Reports

Our inspection identified several concerns with CARES Act and pandemic-related contract actions made through October 31, 2020.

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...

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...

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...

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...

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)...

On March 27, 2020, the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) was enacted. It included $8 billion for direct payments to Indian Tribes and $522 million of direct appropriations to the Bureau of Indian Affairs (BIA) and Bureau of Indian Education (BIE) for COVID-19 response. Given this infusion of funding, we examined the impact of COVID-19 on the Indian detention system from April 1, 2020, to May 31, 2020, including the actions the BIA and the tribes have taken to respond to outbreaks of this virus, and how other longstanding challenges have affected the BIA’s response...

Under the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) enacted on March 27, 2020, the U.S. Department of the Interior (DOI) received $909.7 million to prevent, prepare for, and respond to the coronavirus pandemic. The Office of the Secretary (OS) received $158.4 million of the DOI’s CARES Act funding and transferred funds to the U.S. Fish and Wildlife Service (FWS), National Park Service (NPS), Bureau of Land Management (BLM), Office of Inspector General (OIG), Bureau of Reclamation (BOR), and Office of Wildland Fire (OWF). As of November 30, 2020, 5.3 percent of the funding...

On March 27, 2020, the President signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). To date the CARES Act has provided the U.S. Department of the Interior (DOI) with $909.7 million, which includes direct apportionments of $756 million to support the needs of DOI programs, bureaus, Indian Country, and the Insular Areas, and a $153.7 million transfer from the U.S. Department of Education to the BIE. This report presents the DOI’s progress as of October 31, 2020, in spending CARES Act appropriations. Specifically, the DOI’s expenditures to date total $566,168,083...

On March 27, 2020, the President signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). To date the CARES Act has provided the U.S. Department of the Interior (DOI) with $909.7 million, which includes direct apportionments of $756 million to support the needs of DOI programs, bureaus, Indian Country, and the Insular Areas, and a $153.7 million transfer from the U.S. Department of Education to the BIE. This report presents the DOI’s progress as of September 30, 2020, in spending CARES Act appropriations. Specifically, the DOI’s expenditures to date total $546,908...