Reports
Search reports, investigative results, and agency plansShowing 61 - 70 of 77 results
Department of Veterans Affairs OIG
Medical/Surgical Prime Vendor Contract Emergency Supply Strategies Available Before the COVID-19 Pandemic
VA medical facilities’ demand for personal protective equipment (PPE) increased dramatically during the COVID-19 pandemic. The VA Office of Inspector General (OIG) reviewed how the Veterans Health Administration (VHA) ensured the Medical/Surgical Prime Vendor-Next Generation (MSPV-NG) program and its prime vendors met contract requirements by offering medical facilities a no-cost option to develop advance-order supply lists tailored to catastrophic events and contingency plans. The OIG also assessed whether facilities took advantage of those options and strategies and relied on the contracts...
Department of Veterans Affairs OIG
Review of VHA’s Financial Oversight of COVID-19 Supplemental Funds
In response to the Coronavirus Aid, Relief, and Economic Security (CARES) Act, the VA Office of Inspector General (OIG) reviewed the Veterans Health Administration’s (VHA) tracking and reporting of COVID-19 supplemental funding from legislation for pandemic relief. VA met monthly reporting requirements to OMB and Congress on supplemental fund obligations and expenditures. VA also submitted required weekly obligations and expenditures from supplemental funding to OMB by program activity. Of approximately $17.3 billion in medical care supplemental funds, VA reported it had obligated about $7.11...
Department of Veterans Affairs OIG
Use and Oversight of the Emergency Caches Were Limited during the First Wave of the COVID-19 Pandemic
The OIG assessed how effectively VA managed its emergency caches during the first wave of the COVID-19 pandemic in early 2020. These caches contain a standard supply of drugs and medical supplies, including some personal protective equipment, for use during a public health emergency. The review team found that use and oversight of the emergency caches were limited. Only nine of 144 medical facilities activated their emergency caches during the review period (February through June 2020). Among the reasons they were not used included medical facility directors reporting supplies were not needed...
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 Homeland Security OIG
Violations of Detention Standards at Pulaski County Jail
During our unannounced inspection of Pulaski County Jail, we identified violations of U.S. Immigration and Customs Enforcement (ICE) detention standards that threatened the health, safety, and rights of detainees. In addressing COVID-19, Pulaski did not consistently enforce precautions including use of facial coverings and social distancing, which may have contributed to repeated COVID-19 transmissions at the facility. Pulaski did not meet standards for classification, medical care, segregation, or detainee communication. We found that the facility was not providing a color-coded visual...
Department of Homeland Security OIG
Violations of Detention Standards Amidst COVID-19 Outbreak at La Palma Correctional Center in Eloy, AZ
We identified violations of U.S. Immigration and Customs Enforcement (ICE) detention standards that threatened the health, safety, and rights of detainees. La Palma Correctional Center (LPCC) complied with the ICE detention standard regarding classification. However, detainee reports and grievances allege an environment of mistreatment and verbal abuse, including in response to peaceful detainee protests of the facility’s handling of the pandemic. In addressing the coronavirus disease 2019 (COVID-19), LPCC did not enforce ICE’s precautions including facial coverings and social distancing...
Department of Veterans Affairs OIG
Review of Veterans Health Administration’s Virtual Primary Care Response to the COVID-19 Pandemic
The VA Office of Inspector General (OIG) conducted a review to assess Veterans Health Administration’s (VHA) virtual primary care response to the COVID-19 pandemic, as well as the use of virtual care by primary care providers and their perceptions of VA Video Connect (VVC) between February 7 and June 16, 2020. The COVID-19 pandemic presented significant challenges to health care delivery worldwide. One strategy initiated by VHA, in accordance with the Centers for Disease Control and Prevention recommendation to social distance, included expanding the delivery of primary care via virtual care...
Department of Veterans Affairs OIG
Reporting and Monitoring Personal Protective Equipment Inventory during the Pandemic
The spread of COVID-19 drastically increased the demand for personal protective equipment (PPE) such as masks, gloves, and gowns, and significantly disrupted the global supply chain. As the nation’s largest integrated healthcare system, the Veterans Health Administration (VHA) had to compete for PPE for its personnel and patients. The VA Office of Inspector General (OIG) received hotline allegations that VHA medical facilities could not acquire and maintain enough PPE to keep pace with escalating needs. The OIG assessed how VHA reported and monitored PPE supply levels during the pandemic. The...
Department of Veterans Affairs OIG
Medication Delivery Delays Prior to and During the COVID-19 Pandemic at the Manila Outpatient Clinic in Pasay City, Philippines
The VA Office of Inspector General (OIG) conducted an inspection to assess allegations related to delayed medication delivery from the VA Manila Outpatient Clinic (clinic) pharmacy in Pasay City, Philippines, prior to and during the COVID-19 pandemic. The OIG substantiated a patient experienced medication delivery delays and did not timely receive morphine from the clinic pharmacy in October and November 2019. While the patient requested a renewal in a timely manner, pharmacists could not fill the medication because there was no available stock from the Veterans Health Administration’s (VHA)...
Department of Homeland Security OIG
Ineffective Implementation of Corrective Actions Diminishes DHS' Oversight of Its Pandemic Planning
DHS OIG issued a series of three reports between August 2014 and October 2016 examining DHS’ pandemic activities, including 28 recommendations to improve the efficiency and effectiveness of DHS planning and response activities. We conducted this verification review to determine the adequacy and effectiveness of DHS’ corrective actions. We focused our review on 11 of 28 key recommendations that dealt with DHS-wide pandemic planning and response activities. We determined that DHS provided the OIG with adequate documentation of its initial plans and actions to address the recommendations to...