Reports
Search reports, investigative results, and agency plansShowing 11 - 20 of 25 results
Department of Veterans Affairs OIG
Care in the Community Consult Management During the COVID-19 Pandemic at the Martinsburg VA Medical Center in West Virginia
The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Martinsburg VA Medical Center (facility) in West Virginia to assess allegations of failure to schedule a Care in the Community (CITC) COVID Priority 1 cardiology consult within Veterans Health Administration requirements, and delays in CITC consult scheduling caused by inadequate CITC staffing. The OIG substantiated that a COVID Priority 1 CITC cardiology consult was not scheduled within 30 days of the clinically indicated date. The OIG determined that the consult was amongst a backlog of approximately 5,000...
Small Business Administration OIG
SBA’s Oversight of the Grant Recipient’s Implementation of the CARES Act Resource Partners Training Portal
We evaluated the SBA’s handling of the grant to train small businesses on federal resources available in the wake of the Coronavirus Disease 2019 (COVID-19) pandemic. The Coronavirus Aid Relief and Economic Security (CARES) Act authorized funds up to $25 million for SBA to administer a grant to an association or associations representing resource partner centers to establish a single centralized hub for COVID-19 information. We found SBA did not ensure the grant recipient developed and implemented an effective marketing and outreach strategy to ensure the hub successfully achieved the...
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...
Small Business Administration OIG
SBA Emergency EIDL Grants to Sole Proprietors and Independent Contractors
The Office of Inspector General examined Emergency EIDL grants to sole proprietors and independent contractors from March 29, 2020, until the funds were exhausted just 14 weeks later on July 10. We set out to determine whether the agency complied with its internal policy that set Emergency EIDL grants at $1,000 per employee up to the Coronavirus Aid, Relief, and Economic Security (CARES) Act mandated maximum amount of $10,000. Using SBA’s data, we found SBA provided $4.5 billion more in Emergency EIDL grants to sole proprietors and independent contractors than they were entitled to receive...
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 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...
Small Business Administration OIG
SBA’s Handling of Identity Theft in the COVID-19 Economic Injury Disaster Loan Program
The Office of Inspector General (OIG) is issuing this Evaluation report to notify Small Business Administration (SBA) officials of significant matters regarding its handling of complaints of identity theft in the Coronavirus Disease 2019 (COVID-19) Economic Injury Disaster Loan (EIDL) program. We recommend the Administrator to direct the Associate Administrator for the Office of Disaster Assistance, the Chief Financial Officer for the Office of Performance Management and Chief Financial Officer, and the Associate Administrator for the Office of Capital Access to: 1. Develop a process to...
Small Business Administration OIG
Evaluation of SBA’s Award Procedures for the CARES Act Entrepreneurial Development Cooperative Agreements
This report found that SBA awarded the CARES Act entrepreneurial development cooperative agreements and grants in accordance with applicable federal laws, regulations, and guidance. We found program officials established performance goals and identified performance indicators. To more effectively ensure performance goals are achieved as intended, SBA should clearly define the performance goals and set performance targets. We recommended that SBA enforce standard operating procedures requiring defined performance goals and include performance targets in all future SBDC and WBC cooperative...