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Department of Veterans Affairs OIG

Comprehensive Healthcare Inspection Summary Report: Evaluation of Breast Cancer Surveillance in Veterans Health Administration Facilities

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report evaluates notification and surveillance for patients with mammogram results requiring action during the COVID-19 pandemic. The inspections involved interviews with key staff and evaluations of clinical processes. The OIG reviewed providers’ notification of mammogram results requiring action to patients within VHA’s defined time frame and patients’ completion of the recommended actions. The OIG issued no recommendations for improvement.
Department of Veterans Affairs OIG

Review of Personnel Shortages in Federal Health Care Programs During the COVID-19 Pandemic

The COVID-19 pandemic put an unprecedented strain on the nation’s federal healthcare systems. The Pandemic Response Accountability Committee (PRAC) Health Care Subgroup surveyed more than 300 facilities across four federal healthcare programs to determine if the facilities had sufficient medical staff during the pandemic. The VA Office of Inspector General (OIG) reviewed staffing at Veterans Health Administration facilities, the Department of Justice OIG reviewed Federal Bureau of Prisons facilities, the Department of Defense OIG reviewed medical treatment facilities, and the Health and Human...
Department of Homeland Security OIG

Ineffective Controls Over COVID-19 Funeral Assistance Leave the Program Susceptible to Waste and Abuse

The Federal Emergency Management Agency (FEMA) did not always implement effective internal controls to provide oversight of COVID-19 Funeral Assistance. FEMA’s funeral assistance program greatly expanded the universe of reimbursable expenses for deaths related to COVID-19, even beyond those specifically identified as ineligible under established FEMA policy, without establishing guardrails to ensure relief was limited to necessary expenses and serious needs as required by statute.
Department of Homeland Security OIG

FEMA Did Not Effectively Manage the Distribution of COVID-19 Medical Supplies and Equipment

Although the Federal Emergency Management Agency (FEMA) worked with its strategic partners to deliver critical medical supplies and equipment in response to COVID-19, FEMA did not effectively manage the distribution process. Specifically, FEMA did not use the Logistics Supply Chain Management System (LSCMS), its system of record for managing the distribution process, to track about 30 percent of the critical medical resources shipped, as required.
Department of Veterans Affairs OIG

VHA Can Improve Controls Over Its Use of Supplemental Funds

The Coronavirus Aid, Relief, and Economic Security (CARES) Act appropriated about $17.2 billion in supplemental funds to the Veterans Health Administration (VHA) to support VA’s efforts to prevent, prepare for, and respond to the COVID-19 pandemic. The OIG conducted this audit to assess the effectiveness of VA’s controls over VHA’s use of these funds. Because VA’s financial management system does not support the direct obligation of supplemental funds for all expenses, staff used expenditure transfers to shift funds between appropriation accounts. Expenditure transfers are documented using...
Department of Veterans Affairs OIG

Audie L. Murphy Memorial Veterans’ Hospital Missed Opportunities to Distribute Excess Ventilators during the COVID-19 Pandemic

The COVID-19 pandemic caused a surge in demand for ventilators and provoked concerns about potential supply shortages across VA medical facilities. During the course of a previous broader review, the VA Office of Inspector General (OIG) uncovered a potential issue with the number of ventilators procured and stored at the Audie L. Murphy Memorial Veterans’ Hospital in San Antonio, Texas, and sought to determine whether they had been properly requested, acquired, received, and accounted for. The OIG found the facility acquired more ventilators from March 1, 2020, through November 30, 2021, than...
Department of Homeland Security OIG

FEMA Did Not Provide Sufficient Oversight of Project Airbridge

The Federal Emergency Management Agency (FEMA) did not provide sufficient oversight of Project Airbridge, a COVID-19 initiative. Under unprecedented pressure to mitigate disruptions in global medical supply chains, FEMA established Project Airbridge.
Department of Homeland Security OIG

FEMA Did Not Provide Sufficient Oversight of Project Airbridge

The Federal Emergency Management Agency (FEMA) did not provide sufficient oversight of Project Airbridge, a COVID-19 initiative. Under unprecedented pressure to mitigate disruptions in global medical supply chains, FEMA established Project Airbridge.
Department of Veterans Affairs OIG

Insights on Telehealth Use and Program Integrity Risks Across Selected Health Care Programs During the Pandemic

The Pandemic Response Accountability Committee’s (PRAC) Health Care Subgroup developed this report to share insights about the expansion—and the emerging risks—of telehealth in selected programs across six federal agencies during the first year of the COVID-19 pandemic. The selected programs, which provided telehealth services to about 37 million people in 2020 (up from just three million in 2019), included the Veterans Health Administration, Medicare, TRICARE, Federal Employees Health Benefits Program, Office of Workers’ Compensation Programs, and Department of Justice prisoner healthcare...
Department of Veterans Affairs OIG

VHA Progressed in the Follow-Up of Canceled Appointments during the Pandemic but Could Use Additional Oversight Metrics

The OIG reviewed the Veterans Health Administration’s (VHA) progress in monitoring their follow-up of canceled appointments during the COVID-19 pandemic. In 2020, the OIG reported that VHA had not followed up on about 32 percent of canceled appointments. VHA then implemented the Cancelled Appointments and Consult Management Initiative and created a cancellation report to track follow-up conducted for appointments originally scheduled to occur after July 21, 2020. The report allowed tracking by types of care, by month, and cumulatively, but VHA did not use all the reporting features. VHA...