Reports

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...

The Fiscal Year 2022 Inspectors General Coordinated Oversight Plan for Foreign Assistance To Combat HIV/AIDS, Tuberculosis, and Malaria outlines ongoing PEPFAR oversight work initiated in the prior year as well as new work each OIG plans to undertake in fiscal year 2022. In preparing this plan and executing current oversight work within it, the coordinating OIGs continued holding quarterly PEPFAR oversight meetings and introduced a smaller working group for more focused coordination. The plan includes a coordinated proposal, developed within the smaller working group, to be implemented by...

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...

Our objective was to determine whether NIST is complying with the requirements of the CARES Act. Specifically, we determined (1) what steps NIST took to implement and comply with the CARES Act, (2) challenges NIST faced during implementation, and (3) NIST’s status in the processing of applications and awarding funds under the CARES Act. Overall, we found that NIST implemented and followed the requirements of the CARES Act and applicable grant award policies and procedures. In addition, NIST implemented measures to mitigate challenges resulting from an increased workload and a forced transition...

For our evaluation of the National Oceanic and Atmospheric Administration’s (NOAA’s) National Marine Fisheries Service (NMFS, also known as NOAA Fisheries) plan for the implementation of Coronavirus Aid, Relief, and Economic Security Act (CARES Act) funding, our objective was to determine whether NOAA complied with the requirements of the CARES Act. Specifically, we determined (1) what steps NOAA took in implementing the requirements for awarding funds, (2) challenges NOAA faced during implementation, and (3) NOAA’s current status in processing applications and award funds under the CARES Act...

This brief provides information on USAID’s response to the COVID-19 pandemic and associated challenges, as well as related oversight plans and activities. Information about the pandemic response of the other three foreign assistance agencies we oversee – the Millennium Challenge Corporation, U.S. African Development Foundation, and Inter‐American Foundation – is also included. We prepared this informational brief to increase stakeholder knowledge and public transparency regarding these efforts. This brief reports on activities from the start of the pandemic through March 31, 2021, but has a...

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...

To read this report, visit the Pandemic Response Accountability website:https://www.pandemicoversight.gov/oversight/our-publications-reports/ke…

While reviewing the Veterans Health Administration’s (VHA) plans to document receipt and distribution of the COVID-19 vaccine, the VA Office of Inspector General (OIG) determined that VHA facilities did not consistently document the COVID-19 vaccination status of veterans living in VA’s Community Living Centers (CLCs). The OIG determined that VHA could not know at a national level whether the vaccine was offered to some CLC residents, and if so, what their status was. Because CLC residents are in the highest COVID-19 vaccine priority group, they should be offered the vaccine, when possible...