Reports
Search reports, investigative results, and agency plansShowing 51 - 60 of 92 results
U.S. Agency for International Development OIG
USAID Adapted To Continue Program Monitoring During COVID-19, But the Effectiveness of These Efforts Is Still To Be Determined
Department of Veterans Affairs OIG
Inadequate Resident Supervision and Documentation of an Ophthalmology Procedure at the Oklahoma City VA Health Care System in Oklahoma
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...
Department of Veterans Affairs OIG
Comprehensive Healthcare Inspection Program (virtual reviews) Reports VISN 6 & 2
This report will provide (1) a descriptive evaluation of Veterans Integrated Service Network facilities’ pandemic readiness and response as determined by recent Comprehensive Healthcare Inspection Program inspections.
Department of Veterans Affairs OIG
Inconsistent Documentation and Management of COVID-19 Vaccinations for Community Living Center Residents
While reviewing the Veterans Health Administration’s (VHA) plans to document receipt and distribution of the COVID-19 vaccine, the VA Office of Inspector General (OIG) determined that VHA facilities did not consistently document the COVID-19 vaccination status of veterans living in VA’s Community Living Centers (CLCs). The OIG determined that VHA could not know at a national level whether the vaccine was offered to some CLC residents, and if so, what their status was. Because CLC residents are in the highest COVID-19 vaccine priority group, they should be offered the vaccine, when possible...
Department of Veterans Affairs OIG
Review of Community-Based Outpatient Clinics Closed Due to the COVID-19 Pandemic
The VA Office of Inspector General (OIG) reviewed community-based outpatient clinic (CBOC) closures that occurred due to the COVID-19 pandemic to evaluate the impact on patient care. The OIG virtually interviewed Veterans Health Administration (VHA) staff at 140 facilities that oversaw the 1,031 CBOCs that were operational prior to the World Health Organization’s pandemic declaration. Of these CBOCs, 173 were closed to face-to-face visits on or after February 1, 2020. Reasons for closure fell into four categories including (a) safety of patients and staff, (b) need for consolidation of...
Railroad Retirement Board OIG
Management Information Report - Interim Review of Railroad Retirement Board CARES Act Benefit Payments During the Pandemic
Management Information Report - Interim Review of Railroad Retirement Board CARES Act Benefit Payments During the Pandemic
Department of Veterans Affairs OIG
Comprehensive Healthcare Inspection of Facilities' COVID-19 Pandemic Readiness and Response in Veterans Integrated Service Networks 10 and 20
This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of Veterans Integrated Service Network (VISN) 10 and 20 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; and facility staff feedback. The OIG has aggregated findings on COVID-19 preparedness and responsiveness from routine inspections to ensure prompt dissemination of information given the...
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
Review of Veterans Health Administration’s Virtual Primary Care Response to the COVID-19 Pandemic
The VA Office of Inspector General (OIG) conducted a review to assess Veterans Health Administration’s (VHA) virtual primary care response to the COVID-19 pandemic, as well as the use of virtual care by primary care providers and their perceptions of VA Video Connect (VVC) between February 7 and June 16, 2020. The COVID-19 pandemic presented significant challenges to health care delivery worldwide. One strategy initiated by VHA, in accordance with the Centers for Disease Control and Prevention recommendation to social distance, included expanding the delivery of primary care via virtual care...
Department of Veterans Affairs OIG
Reporting and Monitoring Personal Protective Equipment Inventory during the Pandemic
The spread of COVID-19 drastically increased the demand for personal protective equipment (PPE) such as masks, gloves, and gowns, and significantly disrupted the global supply chain. As the nation’s largest integrated healthcare system, the Veterans Health Administration (VHA) had to compete for PPE for its personnel and patients. The VA Office of Inspector General (OIG) received hotline allegations that VHA medical facilities could not acquire and maintain enough PPE to keep pace with escalating needs. The OIG assessed how VHA reported and monitored PPE supply levels during the pandemic. The...