Reports
Search reports, investigative results, and agency plansShowing 11 - 19 of 19 results
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 Veterans Affairs OIG
Inadequate Resident Supervision and Documentation of an Ophthalmology Procedure at the Oklahoma City VA Health Care System in Oklahoma
The VA Office of Inspector General (OIG) conducted an inspection in response to allegations related to ophthalmology resident supervision and quality of care by an attending ophthalmologist (subject ophthalmologist) at the Oklahoma City VA Health Care System in Oklahoma. The OIG substantiated that the subject ophthalmologist failed to provide adequate resident supervision and entered inaccurate documentation related to supervision for a single patient case. The ophthalmology residents were unable to reach the subject ophthalmologist when the patient experienced a complication during an eye...
U.S. Postal Service OIG
Customer Perceptions of the U.S. Postal Service During the COVID-19 Pandemic
The OIG conducted a nationally representative survey to understand the ways the COVID-19 pandemic may have altered customer perceptions of the Postal Service and their habits around mail and other postal-related activities. The OIG found that Americans continued to hold favorable views of the Postal Service during the pandemic, underscoring the important role USPS plays for the nation. During the pandemic, the core ways customers interacted with the Postal Service were through mail receipt, post office visits, and delivery of online orders. Nearly 70 percent of survey respondents reported...
Department of Veterans Affairs OIG
Medication Delivery Delays Prior to and During the COVID-19 Pandemic at the Manila Outpatient Clinic in Pasay City, Philippines
The VA Office of Inspector General (OIG) conducted an inspection to assess allegations related to delayed medication delivery from the VA Manila Outpatient Clinic (clinic) pharmacy in Pasay City, Philippines, prior to and during the COVID-19 pandemic. The OIG substantiated a patient experienced medication delivery delays and did not timely receive morphine from the clinic pharmacy in October and November 2019. While the patient requested a renewal in a timely manner, pharmacists could not fill the medication because there was no available stock from the Veterans Health Administration’s (VHA)...
U.S. Postal Service OIG
Package Delivery in Rural and Dense Urban Areas
In 2019, carriers delivered nearly 6 billion packages to every corner of America—more than 19 million every day. This represents an 87 percent increase in the U.S. Postal Service’s package volume since 2013, driven by booming ecommerce sales.
U.S. Postal Service OIG
The U.S. Postal Service and Emergency Response: A History of Delivering for the American Public
The U.S. Postal Service has a formal role in the federal National Response Framework, which guides the country’s response to disasters and emergencies like hurricanes, bioterrorism, pandemics and other incidents. The OIG examined how the Postal Service continues to support the American public during the ongoing COVID-19 pandemic, even as the outbreak affects postal operations. The Postal Service has delivered essential items like prescriptions, unemployment benefit and stimulus payments, personal protective equipment, and coronavirus test kits. The Postal Service also has provided a backbone...
Department of Veterans Affairs OIG
Alleged Deficiencies in the Management of Staff Exposure to a Patient with COVID-19 at the VA Portland Health Care System in Oregon
The VA Office of Inspector General (OIG) conducted a healthcare inspection to determine the validity of allegations related to the management of staff exposure to a patient diagnosed with COVID-19 at the VA Portland Medical Center (facility) in Oregon. The events under review involved the facility’s first patient diagnosed with COVID-19. The OIG did not substantiate that emergency department staff failed to notify imaging department staff that a patient was suspected to have COVID-19 before sending the patient to the imaging department. At the time of the patient’s transport to the imaging...
Department of Veterans Affairs OIG
Review of Highly Rural Community-Based Outpatient Clinics Limited Access to Select Specialty Care
The VA Office of Inspector General (OIG) reviewed the accessibility of dermatology, orthopedics, and urology specialty care for patients in the 17 Veterans Health Administration (VHA) community-based outpatient clinics (CBOCs) classified as highly rural. The OIG also reviewed accessibility, barriers, and the availability and utilization of resources for the time frame March 1, 2018 (or from the date the CBOC became highly rural), through February 28, 2019. VHA utilized clinical consults, electronic consults (eConsults), telehealth, and community care to provide specialty care at the highly...
Department of Veterans Affairs OIG
OIG Inspection of Veterans Health Administration’s COVID-19 Screening Processes and Pandemic Readiness
The VA Office of Inspector General (OIG) conducted an inspection to evaluate novel coronavirus disease (COVID-19) screening processes at 237 VA facilities (medical centers, community-based outpatient clinics, and community living centers) and to collect data on pandemic preparations. Screening processes at 71 percent of visited medical centers were adequate, while 28 percent had opportunities for improvement. The vast majority of community-based outpatient clinics had screening procedures in place. Although VA announced a no visitors policy for community living centers on March 10, 2020, OIG...