Reports
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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...
Environmental Protection Agency OIG
Pandemic Highlights Need for Additional Tribal Drinking Water Assistance and Oversight in EPA Regions 9 and 10
The coronavirus pandemic negatively impacted the oversight and assistance that Regions 9 and 10 provide to the tribal drinking water systems under their purview, as well as the capacity of these systems to provide safe drinking water. The pandemic also underscored the limitations of both EPA resources and tribal drinking water system resiliency. As a result, tribal drinking water systems may be unable to operate safely and comply with drinking water regulations. Access to safe and clean water is critical at all times, but even more so during pandemic situations.
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 Homeland Security OIG
Lessons Learned from FEMA’s Initial Response to COVID-19
The objective was to determine how effectively FEMA supported and coordinated Federal efforts to distribute personal protective equipment (PPE) and ventilators in response to the COVID-19 outbreak. We determined that FEMA did not have reliable data to inform allocation decisions and ensure accurate adjudication of resource requests, it did not have a process to allocate the limited supply of PPE, and FEMA’s strategic documents did not clearly outline roles and responsibilities to lead the Federal response. We made three recommendations that FEMA improve the reliability of WebEOC, formally...
Department of Homeland Security OIG
DHS Needs to Enhance Its COVID-19 Response at the Southwest Border
The objective of this review was to determine to what extent the Department of Homeland Security has implemented COVID-19 measures for migrants at the southwest border. We reported that U.S. Customs and Border Protection (CBP) does not conduct COVID-19 testing for migrants who enter CBP custody and is not required to do so. Instead, CBP relies on local public health systems to test symptomatic individuals. According to CBP officials, as a frontline law enforcement agency, it does not have the necessary resources to conduct such testing. For migrants that are transferred or released from CBP...
Department of Homeland Security OIG
Violations of ICE Detention Standards at Otay Mesa Detention Center
During our unannounced inspection of Otay Mesa in San Diego, California, we identified violations of ICE detention standards that compromised the health, safety, and rights of detainees. Otay Mesa complied with standards for classification and generally provided sufficient medical care to detainees. In addressing COVID-19, Otay Mesa did not consistently enforce precautions including use of facial coverings and social distancing. Overall, we found that Otay Mesa did not meet standards for grievances, segregation, or staff-detainee communications. Specifically, Otay Mesa did not respond timely...
Department of Homeland Security OIG
ICE’s Management of COVID-19 in Its Detention Facilities Provides Lessons Learned for Future Pandemic Responses
ICE has taken various actions to prevent the pandemic’s spread among detainees and staff at their detention facilities. At the nine facilities we remotely inspected, these measures included maintaining adequate supplies of PPE such as face masks, enhanced cleaning, and proper screening for new detainees and staff. However, we found other areas in which detention facilities struggled to properly manage the health and safety of detainees. For example, we observed instances where staff and detainees did not consistently wear face masks or socially distance. In addition, we noted that some...
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 Homeland Security OIG
CBP Needs to Strengthen Its Oversight and Policy to Better Care for Migrants Needing Medical Attention
U.S. Customs and Border Protection (CBP) needs better oversight and policy to adequately safeguard migrants experiencing medical emergencies or illnesses along the southwest border. CBP concurred with all three of our recommendations, which when implemented, should improve medical attention and procedures for migrants at the southwest border
Department of Homeland Security OIG
Violations of Detention Standards at Adams County Correctional Center
During our unannounced inspection of Adams in Natchez, Mississippi, we identified violations of ICE detention standards that threatened the health, safety, and rights of detainees. We made seven recommendations to ICE’s Executive Associate Director of Enforcement and Removal Operations (ERO) to ensure the New Orleans ERO Field Office overseeing Adams addresses identified issues and ensures facility compliance with relevant detention standards. ICE concurred with all seven recommendations.