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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 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

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 Agriculture OIG

COVID-19—Oversight of the Emergency Food Assistance Program-Interim Report

The objective of our ongoing inspection is to evaluate FNS’ oversight of TEFAP— this report provides interim results on whether FNS identified risks related to the safe and efficient distribution of USDA-food assistance to States during the COVID-19 pandemic.
Department of Agriculture OIG

COVID-19—Supplemental Nutrition Assistance Program Online Purchasing in Response to the Coronavirus Disease 2019

OIG reviewed FNS’ controls over the SNAP Online Purchasing Pilot in response to the COVID 19 pandemic.
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...