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 Homeland Security OIG
Continued Reliance on Manual Processing Slowed USCIS’ Benefits Delivery During the COVID-19 Pandemic
The objective was to determine the effectiveness of USCIS’ technology systems to provide timely and accurate electronic processing of immigration and naturalization benefit requests while field offices, asylum offices, and application support centers were closed or operating on a reduced workforce during the COVID-19 pandemic.
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 Homeland Security OIG
Lessons Learned from FEMA’s Initial Response to COVID-19
The objective was to determine how effectively FEMA supported and coordinated Federal efforts to distribute personal protective equipment (PPE) and ventilators in response to the COVID-19 outbreak. We determined that FEMA did not have reliable data to inform allocation decisions and ensure accurate adjudication of resource requests, it did not have a process to allocate the limited supply of PPE, and FEMA’s strategic documents did not clearly outline roles and responsibilities to lead the Federal response. We made three recommendations that FEMA improve the reliability of WebEOC, formally...
Department of Homeland Security OIG
DHS Needs to Enhance Its COVID-19 Response at the Southwest Border
The objective of this review was to determine to what extent the Department of Homeland Security has implemented COVID-19 measures for migrants at the southwest border. We reported that U.S. Customs and Border Protection (CBP) does not conduct COVID-19 testing for migrants who enter CBP custody and is not required to do so. Instead, CBP relies on local public health systems to test symptomatic individuals. According to CBP officials, as a frontline law enforcement agency, it does not have the necessary resources to conduct such testing. For migrants that are transferred or released from CBP...
Department of Homeland Security OIG
ICE’s Management of COVID-19 in Its Detention Facilities Provides Lessons Learned for Future Pandemic Responses
ICE has taken various actions to prevent the pandemic’s spread among detainees and staff at their detention facilities. At the nine facilities we remotely inspected, these measures included maintaining adequate supplies of PPE such as face masks, enhanced cleaning, and proper screening for new detainees and staff. However, we found other areas in which detention facilities struggled to properly manage the health and safety of detainees. For example, we observed instances where staff and detainees did not consistently wear face masks or socially distance. In addition, we noted that some...
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
CBP Needs to Strengthen Its Oversight and Policy to Better Care for Migrants Needing Medical Attention
U.S. Customs and Border Protection (CBP) needs better oversight and policy to adequately safeguard migrants experiencing medical emergencies or illnesses along the southwest border. CBP concurred with all three of our recommendations, which when implemented, should improve medical attention and procedures for migrants at the southwest border
Department of Veterans Affairs OIG
Medical/Surgical Prime Vendor Contract Emergency Supply Strategies Available Before the COVID-19 Pandemic
VA medical facilities’ demand for personal protective equipment (PPE) increased dramatically during the COVID-19 pandemic. The VA Office of Inspector General (OIG) reviewed how the Veterans Health Administration (VHA) ensured the Medical/Surgical Prime Vendor-Next Generation (MSPV-NG) program and its prime vendors met contract requirements by offering medical facilities a no-cost option to develop advance-order supply lists tailored to catastrophic events and contingency plans. The OIG also assessed whether facilities took advantage of those options and strategies and relied on the contracts...