Reports
Search reports, investigative results, and agency plansShowing 11 - 20 of 28 results
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 Education OIG
Inconsistent Grantee and Subgrantee Reporting of Education Stabilization Fund Subprograms in the Federal Audit Clearinghouse
The purpose of this flash report is to share with the U.S. Department of Education (Department) observations made by the Office of Inspector General (OIG) concerning grantees and subgrantees inconsistently reporting audit data on Department subprograms, or unique components of a program, to the Federal Audit Clearinghouse (FAC), the designated repository of single audit data. We found that grantees and subgrantees are not consistently reporting expenditures of Education Stabilization Fund (ESF) subprogram awards in the FAC. Specifically, when entering Federal award information into the Data...
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 Education OIG
Fraud Reporting Requirements for Federal Program Participants and Auditors
This guide summarizes the fraud reporting requirements most relevant to entities receiving pandemic relief funds and auditors of those entities.
Department of Education OIG
Federal Student Aid’s Suspension of Involuntary Collection in Response to the Coronavirus Pandemic
The objective of our review was to evaluate the results of Federal Student Aid’s (FSA) process for suspending involuntary collection and refunding payments involuntarily collected on defaulted Department-held loans in response to the Coronavirus pandemic. We found that FSA suspended administrative wage garnishments and the U.S. Department of Treasury (Treasury) offsets for over 96 percent of the borrowers that FSA collected payments for within 90 days of March 13, 2020, the start of the suspension period. However, as of October 23, 2020, we found that FSA continued to receive administrative...
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...
Department of Veterans Affairs OIG
Inconsistent Documentation and Management of COVID-19 Vaccinations for Community Living Center Residents
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...
Department of Veterans Affairs OIG
Potential Risks Associated with Expedited Hiring in Response to COVID-19
This management advisory memo identifies potential risks associated with the Veterans Health Administration’s (VHA) efforts to expedite adding new staff to meet increased demand caused by the COVID-19 pandemic. The VA Office of Inspector General (OIG) recognizes the tremendous pressure to quickly hire staff to meet unprecedented needs. To achieve VHA’s goal of bringing all new employees on duty within three days of making a tentative offer, VHA has modified or deferred tasks such as fingerprinting, background investigations, drug testing, credentialing, and preplacement physicals. The...