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Read our report on six communities’ experiences with pandemic funding and programs, which provides valuable lessons learned to improve federal emergency response programs.

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Reports

Search reports, investigative results, and agency plansShowing 11 - 20 of 34 results
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

Review of VHA’s Telehealth Billing Practices for Community Care during the COVID-19 Pandemic

Management advisory memorandum detailing the growth of community telehealth claims and the associated risks.

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.
Department of Veterans Affairs OIG

Comprehensive Healthcare Inspection of Facilities' COVID-19 Pandemic Readiness and Response in Veterans Integrated Service Network 19

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of Veterans Integrated Service Network (VISN) 19 facilities’ COVID-19 pandemic readiness and response. This evaluation focused on emergency preparedness; supplies, equipment, and infrastructure; staffing; access to care; community living center patient care and operations; facility staff feedback; and VA and VISN 19 vaccination efforts. The OIG has aggregated findings on COVID-19 preparedness and responsiveness from routine inspections to ensure prompt dissemination of...
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

Comprehensive Healthcare Inspection Program (virtual reviews) Reports VISN 6 & 2

This report will provide (1) a descriptive evaluation of Veterans Integrated Service Network facilities’ pandemic readiness and response as determined by recent Comprehensive Healthcare Inspection Program inspections.
 

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 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

Review of Community-Based Outpatient Clinics Closed Due to the COVID-19 Pandemic

The VA Office of Inspector General (OIG) reviewed community-based outpatient clinic (CBOC) closures that occurred due to the COVID-19 pandemic to evaluate the impact on patient care. The OIG virtually interviewed Veterans Health Administration (VHA) staff at 140 facilities that oversaw the 1,031 CBOCs that were operational prior to the World Health Organization’s pandemic declaration. Of these CBOCs, 173 were closed to face-to-face visits on or after February 1, 2020. Reasons for closure fell into four categories including (a) safety of patients and staff, (b) need for consolidation of...