Reports

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 pandemic has presented significant challenges to Multnomah County. We conducted this audit to support transparent and accountable government operations during this unprecedented time. This report details what the county spent pandemic funding on, which provider organizations received pandemic funding from the county, and whether funds were distributed in alignment with the county’s stated commitment to leading with race. In this audit, we found that county management sought to balance the need to get resources out to the community quickly with also maintaining effective policies...

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 Auditor’s Office follows up on audit recommendations to support county government’s accountability. The county implemented most of the Auditor’s recommendations from the first audit report on the county’s response to the COVID-19 pandemic. However. the Multnomah County Sheriff’s Office did not implement our recommendation to expand the use of free-phone calls or modify lobby video visit operations to allow for safe use. Also, for Library locations, the county did not implement our recommendation to add COVID-19 specific cleaning and disinfecting requirements into its contracts with...

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...

Management advisory memorandum detailing the growth of community telehealth claims and the associated risks.

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...