Reports
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Department of Veterans Affairs 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
The VA Office of Inspector General (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 (CLC), 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, the OIG identified concerns related to leaders’ post-outbreak actions. The OIG substantiated a failure to observe general infection control...
Department of Veterans Affairs OIG
Care Concerns and the Impact of COVID-19 on a Patient at the Fayetteville VA Coastal Health Care System in North Carolina
The VA Office of Inspector General (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. The OIG substantiated that the primary care provider and dietitians did not provide quality care to the patient. The primary care provider’s failure to follow-up on an earlier finding and not place an order for a medical test...
Department of Health & Human Services OIG
Indian Health Service Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic
Department of Health & Human Services OIG
Medicare Beneficiaries Hospitalized With COVID-19 Experienced a Wide Range of Serious, Complex Conditions
Coronavirus disease 2019 (COVID-19) has affected millions of Americans, resulting in more than 600,000 deaths. Medicare beneficiaries have been particularly affected and remain vulnerable to new variants and additional surges of the virus. Clinicians and researchers are still working to fully understand the damage to the body from the disease and what underlying chronic conditions potentially lead to more severe complications or hospitalization. Understanding the types of conditions for which Medicare beneficiaries with COVID-19 are being treated and who was more likely to be hospitalized with...
Department of Health & Human Services 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
The United States currently faces a nationwide public health emergency because of the COVID-19 pandemic. Federal regulations, effective May 8, 2020, required nursing homes to report COVID-19 information, such as the number of confirmed COVID-19 cases among residents, at least weekly to the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network. Each week, CDC aggregates the reported information and sends the data to the Centers for Medicare & Medicaid Services (CMS) for posting to the CMS website. These data are used to assist with national surveillance of...
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 Housing and Urban Development OIG
COVID-19 Forbearance Data in HUD’s Single Family Default Monitoring System Generally Agreed With Information Maintained by Loan Servicers
We audited lender reporting of COVID-19 forbearances for Federal Housing Administration (FHA)-insured loans in the Single Family Default Monitoring System (SFDMS). We compared default reporting data from SFDMS to loan data provided by five sampled servicing lenders that serviced a third of the FHA single-family portfolio. Our audit objective was to determine whether COVID-19 forbearance data available in SFDMS were consistent with the information maintained by loan servicers. We found that COVID-19 forbearance data available in SFDMS were generally consistent with the information maintained by...
Department of Housing and Urban Development OIG
Limited Review of HUD’s Office of Chief Procurement Officer Pandemic-Related Procurement Accommodations and Challenges
We conducted a limited review of the U.S. Department of Housing and Urban Development’s (HUD) Office of the Chief Procurement Officer’s (OCPO) administration of five procurement activities under the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). The CARES Act and related Office of Management and Budget memorandums gave HUD flexibility in modifying existing contracts and required rapid delivery of CARES Act funds. Our objective was to determine what HUD had done to accommodate contractors’ pandemic-related issues while ensuring that HUD met its business objectives. In addition...
Department of Veterans Affairs OIG
Comprehensive Healthcare Inspection of Facilities' COVID-19 Pandemic Readiness and Response in Veterans Integrated Service Network 19
This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) 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. The OIG has aggregated findings on COVID-19 preparedness and responsiveness from routine inspections to ensure prompt dissemination of...