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Department of Veterans Affairs OIG

Audit of Community Care Consults during COVID-19

During COVID-19, VHA’s Office of Community Care (OCC) took steps to ensure veterans continued to have expanded access to health care in the community, as required by the VA MISSION Act of 2018. OCC issued policies to VA facilities to postpone nonurgent appointments and offer alternatives to in-person care, such as telehealth. The VA Office of Inspector General (OIG) conducted this audit to determine whether VHA effectively managed community care consults for routine appointments during the pandemic. The OIG found that routine community care consults were unscheduled for an average of 42 days...

Department of Health & Human Services OIG

COVID-19 Tests Drove an Increase in Total Medicare Part B Spending on Lab Tests in 2020, While Use of Non-COVID-19 Tests Decreased Significantly

Medicare Part B spent $1.5 billion on COVID-19 tests in 2020, while at the same time, spending on non-COVID-19 tests declined by $1.2 billion. The result was a net spending increase of 4 percent, but the decrease in utilization of non-COVID-19 tests raises questions about the potential impacts on beneficiary health.

Department of Veterans Affairs OIG

Systems and Tools Implemented to Track COVID-19 Vaccine Data

The VA Office of Inspector General (OIG) examined whether the Veterans Health Administration (VHA) implemented data collection and reporting systems to report on the supply of COVID-19 vaccines to VA medical facilities and doses administered to VA employees and veterans enrolled in VA’s healthcare system (approximately 9.5 million individuals). Although essential for national reporting, tracking VA vaccine data is difficult because VA does not have a centralized national pharmacy inventory management system to track vaccine supply at facilities. Although VHA staff swiftly developed data...

Department of Veterans Affairs OIG

Comprehensive Healthcare Inspection of Facilities' COVID-19 Pandemic Readiness and Response in Veterans Integrated Service Networks 1 and 8

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of Veterans Integrated Service Network (VISN) 1 and 8 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 1 and 8 vaccination efforts. The OIG has aggregated findings on COVID-19 preparedness and responsiveness from routine inspections to ensure prompt...

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 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 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

Six of Eight Home Health Agency Providers Had Infection Control Policies and Procedures That Complied With CMS Requirements and Followed CMS COVID-19 Guidance To Safeguard Medicare Beneficiaries, Caregivers, and Staff During the COVID-19 Pandemic

Medicare beneficiaries receiving home health services may be at a high risk of developing severe illness from COVID-19. Home health agencies (HHAs) must comply with the Centers for Medicare & Medicaid Services' (CMS's) infection prevention and control requirements and follow CMS guidance by having policies and procedures to protect HHA staff, Medicare beneficiaries, and caregivers during the pandemic. Our objective was to determine whether eight selected HHAs had infection control policies and procedures that complied with CMS requirements and followed CMS guidance to safeguard HHA staff...

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

Coronavirus disease 2019 (COVID-19) is a highly contagious, sometimes fatal, disease that has disproportionately affected American Indians and Alaska Natives (AI/ANs). IHS and Tribal health care facilities are the main health care providers for the AI/AN population. Prior OIG work found that IHS facilities often lacked sufficient staff and had limited access to clinical specialists, as well as finding other quality-of-care concerns. One recent IHS effort to address staffing and quality concerns is its development of Critical Care Response Teams (CCRTs) to support IHS and Tribal facilities in...