Reports
Search reports, investigative results, and agency plansShowing 21 - 27 of 27 results
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
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...
Small Business Administration OIG
Inspection of SBA's Implementation of the Paycheck Protection Program
Department of Education OIG
Assessment of the Department’s Reconstitution Plans Following COVID-19
The objective of our inspection was to assess the U.S. Department of Education’s (Department) plans and procedures for returning employees to the federal office in the wake of the coronavirus pandemic, including what existing guidance the Department considered when developing its plans and procedures. We found that the Department generally incorporated available guidance, which was intended to provide for a safe and gradual return to federal offices, in its Workplace Reconstitution Transition Plan (Reconstitution Plan). However, we noted that the Department’s Reconstitution Plan does not...