Reports
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Department of Veterans Affairs OIG
Deficiencies in COVID-19 Screening and Facility Response for a Patient Who Died at the Michael E. DeBakey VA Medical Center in Houston, Texas
The VA Office of Inspector General (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). The OIG substantiated that facility staff did not complete the patient’s COVID-19 temperature screening. The 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...
Department of Homeland Security OIG
Violations of Detention Standards at Adams County Correctional Center
During our unannounced inspection of Adams in Natchez, Mississippi, we identified violations of ICE detention standards that threatened the health, safety, and rights of detainees. We made seven recommendations to ICE’s Executive Associate Director of Enforcement and Removal Operations (ERO) to ensure the New Orleans ERO Field Office overseeing Adams addresses identified issues and ensures facility compliance with relevant detention standards. ICE concurred with all seven recommendations.
Department of Health & Human Services OIG
COVID-19 Had a Devastating Impact on Medicare Beneficiaries in Nursing Homes During 2020
Pandemic Response Accountability Committee
Key Insights: COVID-19 in Correctional and Detention Facilities
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. The Centers for Disease Control and Prevention has noted that the confined nature of correctional and detention facilities, combined with their congregate environments, heightens the potential for COVID-19 to spread once introduced into a facility. Individuals typically eat, sleep, and participate in activities...
Department of Homeland Security OIG
Violations of Detention Standards at Pulaski County Jail
During our unannounced inspection of Pulaski County Jail, we identified violations of U.S. Immigration and Customs Enforcement (ICE) 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. We found that the facility was not providing a color-coded visual...
Department of Veterans Affairs OIG
Inconsistent Documentation and Management of COVID-19 Vaccinations for Community Living Center Residents
While reviewing the Veterans Health Administration’s (VHA) plans to document receipt and distribution of the COVID-19 vaccine, the VA Office of Inspector General (OIG) determined that VHA facilities did not consistently document the COVID-19 vaccination status of veterans living in VA’s Community Living Centers (CLCs). The OIG determined that VHA could not know at a national level whether the vaccine was offered to some CLC residents, and if so, what their status was. Because CLC residents are in the highest COVID-19 vaccine priority group, they should be offered the vaccine, when possible...
Department of Homeland Security OIG
Violations of Detention Standards Amidst COVID-19 Outbreak at La Palma Correctional Center in Eloy, AZ
We identified violations of U.S. Immigration and Customs Enforcement (ICE) detention standards that threatened the health, safety, and rights of detainees. La Palma Correctional Center (LPCC) complied with the ICE detention standard regarding classification. However, detainee reports and grievances allege an environment of mistreatment and verbal abuse, including in response to peaceful detainee protests of the facility’s handling of the pandemic. In addressing the coronavirus disease 2019 (COVID-19), LPCC did not enforce ICE’s precautions including facial coverings and social distancing...
Oregon Secretary of State
Advisory Report: Oregon Can Take More Steps to Reduce Infections in Long-Term Care Facilities from COVID-19 and Other Communicable Diseases
This advisory report suggests actions the Oregon Department of Human Services (ODHS), Oregon Health Authority (OHA), and the Legislature can take to reduce illness and death from communicable diseases in nursing homes, assisted living, and residential care facilities, now and in the future.