Reports

For the independent program evaluation of National Institute of Standards and Technology (NIST) Pandemic Relief Program, the evaluation objective was to determine whether NIST grantees and subrecipients accounted for and expended pandemic relief funds provided under the Coronavirus Aid, Relief, and Economic Security Act and subsequent funding authorizations in accordance with federal laws and regulations. We contracted with the Institute for Defense Analyses (IDA), an independent firm, to perform this evaluation. Our office oversaw the evaluation’s progress to ensure that IDA performed it in...

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...

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 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...

Our objective was to determine whether NIST is complying with the requirements of the CARES Act. Specifically, we determined (1) what steps NIST took to implement and comply with the CARES Act, (2) challenges NIST faced during implementation, and (3) NIST’s status in the processing of applications and awarding funds under the CARES Act. Overall, we found that NIST implemented and followed the requirements of the CARES Act and applicable grant award policies and procedures. In addition, NIST implemented measures to mitigate challenges resulting from an increased workload and a forced transition...

For our evaluation of the National Oceanic and Atmospheric Administration’s (NOAA’s) National Marine Fisheries Service (NMFS, also known as NOAA Fisheries) plan for the implementation of Coronavirus Aid, Relief, and Economic Security Act (CARES Act) funding, our objective was to determine whether NOAA complied with the requirements of the CARES Act. Specifically, we determined (1) what steps NOAA took in implementing the requirements for awarding funds, (2) challenges NOAA faced during implementation, and (3) NOAA’s current status in processing applications and award funds under the CARES Act...

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)...