it was detected. The installation and use of unauthorized software on EPA computers and networks represent critical cybersecurity risks and ethics violations for the Agency.

Access to retail services is an important part of the Postal Service’s universal service obligation. The Postal Service relies on a network of over 31,000 facilities (“units”) where customers can conduct various retail transactions, and this network hosted over 655 million visits in fiscal year 2024. It is imperative for retail units to be accessible to customers by being open during scheduled hours and not closed for prolonged periods of time (such as suspensions).

We found that DOI may have misstated its total acres by 82 percent in its FY 2023 AFR.

A yardmaster based in Chicago, Illinois, resigned from her position on September 20, 2025, prior to her administrative hearing. We found that the former employee violated company policies by secretly recording a conversation she had with her supervisor without his consent or knowledge. The former employee is not eligible for rehire.