Reports

The Pandemic Response Accountability Committee (PRAC) is charged with conducting oversight of pandemic-related spending to prevent and detect fraud, waste, abuse, and mismanagement. In May 2021, we engaged MITRE, a not-for-profit federally funded research and development center, to conduct an independent study of lessons learned from the administration of pandemic-related emergency funding for unemployment insurance (UI) benefit programs in a sample of states. The objective of this study was to increase understanding of how states implemented pandemic UI benefit programs and how their...

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 PRAC examined whether the Small Business Administration (SBA) Phase III fraud controls, which were applied to process Paycheck Protection Program (PPP) loans in 2021, would have likely detected the earlier fraud found in PPP criminal cases. SBA designed the PPP Phase III controls to address significant fraud identified in the earlier phases of the program and some were later used by the SBA in its Restaurant Revitalization Fund (RRF) program.

During COVID-19, VHA’s Office of Community Care (OCC) took steps to ensure veterans continued to have expanded access to health care in the community, as required by the VA MISSION Act of 2018. OCC issued policies to VA facilities to postpone nonurgent appointments and offer alternatives to in-person care, such as telehealth. The VA Office of Inspector General (OIG) conducted this audit to determine whether VHA effectively managed community care consults for routine appointments during the pandemic. The OIG found that routine community care consults were unscheduled for an average of 42 days...

The Office of the Inspector General OIG audited the Tennessee Valley Authority’s (TVA) use of remote application and desktop virtualization due to the risk of increased remote users during the COVID-19 pandemic and recent publicized remote access vulnerabilities. We found several areas where TVA was consistent with cybersecurity remote access best practices. However, we identified gaps in TVA’s configuration settings, architectural design, and administrative procedures. We recommend the Vice President and Chief Information and Digital Officer, Technology & Information, review the identified...

This insights report provides a contextual understanding of the cross-cutting challenges states faced within their unemployment insurance (UI) programs and highlights the substantial work that has been done by State Auditors to ensure their states’ UI programs are functioning effectively. This report examines four common insights across 16 State Auditor Offices: (1) UI workloads surged for states; (2) the claims surge exploited internal control weaknesses; (3) uncommon and varying fraud schemes began to occur as the amount of federal funding expanded; and (4) state workforce agencies...

The VA Office of Inspector General (OIG) examined whether the Veterans Health Administration (VHA) implemented data collection and reporting systems to report on the supply of COVID-19 vaccines to VA medical facilities and doses administered to VA employees and veterans enrolled in VA’s healthcare system (approximately 9.5 million individuals). Although essential for national reporting, tracking VA vaccine data is difficult because VA does not have a centralized national pharmacy inventory management system to track vaccine supply at facilities. Although VHA staff swiftly developed data...

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of Veterans Integrated Service Network (VISN) 1 and 8 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 1 and 8 vaccination efforts. The OIG has aggregated findings on COVID-19 preparedness and responsiveness from routine inspections to ensure prompt...

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...