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Department of Veterans Affairs OIG

Potential Risks Associated with Expedited Hiring in Response to COVID-19

This management advisory memo identifies potential risks associated with the Veterans Health Administration’s (VHA) efforts to expedite adding new staff to meet increased demand caused by the COVID-19 pandemic. The VA Office of Inspector General (OIG) recognizes the tremendous pressure to quickly hire staff to meet unprecedented needs. To achieve VHA’s goal of bringing all new employees on duty within three days of making a tentative offer, VHA has modified or deferred tasks such as fingerprinting, background investigations, drug testing, credentialing, and preplacement physicals. 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 Health & Human Services OIG

Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23-May 30, 2020

We did this review to determine the number and results of onsite State surveys of nursing homes during the COVID-19 pandemic. Nursing home residents are particularly vulnerable to infectious diseases such as COVID-19, and infection control has been a persistent problem for most nursing homes. As of November 8, 2020, more than 67,000 nursing home residents had died of COVID-19-related illnesses, which represented almost 30 percent of all COVID 19 deaths in the United States at that time. Onsite State surveys assess the quality of services in nursing homes, a critical function for protecting...
Department of Health & Human Services OIG

Onsite Surveys of Nursing Homes During the COVID-19 National Emergency: March 23-May 30, 2020

Department of Veterans Affairs OIG

Alleged Deficiencies in the Management of Staff Exposure to a Patient with COVID-19 at the VA Portland Health Care System in Oregon

The VA Office of Inspector General (OIG) conducted a healthcare inspection to determine the validity of allegations related to the management of staff exposure to a patient diagnosed with COVID-19 at the VA Portland Medical Center (facility) in Oregon. The events under review involved the facility’s first patient diagnosed with COVID-19. The OIG did not substantiate that emergency department staff failed to notify imaging department staff that a patient was suspected to have COVID-19 before sending the patient to the imaging department. At the time of the patient’s transport to the imaging...
Department of Veterans Affairs OIG

Review of Highly Rural Community-Based Outpatient Clinics Limited Access to Select Specialty Care

The VA Office of Inspector General (OIG) reviewed the accessibility of dermatology, orthopedics, and urology specialty care for patients in the 17 Veterans Health Administration (VHA) community-based outpatient clinics (CBOCs) classified as highly rural. The OIG also reviewed accessibility, barriers, and the availability and utilization of resources for the time frame March 1, 2018 (or from the date the CBOC became highly rural), through February 28, 2019. VHA utilized clinical consults, electronic consults (eConsults), telehealth, and community care to provide specialty care at the highly...