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Department of Veterans Affairs OIG

Reporting and Monitoring Personal Protective Equipment Inventory during the Pandemic

The spread of COVID-19 drastically increased the demand for personal protective equipment (PPE) such as masks, gloves, and gowns, and significantly disrupted the global supply chain. As the nation’s largest integrated healthcare system, the Veterans Health Administration (VHA) had to compete for PPE for its personnel and patients. The VA Office of Inspector General (OIG) received hotline allegations that VHA medical facilities could not acquire and maintain enough PPE to keep pace with escalating needs. The OIG assessed how VHA reported and monitored PPE supply levels during the pandemic. The...
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)...
Department of Veterans Affairs OIG

Added Measures Could Reduce Veterans’ Risk of COVID-19 Exposure in Transitional Housing

The VA Office of Inspector General (OIG) reviewed the measures taken by the Veterans Health Administration’s (VHA) Homeless Program Office, medical facilities, and community service providers to mitigate COVID-19 risks in transitional housing programs for veterans experiencing homelessness. The OIG found that while transitional housing service providers successfully implemented four of six specific Centers for Disease Control and Prevention (CDC) COVID-19 risk mitigation measures, the providers could have strengthened implementation of two others. VHA and service provider staff said the...
Department of Veterans Affairs OIG

Review of Veterans Health Administration’s Emergency Department and Urgent Care Center Operations During the COVID-19 Pandemic

The VA Office of Inspector General (OIG) conducted a review of the Veterans Health Administration’s response to anticipated demand and use of emergency department and urgent care center services when faced with the possibility of an influx of patients needing evaluation during the COVID-19 pandemic. A survey was deployed and 63 emergency department and urgent care center directors were interviewed. The OIG learned there was a decreased number of patient visits to the emergency departments (19.8 percent decline) and to the urgent care centers (28.6 percent decline) for January–June 2020 when...
Department of Veterans Affairs OIG

Enhanced Strategy Needed to Reduce Disability Exam Inventory Due to the Pandemic and Errors Related to Canceled Exams

The COVID-19 pandemic has affected how the Veterans Benefits Administration (VBA) provides disability benefits to veterans. On April 3, 2020, VBA discontinued all in-person disability exams that help determine the severity of medical conditions and the amount of benefits paid. The OIG conducted this review to assess how VBA scheduled and conducted exams during the pandemic to limit veterans’ exposure, minimize processing delays, and ensure claims were not prematurely denied due to missed or canceled in-person exams. The OIG also evaluated VBA’s strategy for addressing the inventory of delayed...
Department of Veterans Affairs OIG

Veterans Crisis Line Challenges, Contingency Plans, and Successes During the COVID-19 Pandemic

The Office of Inspector General (OIG) reviewed Veterans Crisis Line (VCL) operations ranging from contingency planning to quality metrics and lessons learned during the COVID-19 pandemic. The OIG completed remote interviews, document reviews, and surveyed VCL employees and Suicide Prevention staff. VCL staff had historically worked from communal call centers with shared space and equipment, a model that posed a safety risk to staff during the pandemic. To continue operations, VCL’s primary challenge was to equip and transition nearly 800 employees to telework-based operations. Over the course...
Department of Veterans Affairs OIG

Date of Receipt of Claims and Mail Processing During the COVID-19 National State of Emergency

The OIG reviewed the Veterans Benefits Administration’s (VBA) processing of mail and benefit claims during the COVID-19 pandemic. Specifically, the review team examined whether VBA staff documented the date of receipt for benefits-related correspondence as required by new guidance during the national state of emergency and continued mail operations at VA facilities to ensure benefit claims were processed. Based on its sample analysis, the OIG found VBA staff did not properly apply date of receipt documentation guidance for an estimated 98 percent of 3,200 claims established from April 7...
Department of Veterans Affairs OIG

Appointment Management During the COVID-19 Pandemic

The Veterans Health Administration (VHA) took measures to protect patients and employees from COVID-19 by canceling face-to-face appointments that were not urgent and converting some of them to virtual appointments. The VA Office of Inspector General (OIG) assessed VHA’s appointment management strategies and the status of canceled appointments. The review team found that about five million appointments (68 percent) canceled from March 15 through May 1, 2020, had evidence of follow up or other tracking. Patients completed appointments predominantly by telephone and some by video. Other...
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 Veterans Health Administration’s COVID-19 Response and Continued Pandemic Readiness

On March 26, 2020, the VA Office of Inspector General (OIG) published its first COVID-19-focused report, OIG Inspection of Veterans Health Administration’s COVID-19 Screening and Pandemic Readiness. In that report, the OIG evaluated how the Veterans Health Administration (VHA) was preparing facilities to meet anticipated rising demands. This report outlines VHA’s continued response to the pandemic and provides VHA leaders’ descriptions of the evolving challenges they faced in caring for veterans and potentially nonveteran patients as well. The OIG engaged leaders from 70 selected facilities in...