Reports
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Department of Veterans Affairs OIG
Deficiencies in Select Community Care Consult (Stat) Processes During the COVID-19 Pandemic
The VA Office of Inspector General (OIG) conducted a national review of stat community care consults generated during the outset of the COVID-19 pandemic to evaluate consult processes. Patient involvement in care urgency disagreements and reporting of adverse events in community care were also reviewed. When the OIG identified deficiencies in processes, electronic health records (EHRs) of the patients at issue were further examined for potential negative outcomes. The OIG did not identify any negative care outcomes. For the 2,236 stat community care consults generated from March 20, 2020...
Department of Housing and Urban Development OIG
Lessons Learned and Key Considerations From Prior Audits and Evaluations of the CDBG Disaster Recovery Program
On March 27, 2020, the Coronavirus Aid, Relief, and Economic Security (CARES) Act made available $5 billion in supplemental CDBG funding for grants to prevent, prepare for, and respond to the coronavirus pandemic (CDBG-CV grants). Because of similarities, we reviewed 132 CDBG-DR program audits and evaluations issued from May 2002 to March 2020 to summarize the common CDBG-DR program weaknesses and risks for CPD to consider to help its CDBG-CV grantees effectively and efficiently manage their CDBG-CV program operations. We found that grantees had common areas of weaknesses and risks in the...
Department of Health & Human Services OIG
Changes Made to States' Medicaid Programs To Ensure Beneficiary Access to Prescriptions During the COVID-19 Pandemic
On March 13, 2020, the President of the United States declared that the COVID-19 pandemic was a national emergency. That same day, in accordance with section 1135(b) of the Social Security Act (the Act), the Secretary of HHS invoked his authority to waive or modify certain requirements of Titles XVIII, XIX, and XXI of the Act. To limit the spread of the virus, Federal, State and local governments urged individuals to stay at home and for individuals who test positive to quarantine, among other preventive measures. As a result, the usual and customary ways that many individuals obtained...
Department of Housing and Urban Development OIG
Fraud Risk Inventory for the CDBG and ESG CARES Act Funds
We conducted this engagement in coordination with the Pandemic Response Accountability Committee (PRAC) to gain an understanding of the U.S. Department of Housing and Urban Development’s (HUD) fraud risk management practices and develop an inventory of fraud risks that HUD had not already identified for the funds appropriated by the Coronavirus Aid, Relief, and Economic Security (CARES) Act for the Community Development Block Grant (CDBG) and Emergency Solutions Grant (ESG) programs. We identified five overall risk factors that contribute to the risk of fraud for the CDBG and ESG CARES Act...
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
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 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...