Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Martinsburg VA Medical Center (facility) in West Virginia to assess allegations of failure to schedule a Care in the Community (CITC) COVID Priority 1 cardiology consult within Veterans Health Administration requirements, and delays in CITC consult scheduling caused by inadequate CITC staffing. The OIG substantiated that a COVID Priority 1 CITC cardiology consult was not scheduled within 30 days of the clinically indicated date. The OIG determined that the consult was amongst a backlog of approximately 5,000...

OIG’s FY 2022 Annual Oversight Plan describes ongoing and planned oversight activities for the U.S. Agency for International Development (USAID), the Millennium Challenge Corporation (MCC), the U.S. African Development Foundation (USADF), and the Inter-American Foundation (IAF). OIG audits assess the efficiency and effectiveness of agency programs and operations; isolate the root causes of identified fraud, waste, and abuse in development and humanitarian assistance programs; and make sound recommendations for addressing these vulnerabilities and improving foreign assistance programs and...

The VA Office of Inspector General (OIG) conducted a national review of stat community care consults generated during the outset of the COVID-19 pandemic to evaluate consult processes. Patient involvement in care urgency disagreements and reporting of adverse events in community care were also reviewed. When the OIG identified deficiencies in processes, electronic health records (EHRs) of the patients at issue were further examined for potential negative outcomes. The OIG did not identify any negative care outcomes. For the 2,236 stat community care consults generated from March 20, 2020...

The COVID-19 Information Brief provides information on USAID’s response to the COVID-19 pandemic and associated challenges, as well as related oversight plans and activities. Information about the pandemic response of the other three foreign assistance agencies we oversee – the Millennium Challenge Corporation, U.S. African Development Foundation, and Inter‐American Foundation – is also included. We prepared this informational brief to increase stakeholder knowledge and public transparency regarding these efforts. This brief reports on activities from the start of the pandemic through July 31...

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 Fiscal Year 2022 Inspectors General Coordinated Oversight Plan for Foreign Assistance To Combat HIV/AIDS, Tuberculosis, and Malaria outlines ongoing PEPFAR oversight work initiated in the prior year as well as new work each OIG plans to undertake in fiscal year 2022. In preparing this plan and executing current oversight work within it, the coordinating OIGs continued holding quarterly PEPFAR oversight meetings and introduced a smaller working group for more focused coordination. The plan includes a coordinated proposal, developed within the smaller working group, to be implemented by...

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...

This brief provides information on USAID’s response to the COVID-19 pandemic and associated challenges, as well as related oversight plans and activities. Information about the pandemic response of the other three foreign assistance agencies we oversee – the Millennium Challenge Corporation, U.S. African Development Foundation, and Inter‐American Foundation – is also included. We prepared this informational brief to increase stakeholder knowledge and public transparency regarding these efforts. This brief reports on activities from the start of the pandemic through March 31, 2021, but has a...

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...