Reports

Department of Defense OIG

Audit of DoD Health Care Personnel Shortages During the Coronavirus Disease–2019 Pandemic

Audit | 5/23/2024

D-2024-0086-D000AW-0001-0001.a - Open

Rec. 1.a: The DoD OIG recommended that the Defense Health Agency Director, in consultation with the Defense Civilian Personnel Advisory Service develop and implement a plan to ensure a more competitive pay rate for nursing and other hard to fill medical positions in all Defense Health Agency regions.

D-2024-0086-D000AW-0001-0001.c - Open

Rec. 1.c: The DoD OIG recommended that the Defense Health Agency Director, in consultation with the Defense Civilian Personnel Advisory Service develop and implement a plan to establish qualification requirements for nursing and other hard to fill medical positions if it is determined that it would enhance the DoD's efforts to help recruit and retain health care personnel.

D-2024-0086-D000AW-0001-0002.a - Open

Rec. 2.a: The DoD OIG recommended that the Under Secretary of Defense for Personnel and Readiness, in consultation with the Assistant Secretary of Defense for Health Affairs and the Defense Health Agency Director determine whether the DoD needs to extend waiving the authority to apply section 3326, title 5, United States Code, for appointments made to positions in medical or health profession with the DoD under the direct hire authority and, if so, provide the extension in a subsequent memo before the authority for covered positions expires on September 30, 2025.

D-2024-0086-D000AW-0001-0003.a - Open

Rec. 3.a: The DoD OIG recommended that the Defense Health Agency Director revise Defense Health Agency Administrative Instruction 5136.03 to establish approval authority for any civilian personnel extensions outside the continental United States beyond a period of 7 years.

D-2024-0086-D000AW-0001-0003.b - Open

Rec. 3.b: The DoD OIG recommended that the Defense Health Agency Director establish maximum time frames to approve civilian personnel extensions outside of the continental United States and require monitoring of extension approval timelines.

D-2024-0086-D000AW-0001-0003.d - Open

Rec. 3.d: The DoD OIG recommended that the Defense Health Agency Director develop and implement a plan to apply strategies and incentives used by other Federal agencies to hire entry-level registered nurses if it is determined the strategies and incentives would enhance the DoD's recruitment efforts.

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.

Full Details: Oversight.gov Report Page

Department of Defense OIG

Management Advisory: DoD Office of Inspector General Review of Other Transaction Agreement W912CG-21-9-0001

Full Details: Oversight.gov Report Page

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...

Full Details: Oversight.gov Report Page

Department of Defense OIG

Audit of the Reliability of the DoD Coronavirus Disease–2019 Patient Health Data

Full Details: Oversight.gov Report Page

Audit | 7/07/2023

D-2023-0093-D000CT-0001-0001 - Open

(U) Rec. 1: The DoD OIG recommended that the Director of the Defense Health Agency work with the Program Executive Officer of the Program Executive Office, Defense Healthcare Management Systems to document and implement the process for identifying and collecting patient health data of DoD patients in the Military Health System in current and future registries within their purview in a written document, such as a standard operating procedure. The procedure should identify, at a minimum, the internal controls throughout the process, the relevant data sources, data fields, and diagnostic codes used in the computer scripts, and should be reviewed and approved when updates occur.

D-2023-0093-D000CT-0001-0002.1 - Closed

(U) Rec. 2: The DoD OIG recommended that the Senior Contracting Official of the U.S. Army Medical Research Acquisition Activity and the Chief of the Joint Trauma System work with the Joint Trauma System contracting officer's representative to revise the quality assurance surveillance plan. The plan should include an appropriate sampling methodology for selecting patient health records from the Coronavirus Disease-2019 Registry to verify that the contractor is achieving the contract-required accuracy rate for entering patient data, and submit the revised quality assurance surveillance plan to the contracting officer.

D-2023-0093-D000CT-0001-0002.2 - Closed

D-2023-0093-D000CT-0001-0003 - Closed

(U) Rec. 3.a: If the contractor did not meet the 90 percent accuracy requirement, the DoD OIG recommended that the Chief of the Joint Trauma System work with the Senior Contracting Official of the U.S. Army Medical Research Acquisition Activity to update the contractor's rating in the contractor's performance assessment reports for contract W81XWH-22-C-0151 and contract W81XWH-20-P-0197, when feasible.

D-2023-0093-D000CT-0001-0003.a - Closed

(U) Rec. 3.b: If the contractor did not meet the 90 percent accuracy requirement, the DoD OIG recommended that the Chief of the Joint Trauma System work with the Senior Contracting Official of the U.S. Army Medical Research Acquisition Activity to recoup any of the $3.9 million in questioned costs paid for services that did not comply with the terms of contract W81XWH-20-P-0197, if feasible.

D-2023-0093-D000CT-0001-0003.b - Closed

(U) Rec. 3.c: If the contractor did not meet the 90 percent accuracy requirement, the DoD OIG recommended that the Chief of the Joint Trauma System work with the Senior Contracting Official of the U.S. Army Medical Research Acquisition Activity to recoup any of the $2.3 million in questioned costs paid for services that did not comply with the terms of contract W81XWH-22-C-0151.

D-2023-0093-D000CT-0001-0003.c - Closed

(U) Rec. 3.d: If the contractor did not meet the 90 percent accuracy requirement, the DoD OIG recommended that the Chief of the Joint Trauma System work with the Senior Contracting Official of the U.S. Army Medical Research Acquisition Activity to consider all available contract remedies for contract W81XWH-22-C-0151, including modifying and, if necessary, terminating and re-competing the contract, and take action to ensure that the Department receives full value for the funds it expends for contract W81XWH-22-C-0151.

D-2023-0093-D000CT-0001-0003.d - Closed

(U) Rec. 3.e: If the contractor did not meet the 90 percent accuracy requirement, the DoD OIG recommended that the Chief of the Joint Trauma System work with the Senior Contracting Official of the U.S. Army Medical Research Acquisition Activity to delegate an official to review the concerns identified in this report, including the actions of the contracting officials, and take administrative actions, as necessary. The review should include a determination on whether the contractor's performance assessment reports were accurate and make updates as necessary.

D-2023-0093-D000CT-0001-0003.e - Closed

D-2023-0093-D000CT-0001-0004.a - Open

(U) Rec. 4.a: The DoD OIG recommended that the Director of the Defense Health Agency work with the Chief of the Joint Trauma System establish and implement a process for selecting Coronavirus Disease-2019 events for entry into the Coronavirus Disease-2019 Registry to limit selection bias.

D-2023-0093-D000CT-0001-0004.b - Closed

(U) Rec. 4.b: The DoD OIG recommended that the Director of the Defense Health Agency work with the Chief of the Joint Trauma System to include a bias disclosure notice on all reports generated from the Coronavirus Disease-2019 Registry until the Coronavirus Disease-2019 Registry data represent the population of DoD patients who had a Coronavirus Disease-2019 event.

D-2023-0093-D000CT-0001-0005.a - Open

(U) Rec. 5.a: The DoD OIG recommended that the Assistant Secretary of Defense (Health Affairs) establish and implement a policy for developing and populating patient registries that aligns with the Department of Health and Human Services best practices, "Agency for Healthcare Research and Quality, Registries for Evaluating Patient Outcomes: A User's Guide," current edition.

D-2023-0093-D000CT-0001-0005.b - Open

(U) Rec. 5.b: The DoD OIG recommended that the Assistant Secretary of Defense (Health Affairs) conduct a review of all patient registries in the Military Health System to verify the reliability of data in each registry and implement corrective actions, as necessary.

Department of Defense OIG

Audit of DoD Actions Taken to Protect DoD Information When Using Collaboration Tools During the Coronavirus Disease–2019 Pandemic

Full Details: Oversight.gov Report Page

Audit | 6/06/2023

D-2023-0079-D000CR-0001-0001.A1a - Closed

(U) Rec.A.1.a : This recommendation is Controlled Unclassified Information

D-2023-0079-D000CR-0001-0001.A1b - Closed

(U) Rec.A.1.b: This recommendation is Controlled Unclassified Information

D-2023-0079-D000CR-0001-0002.A2 - Closed

(U) Rec.A.2 : This recommendation is Controlled Unclassified Information

D-2023-0079-D000CR-0001-0003.A3 - Closed

(U) Rec.A.3 : This recommendation is Controlled Unclassified Information

D-2023-0079-D000CR-0001-0004.A4 - Closed

(U) Rec.A.4 : This recommendation is Controlled Unclassified Information

D-2023-0079-D000CR-0001-0005.A5 - Closed

(U) Rec.A.5 : This recommendation is Controlled Unclassified Information

D-2023-0079-D000CR-0002-0001.B1a - Closed

(U) Rec. B.1.a: The DoD OIG recommended that the Chief Information Officer for the Defense Finance and Accounting Service renegotiate changes with the Adobe Connect vendor to configure Adobe Connect to require privileged users to authenticate into the collaboration tool using multifactor authentication.

D-2023-0079-D000CR-0002-0001.B1b - Closed

(U) Rec.B.1.b : This recommendation is Controlled Unclassified Information

D-2023-0079-D000CR-0002-0002.B2 - Closed

(U) Rec.B.2 : This recommendation is Controlled Unclassified Information

D-2023-0079-D000CR-0002-0003.B3a - Closed

(U) Rec.B.3.a : This recommendation is Controlled Unclassified Information

D-2023-0079-D000CR-0002-0003.B3b - Closed

(U) Rec.B.3.b : This recommendation is Controlled Unclassified Information

D-2023-0079-D000CR-0002-0003.B3c - Closed

Rec. B.3.c: The DoD OIG recommended that the Chief Information Officer for the Defense Threat Reduction Agency configure Zoom for Government to lock user accounts after three unsuccessful logon attempts in a 15-minute period.

D-2023-0079-D000CR-0003-0001.C1 - Closed

(U) Rec.C.1 : This recommendation is Controlled Unclassified Information

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...

Full Details: Oversight.gov Report Page

Audit | 5/09/2023

01 - Closed

VA’s assistant secretary for management and chief financial officer assess the iFAMS configuration to determine whether integration with the payroll subsystems can be accomplished to resolve some of the payroll-related issues that require the need for expenditure transfers.

01 - Closed

Assess the iFAMS configuration to determine whether integration with the payroll subsystems can be accomplished to resolve some of the payroll-related issues that require the need for expenditure transfers.

02 - Closed

Establish guidance that outlines the type of documentation required to support the amounts identified in the manual journal vouchers when processing expenditure transfers.

03 - Closed

Require medical facility staff have documented authority, through proper delegation, to make purchases.

04 - Closed

Verify that medical facility staff segregate duties so that the same person is not both authorizing and receiving goods and services.

05 - Closed

Make certain the purchase card holder is not the requestor or approver for the purchase.

06 - Closed

Ensure contracting officers representatives know and understand their duties and responsibilities for the certification and payment of invoices.

07 - Closed

Check vendors compliance with contract terms to include the comparison of invoiced amounts with the contract line-item unit costs.esponse to the pandemic and develop appropriate action plans to integrate oversight roles, responsibilities, and clear guidance into the use of supplemental funds.

08 - Closed

Ensure that medical facility staff track the receipt of goods to make certain they are the correct quantity.

09 - Closed

Conduct an assessment of lessons learned from the emergency response to the pandemic and develop appropriate action plans to integrate oversight roles, responsibilities, and clear guidance into the use of supplemental funds.

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...

Full Details: Oversight.gov Report Page

Review | 4/11/2023

Department of Defense OIG

Audit of DoD Actions Taken to Implement Cybersecurity Protections Over Remote Access Software in the Coronavirus Disease–2019 Telework Environment

Full Details: Oversight.gov Report Page

Audit | 3/24/2023

D-2023-0057-D000CR-0001-0001.A1 - Closed

(U) Rec. A.1: The DoD OIG recommended that the Director of the U.S. Southern Command - Joint Interagency Task Force South Command, Control, Communications, Computers, Cyber and Intelligence direct its network administrators to scan the VMware Horizon main virtual desktop for malware in accordance with the McAfee Endpoint Security Technical Implementation Guide, develop compensating controls, or formally accept the risk of not scanning the main virtual desktop.

D-2023-0057-D000CR-0001-0002.A2a - Closed

(U) Rec. A.2.a: The DoD OIG recommended that the Chief Information Officer of the Department of the Air Force revise its policy to align with the Windows 10 Security Technical Implementation Guide requirement for disabling inactive user accounts after no more than 35 days.

D-2023-0057-D000CR-0001-0002.A2b - Closed

(U) Rec. A.2.b: The DoD OIG recommended that the Chief Information Officer of the Department of the Air Force direct network and system administrators to disable inactive user accounts after no more than 35 days of inactivity in accordance with the Windows 10 Security Technical Implementation Guide, develop compensating controls, or formally accept the risk of not disabling the inactive user accounts.

D-2023-0057-D000CR-0001-0003.A3 - Closed

(U) Rec. A.3: The DoD OIG recommended that the Chief Information Officer of the Naval Surface Warfare Center - Panama City Division direct network and system administrators to disable inactive user accounts after no more than 35 days of inactivity in accordance with the Windows 10 Security Technical Implementation Guide, develop compensating controls, or formally accept the risk of not disabling the inactive user accounts.

D-2023-0057-D000CR-0001-0004.A4a - Closed

(U) Rec. A.4.a: The DoD OIG recommended that the Chief Information Officer of the Defense Intelligence Agency revise its policy to align with the Windows 10 Security Technical Implementation Guide requirement for disabling inactive users after no more than 35 days.

D-2023-0057-D000CR-0001-0004.A4b - Closed

(U) Rec. A.4.b: The DoD OIG recommended that the Chief Information Officer of the Defense Intelligence Agency direct network and system administrators to disable inactive user accounts after no more than 35 days of inactivity in accordance with the Windows 10 Security Technical Implementation Guide, develop compensating controls, or formally accept the risk of not disabling the inactive user accounts.

D-2023-0057-D000CR-0001-0005.A5a - Closed

(U) Rec. A.5.a: The DoD OIG recommended that the Director of the Marine Corps Information Command, Control, Communications, and Computers revise the organization's policy to align with the Windows 10 Security Technical Implementation Guide requirement for disabling inactive users after no more than 35 days.

D-2023-0057-D000CR-0001-0005.A5b - Closed

(U) Rec. A.5.b: The DoD OIG recommended that the Director of the Marine Corps Information Command, Control, Communications, and Computers direct network and system administrators to disable inactive user accounts after no more than 35 days of inactivity in accordance with the Windows 10 Security Technical Implementation Guide, develop compensating controls, or formally accept the risk of not disabling the inactive user accounts.

D-2023-0057-D000CR-0001-0006.A6 - Closed

(U) Rec. A.6: The DoD OIG recommended that the Director of the Defense Information Systems Agency Joint Service Provider direct network and system administrators to disable inactive user accounts after no more than 35 days of inactivity in accordance with the Windows 10 Security Technical Implementation Guide, develop compensating controls, or formally accept the risk of not disabling the inactive user accounts.

D-2023-0057-D000CR-0002-0001.B1 - Closed

(U) Rec. B.1: The DoD OIG recommended that the Director of the Defense Information Systems Agency Joint Service Provider direct network and system administrators to revise the vulnerability management program to include mitigation timeframes for all vulnerabilities and develop plans of actions and milestones for all vulnerabilities that cannot be mitigated in a timely manner.

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...

Full Details: Oversight.gov Report Page

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...

Full Details: Oversight.gov Report Page

Review | 11/03/2022

Department of Defense OIG

Audit of the DoD Certification Process for Coronavirus Aid, Relief, and Economic Security Act Section 4003 Loans Provided to Businesses Designated as Critical to Maintaining National Security

Full Details: Oversight.gov Report Page

Audit | 9/20/2022

Department of Veterans Affairs OIG

Comprehensive Healthcare Inspection Summary Report: Evaluation of Medication Management in Veterans Health Administration Facilities, Fiscal Year 2021

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report highlights the results of a focused evaluation of Veterans Health Administration (VHA) facilities’ medication management related to remdesivir use. The report describes medication management-related findings from healthcare inspections performed at 34 VHA medical facilities during fiscal year 2021. Each inspection involved interviews with key staff and reviews of clinical and administrative processes.The OIG found that VHA met many elements of expected performance, including the availability of...

Full Details: Oversight.gov Report Page

Review | 9/01/2022

Department of Defense OIG

DoD Cooperative Agreements With Coronavirus Aid, Relief, and Economic Security Act Obligations

Full Details: Oversight.gov Report Page

Department of Defense OIG

Audit of DoD Use of the Government Purchase Card in Response to the Coronavirus Disease–2019 Pandemic

The objective of this audit is to determine whether cardholders used the Government Purchase Card to support DoD's response to the pandemic in accordance with Federal and DoD policies. We may revise the objective as the audit proceeds, and we will also consider suggestions from management for additional or revised objectives.

Full Details: Oversight.gov Report Page

Department of Defense OIG

Audit of North American Aerospace Defense Command and U.S. Northern Command Use of Coronavirus Aid, Relief, and Economic Security Act Funding

Full Details: Oversight.gov Report Page

Audit | 5/17/2022

D-2022-0098-D000AU-0001-0001.a - Closed

Rec. 1.a: The DoD OIG recommended that the Commander, North American Aerospace Defense Command and U.S. Northern Command, develop internal controls that implement emergency funding guidance and ensure proper use of emergency authorized funds.

D-2022-0098-D000AU-0001-0001.b - Closed

Rec. 1.b: The DoD OIG recommended that the Commander, North American Aerospace Defense Command and U.S. Northern Command, develop internal controls that require North American Aerospace Defense Command and U.S. Northern Command officials to retain sufficient evidence, including a clear and accurate description of the goods and services purchased, that demonstrates how those goods and services supported the specific emergency.

D-2022-0098-D000AU-0001-0002.a - Closed

Rec. 2.a: The DoD OIG recommended that the Director, Budget Operations and Personnel, Office of the Deputy Assistant Secretary of the Air Force (Budget) develop and implement internal controls that verify whether current and future emergency expenses meet specific funding requirements prior to reimbursement and retain sufficient evidence of verification.

D-2022-0098-D000AU-0001-0002.b - Closed

Rec. 2.b: The DoD OIG recommended that the Director, Budget Operations and Personnel, Office of the Deputy Assistant Secretary of the Air Force (Budget) conduct a review of North American Aerospace Defense Command and U.S. Northern Command CARES Act transactions 1, 3, 5, 6, 14, 16, 17, 18, 24, and 25 to determine whether the purpose statute was violated. In addition, review the remaining 472 North American Aerospace Defense Command and U.S. Northern Command CARES Act transactions, which were not part of our sample, to ensure CARES Act funds were used as intended.

D-2022-0098-D000AU-0001-0002.c - Closed

Rec. 2.c: The DoD OIG recommended that the Director, Budget Operations and Personnel, Office of the Deputy Assistant Secretary of the Air Force (Budget), in coordination with North American Aerospace Defense Command and U.S. Northern Command, make the appropriate accounting adjustments for transactions 1, 3, 5, 6, 14, 16, 17, 18, 24, and 25 to non-CARES Act funding if the Director's review concludes the purpose statute was violated. The Director's review could result in the potential monetary benefits of $19.2 million (in questioned costs) and $7.4 million (in unsupported costs).

D-2022-0098-D000AU-0001-0002.d - Closed

Rec. 2.d: The DoD OIG recommended that the Director, Budget Operations and Personnel, Office of the Deputy Assistant Secretary of the Air Force (Budget) determine whether any purpose statute violations result in Antideficiency Act violations based on Recommendations 2.b. and 2.c.

D-2022-0098-D000AU-0001-0002.e - Closed

Rec. 2.e: The DoD OIG recommended that the Director, Budget Operations and Personnel, Office of the Deputy Assistant Secretary of the Air Force (Budget) report any resulting Antideficiency Act violations to the Secretary of the Air Force, who then reports relevant information to the President and Congress.

Department of Veterans Affairs OIG

The Veterans Health Administration Needs to Do More to Promote Emotional Well-Being Supports Amid the COVID-19 Pandemic

The Veterans Health Administration (VHA) Office of Emergency Management issued the initial COVID-19 Response Plan on March 23, 2020, and then an updated version on August 7, 2020. The National Center for Organization Development created a COVID-19 rapid response consultation process for VHA leaders in a supervisory role. The Organizational Health Council developed a team that coordinated with multiple VHA program offices to create a COVID-19 Employee Support Toolkit and other resources. Additionally, several program offices independently created and disseminated employee well-being resources...

Full Details: Oversight.gov Report Page

Review | 5/10/2022

Department of Defense OIG

Audit of U.S. Indo-Pacific Command’s Execution of Coronavirus Aid, Relief, and Economic Security Act Funding

Full Details: Oversight.gov Report Page

Department of Veterans Affairs OIG

Purchases of Smartphones and Tablets for Veterans’ Use during the COVID-19 Pandemic

The COVID-19 pandemic accelerated efforts by the Veterans Health Administration (VHA) to expand veteran access to telehealth. Accordingly, VHA’s Connected Care Office created a new digital divide consult to issue iPhones to veterans experiencing homelessness who were enrolled in the Department of Housing and Urban Development VA Supportive Housing (HUD-VASH) Program. VHA was already loaning iPads to other veterans who lacked telehealth capable devices through the digital divide consult process. The VA Office of Inspector General (OIG) initiated this review to evaluate whether purchases of...

Full Details: Oversight.gov Report Page

Review | 5/04/2022

Department of Veterans Affairs OIG

Comprehensive Healthcare Inspection of Facilities’ COVID-19 Pandemic Readiness and Response in Veterans Integrated Service Networks 2, 5, and 6

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of Veterans Integrated Service Networks (VISNs) 2, 5, and 6 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 VISNs 2, 5, and 6 vaccination efforts.The OIG has aggregated findings on COVID-19 preparedness and responsiveness from routine inspections to ensure...

Full Details: Oversight.gov Report Page

Department of Defense OIG

Evaluation of Department of Defense Military Medical Treatment Facility Challenges During the Coronavirus Disease-2019 (COVID-19) Pandemic in Fiscal Year 2021

Full Details: Oversight.gov Report Page

Inspection / Evaluation | 4/05/2022

D-2022-2081-DEV0PB-0001-0001.A1a - Open

(U) Rec. A.1.a: The DoD OIG recommended that the Director of the Defense Health Agency, in conjunction with the Secretaries of the Military Departments, establish a working group to address the staffing challenges identified by Military Medical Treatment Facilities during this evaluation. The working group should establish milestones to streamline the hiring process to allow Military Medical Treatment Facilities to more quickly fill civilian staffing positions.

D-2022-2081-DEV0PB-0001-0001.A1b - Open

(U) Rec. A.1.b: The DoD OIG recommended that the Director of the Defense Health Agency, in conjunction with the Secretaries of the Military Departments, establish a working group to address the staffing challenges identified by Military Medical Treatment Facilities during this evaluation. The working group should establish milestones to determine if salaries for Military Medical Treatment Facility civilian nurses are commensurate with each facility's local market and if military treatment facilities are able to hire nurses at those salaries. For locations where military treatment facility salaries are not commensurate with the local market, take appropriate actions that will reduce the disparity in those markets.

D-2022-2081-DEV0PB-0001-0001.A1c - Open

(U) Rec. A.1.c: The DoD OIG recommended that the Director of the Defense Health Agency, in conjunction with the Secretaries of the Military Departments, establish a working group to address the staffing challenges identified by Military Medical Treatment Facilities during this evaluation. The working group should establish milestones to establish a central authority with the knowledge of the Services' requests for individual and large group deployments of medical staff coming out of Military Medical Treatment Facilities and the associated risks to health care delivery.

D-2022-2081-DEV0PB-0001-0001.A1d - Open

(U) Rec. A.1.d: The DoD OIG recommended that the Director of the Defense Health Agency, in conjunction with the Secretaries of the Military Departments, establish a working group to address the staffing challenges identified by Military Medical Treatment Facilities during this evaluation. The working group should establish milestones to assess the ability of Military Medical Treatment Facilities to rapidly receive augmentation of medical staff from the Reserve Components.

D-2022-2081-DEV0PB-0001-0002.A2a - Open

(U) Rec. A.2.a: The DoD OIG recommended that the Director of the Defense Health Agency, in coordination with the Secretaries of the Military Departments establish the manpower requirements for the coronavirus disease-2019 mission within the Military Medical Treatment Facilities for the staff required to support testing, vaccinations, contact tracing, and acute respiratory clinics.

D-2022-2081-DEV0PB-0001-0002.A2b - Open

(U) Rec. A.2.b: The DoD OIG recommended that the Director of the Defense Health Agency, in coordination with the Secretaries of the Military Departments identify the medical personnel requirements within the Military Medical Treatment Facilities, including clinicians, nurses, and support staff, needed for future long-term pandemic response and biological incidents.

D-2022-2081-DEV0PB-0002-0001.B - Open

(U) Rec. B: The DoD OIG recommended that the Assistant Secretary of Defense (Health Affairs) develop DoD policy for the maximum consecutive hours to be worked, maximum shifts per week, and coverage of duties when absent, for Military Health System staff (at minimum, active duty military and civilian physicians, nurses, respiratory therapists, and lab technicians) working in Military Medical Treatment Facilities to reduce the physical impacts leading to fatigue and burnout, and develop the appropriate waivers of this policy for Military Health System staff.

D-2022-2081-DEV0PB-0003-0001.C - Open

(U) Rec. C: The DoD OIG recommended that the Assistant Secretary of Defense (Health Affairs) direct a new or existing working group to develop a plan to implement the recommendations in the Military Health System COVID-19 After Action Report and to develop and monitor milestones for each recommendation.

Department of Defense OIG

Audit of U.S. Africa Command’s Execution of Coronavirus Aid, Relief, and Economic Security Act Funding

Full Details: Oversight.gov Report Page

Department of Defense OIG

Audit of Entitlements for Activated Army National Guard and Air National Guard Members Supporting the Coronavirus Disease–2019 Mission

Full Details: Oversight.gov Report Page

Audit | 3/30/2022

D-2022-0074-D000RG-0001-0001.a - Closed

Rec. 1.a: The DoD OIG recommended that the Under Secretary of Defense (Comptroller)/Chief Financial Officer, DoD, in coordination with the Under Secretary of Defense for Personnel and Readiness, update the DoD Financial Management Regulation, volume 7A, "Military Pay Policy - Active Duty and Reserve Pay," chapter 27, "Family Separation Allowance" to clearly state that the permanent duty station of a Reserve Component member on temporary duty status is the member's primary residence for the purpose of determining Family Separation Allowance entitlement.

D-2022-0074-D000RG-0001-0001.b - Closed

Rec. 1.b: The DoD OIG recommended that the Under Secretary of Defense (Comptroller)/Chief Financial Officer, DoD, in coordination with the Under Secretary of Defense for Personnel and Readiness, update the DoD Financial Management Regulation, volume 7A, "Military Pay Policy - Active Duty and Reserve Pay," chapter 27, "Family Separation Allowance" to clarify that Family Separation Allowance entitlement determination is based on the commuting distance between the member's primary residence and their temporary duty location.

D-2022-0074-D000RG-0001-0002.a - Open

(U) Rec. 2.e: The DoD OIG recommended that the Chief, National Guard Bureau, in coordination with the Director of the Army National Guard and the Director of the Air National Guard, develop and implement policies and procedures to establish formal dissemination and communication procedures for National Guard Bureau policies related to entitlements provided to the Army National Guard and Air National Guard, including the policies in the preceding recommendations. The procedures should require: 1) creation of a central location where policies and procedures will be kept for easy access by all states, territories, and the District; and 2) confirmation of receipt from all of the states, territories, and the District when procedures are communicated or obtained.

D-2022-0074-D000RG-0001-0002.b - Open

(U) Rec. 2.b: The DoD OIG recommended that the Chief, National Guard Bureau, in coordination with the Director of the Army National Guard and the Director of the Air National Guard, develop and implement policies and procedures to outline the process and frequency of recertification for Basic Allowance for Housing entitlement that Army National Guard and Air National Guard officials will use to verify and fully document the dependency status of members to provide clarification to the DoD Financial Management Regulation, volume 7A, chapter 26. These procedures should include: * how recertifications will be completed; * which members will complete a recertification; and * how Army National Guard and Air National Guard officials will provide oversight to ensure that information is complete and accurate.

D-2022-0074-D000RG-0001-0002.c - Open

(U) Rec. 2.c: The DoD OIG recommended that the Chief, National Guard Bureau, in coordination with the Director of the Army National Guard and the Director of the Air National Guard, develop and implement policies and procedures to require Army National Guard and Air National Guard officials to review and document the status of a military member married to another military member regardless of which Military Service, Reserve or Active Component, or Army National Guard or Air National Guard unit the member's spouse belongs to, and identify which member will claim any applicable dependents.

D-2022-0074-D000RG-0001-0002.d - Open

(U) Rec. 2.d: The DoD OIG recommended that the Chief, National Guard Bureau, in coordination with the Director of the Army National Guard and the Director of the Air National Guard, develop and implement policies and procedures to specify the methods for confirming eligibility and paying Family Separation Allowance for Army National Guard and Air National Guard members, in accordance with the DoD Financial Management Regulation, volume 7A, chapter 27, and include the: * timeliness of payments; * determination of Family Separation Allowance eligibility for back to back orders; * members assigned to their normal duty locations; and * requirement to track members to know when they return to their primary residence.

D-2022-0074-D000RG-0001-0002.e - Open

D-2022-0074-D000RG-0001-0003 - Open

(U) Rec. 3: The DoD OIG recommended that the Chief, National Guard Bureau, in coordination with the Director of the Army National Guard and the Director of the Air National Guard, develop and implement additional internal control procedures for the review of transactions manually submitted by the Army National Guard and Air National Guard to the payment system prior to payment to ensure the completeness and accuracy of transactions.

Department of Veterans Affairs OIG

VA’s Compliance with the VA Transparency & Trust Act of 2021

In November 2021, Congress passed the VA Transparency & Trust Act of 2021 to oversee VA’s spending of emergency relief funding related to the COVID-19 pandemic. The law requires VA to report to Congress how it will spend the funding and provide biweekly updates thereafter.The law also requires the VA OIG to report within 120 days on whether VA is spending the funds according to its plan and must address waste, fraud, and abuse. This inaugural report focuses on whether the spend plans VA provided to Congress on December 22, 2021, satisfy the requirements of the Transparency Act.VA’s spend plans...

Full Details: Oversight.gov Report Page

Review | 3/22/2022

Department of Defense OIG

Audit of Military Departments’ Processing of Coronavirus Disease–2019 Vaccination Exemptions and Disciplinary Actions for Active Duty Service Member

The objective of this audit is to determine whether the Military Departments are processing exemption requests for the Coronavirus Disease–2019 vaccination and taking disciplinary actions for active duty Service members in accordance with Federal and DoD guidance.

Department of Veterans Affairs OIG

Care in the Community Consult Management During the COVID-19 Pandemic at the Martinsburg VA Medical Center in West Virginia

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...

Full Details: Oversight.gov Report Page

Inspection / Evaluation | 2/16/2022

1 - Closed

The Veterans Integrated Service Network Director confirms that weekly calls with facility and Veterans Integrated Service Network leaders are held to discuss active Improvement Action Plans, progress made, timelines, and next steps.

2 - Closed

The Martinsburg VA Medical Center Director verifies that Improvement Action Plans, identifying areas of improvement and outlining recommendations, are in place for unmet national Care in the Community performance metrics.

3 - Closed

The Martinsburg VA Medical Center Director ensures COVID Priority 1 consults are run and reviewed by Care in the Community managers and staff daily.

4 - Closed

The Martinsburg VA Medical Center Director confirms that clinical reviews of COVID Priority 1 active consults are completed and documented, monitors compliance, and takes action as warranted.

5 - Closed

The Martinsburg VA Medical Center Director ensures a process is in place to review and address consults for patients who died prior to being scheduled or seen by a community care provider to determine if an adverse event occurred as a result of a delay in processing a patient’s consult.

6 - Closed

The Martinsburg VA Medical Center Director evaluates the effectiveness of strategies to manage the backlog of active consults and the use of urgent and emergent to prioritize consults for scheduling, determines if changes in practice are warranted, and documents the agreed upon process.

7 - Closed

The Martinsburg VA Medical Center Director conducts a review to determine who, outside Care in the Community staff, is facilitating appointment scheduling and evaluates if the scheduling assistance of other services is an effective use of resources, and establishes a standardized process to align practices.

8 - Closed

The Martinsburg VA Medical Center Director ensures Care in the Community staffing levels are adequate to support the processing of consults according to time frames set by the Veterans Health Administration.

Department of Defense OIG

Audit of DoD Implementation of the DoD Coronavirus Disease–2019 Vaccine Distribution Plan

Full Details: Oversight.gov Report Page

Audit | 2/01/2022

Department of Defense OIG

DoD OIG COVID-19 Oversight Plan – Q1 2022

Full Details: Oversight.gov Report Page

Department of Defense OIG

Management Advisory Regarding Results from Research for Future Audits and Evaluations Related to the Effects of the 2019 Novel Coronavirus on DoD Operations

Full Details: Oversight.gov Report Page

Other | 1/19/2022

Department of Veterans Affairs OIG

Audit of Community Care Consults during COVID-19

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...

Full Details: Oversight.gov Report Page

Audit | 1/19/2022

Department of Defense OIG

Audit of DoD Actions Taken to Implement Cybersecurity Protections Over Remote Access Software in the Coronavirus Disease–2019 Telework Environment

We are conducting the subject audit at the request of the House Committee on Oversight and Reform. The objective of this audit is to determine the actions taken by the DoD to configure remote access software used to facilitate telework during the COVID-19 pandemic to protect DoD networks and systems from potential malicious activity. We will also determine the extent to which the DoD implemented security controls to protect remote connections to its networks. We may revise the objective as the audit proceeds, and we will consider suggestions from management for additional or revised objectives.

Department of Veterans Affairs OIG

Systems and Tools Implemented to Track COVID-19 Vaccine Data

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...

Full Details: Oversight.gov Report Page

Review | 12/07/2021

Department of Defense OIG

Audit of DoD Actions Taken to Protect DoD Information When Using Collaboration Tools During the COVID-19 Pandemic

The objective of this audit is to determine whether DoD’s deployment of collaboration tools used to facilitate telework during the coronavirus disease–2019 (COVID-19) pandemic exposed DoD networks and systems to potential malicious activity, and the extent to which the DoD implemented security controls to protect the collaboration tools used on its networks. We will perform this audit in accordance with generally accepted government auditing standards. We may revise the objective as the audit proceeds, and we will consider suggestions from DoD management for additional or revised objectives.

Department of Veterans Affairs OIG

Comprehensive Healthcare Inspection of Facilities' COVID-19 Pandemic Readiness and Response in Veterans Integrated Service Networks 1 and 8

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...

Full Details: Oversight.gov Report Page

Department of Veterans Affairs OIG

Deficiencies in Select Community Care Consult (Stat) Processes During the COVID-19 Pandemic

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...

Full Details: Oversight.gov Report Page

Inspection / Evaluation | 11/10/2021

01 - Closed

The Under Secretary for Health evaluates community care resources, facility practices, and Veterans Health Administration requirements related to stat community care consult processes and takes action as warranted to ensure that patients receive clinically indicated care in the appropriate time frame

02 - Closed

The Under Secretary for Health clarifies guidance to VA medical facilities for stat community care consults including the timeliness of clinical review and approval, retrieval of medical records, and administrative closure.

03 - Closed

The Under Secretary for Health issues guidance to VA medical facilities regarding the override process for stat community care consults to include collaboration expected between the referring provider and the designee.

04 - Closed

The Under Secretary for Health evaluates patient involvement in decision-making regarding clinical reviewers’ modification of the urgency status of stat community care consults to determine if the process is in alignment with Veterans Health Administration patient-centered care goals and takes action as warranted.

05 - Closed

The Under Secretary for Health evaluates the time frame for adjudicating and communicating clinical appeals, determines applicability to the 24-hour requirement for completing stat community care consults, and takes action as warranted.

06 - Closed

The Under Secretary for Health evaluates adverse event reporting processes in community care, including a review of guidance provided in the VHA National Patient Safety Improvement Handbook, 1050.01 and the VHA Patient Safety Events in Community Care: Reporting, Investigation and Improvement Guidebook for inconsistencies and takes action as warranted.

1 - Closed

2 - Closed

3 - Closed

4 - Closed

5 - Closed

6 - Closed

Department of Defense OIG

DoD OIG COVID-19 Oversight Plan – Q4 2021

Full Details: Oversight.gov Report Page

Department of Veterans Affairs OIG

Failure to Mitigate Risk of and Manage a COVID-19 Outbreak at a Community Living Center at VA Illiana Health Care System in Danville, Illinois

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...

Full Details: Oversight.gov Report Page

Inspection / Evaluation | 9/28/2021

1 - Closed

The VA Great Lakes Health Care System Director evaluates whether administrative action is warranted for individuals regarding failures to mitigate risk and manage a COVID-19 outbreak at the VA Illiana Health Care System, and takes action, as appropriate.

10 - Closed

The VA Illiana Health Care System Director directs community living center leaders to complete a post-baseline plan for the COVID-19 disease that includes the required elements of screening, monitoring, and testing.

11 - Closed

The VA Illiana Health Care System Director evaluates the community living center standard operating procedure titled “COVID-19 Bi-Monthly Resident Surveillance Testing” to ensure that it provides guidance with specific actions for staff to take when a resident tests positive for COVID-19.

12 - Closed

The VA Illiana Health Care System Director verifies that COVID-19 testing for community living center residents and staff occurs as required for both routine surveillance and in response to confirmed cases of COVID-19.

13 - Closed

The VA Illiana Health Care System Director confirms that the community living center COVID-19 standard operating procedure clearly communicates the process, including roles and responsibilities, for notification of a resident’s change in condition or room assignment and communicates the plan to all community living staff.

14 - Closed

The VA Illiana Health Care System Director executes a process to ensure that the facility identifies potential high-risk scenarios, such as an outbreak of COVID-19 at the community living center, and when identified, creates a plan to mitigate and manage risk.

15 - Closed

The VA Illiana Health Care System Director directs those conducting the facility’s after-action review of the community living center outbreak to include input from frontline community living center staff and takes action as necessary.

2 - Closed

The VA Illiana Health Care System Director ensures the plan to monitor and track face mask wearing by staff at the community living center adheres to current Centers for Disease Control and Prevention guidance, is ongoing, results are monitored, and action plans are implemented as warranted.

3 - Closed

The VA Illiana Health Care System Director confirms that all community living center staff identified as requiring respiratory protection are fit tested, trained, and have ready access to respiratory devices.

4 - Closed

The VA Illiana Health Care System Director ensures a plan is in place that adheres to current Centers for Disease Control and Prevention guidance regarding staff with known community exposure to COVID-19, and monitors for compliance.

5 - Closed

The VA Illiana Health Care System Director confirms that a comprehensive plan is in place that adheres to current Centers for Disease Control and Prevention guidance regarding community living center residents with known exposure to individuals diagnosed with COVID-19, and monitors compliance.

6 - Closed

The VA Illiana Health Care System Director ensures operability and use of the bed management system for tracking completion of room cleaning.

7 - Closed

The VA Illiana Health Care System Director oversees the completion and implementation of a policy for administering aerosol-generating procedures during the COVID-19 pandemic that adheres to Centers for Disease Control and Prevention guidance, and monitors compliance.

8 - Closed

The VA Illiana Health Care System Director evaluates the organizational approach for notifying managers of updated Veterans Health Administration policies and guidance for monitoring actions taken to ensure compliance with new requirements.

9 - Closed

The VA Illiana Health Care System Director reinforces facility staff understanding of Veterans Health Administration guidance related to community living center practices, including group activities, disseminated during emergent events such as a pandemic and maintains oversight of community living center leaders’ implementation of such guidance.

Department of Veterans Affairs OIG

Care Concerns and the Impact of COVID-19 on a Patient at the Fayetteville VA Coastal Health Care System in North Carolina

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...

Full Details: Oversight.gov Report Page

Inspection / Evaluation | 9/27/2021

Department of Defense OIG

Audit of Department of Defense Education Activity Controls Related to the Spread of Coronavirus Disease–2019

Full Details: Oversight.gov Report Page

Department of Veterans Affairs OIG

Deficiencies in COVID-19 Screening and Facility Response for a Patient Who Died at the Michael E. DeBakey VA Medical Center in Houston, Texas

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...

Full Details: Oversight.gov Report Page

Inspection / Evaluation | 8/18/2021

1 - Closed

The Michael E. DeBakey VA Medical Center Director evaluates the visitor standard operating procedures for patients who require mental or behavioral health support during COVID-19 screening, and takes action as needed.

2 - Closed

The Michael E. DeBakey VA Medical Center Director ensures that clinical staff screen and manage suspected COVID-19 patients according to Veterans Health Administration and Veterans Integrated Service Network 16 guidelines and Michael E. DeBakey VA Medical Center policies.

3 - Closed

The Michael E. DeBakey VA Medical Center Director monitors compliance with the Veterans Health Administration requirement for Mental Health Intensive Case Management staff to identify and accurately document patients’ surrogates.

4 - Closed

The Michael E. DeBakey VA Medical Center Director strengthens processes to ensure Mental Health Intensive Case Management staff inform patients, families, and other support persons on the procedures for accessing medical and mental health care while navigating the COVID-19 screening and testing process, including visitor policies.

5 - Closed

The Michael E. DeBakey VA Medical Center Director ensures clinical and non-clinical staff comply with Veterans Health Administration and Michael E. DeBakey VA Medical Center policies on missing and at-risk patients.

6 - Closed

The Michael E. DeBakey VA Medical Center Director monitors compliance with Veterans Health Administration policies related to timeliness and reporting of adverse events to the patient safety manager.

7 - Closed

The Michael E. DeBakey VA Medical Center Director ensures that issue briefs are initiated timely and are comprehensive, accurate, and updated as appropriate.

8 - Closed

The Michael E. DeBakey VA Medical Center Director ensures leaders complete root cause analyses within 45 days of leaders’ awareness of applicable adverse events.

9 - Closed

The Michael E. DeBakey VA Medical Center Director consults with the VA Office of General Counsel regarding the accuracy and content of the institutional disclosure to the subject patient’s family, and takes action as appropriate.

Department of Defense OIG

Special Report: The Missile Defense Agency’s Access to Information Technology and Communications During the Coronavirus Disease–2019 Pandemic

Full Details: Oversight.gov Report Page

Department of Defense OIG

Special Report: The Defense Logistics Agency’s Access to Information Technology and Communications During the Coronavirus Disease–2019 Pandemic

Full Details: Oversight.gov Report Page

Department of Veterans Affairs OIG

Review of VHA’s Telehealth Billing Practices for Community Care during the COVID-19 Pandemic

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

Department of Defense OIG

Audit of U.S. Army Corps of Engineers Quality Assurance Over Contracts for the Conversion of Facilities to Alternative Care Sites in Response to the Coronavirus Disease–2019 Pandemic

Full Details: Oversight.gov Report Page

Department of Defense OIG

DoD OIG COVID-19 Oversight Plan – Q3 2021

Full Details: Oversight.gov Report Page

Department of Veterans Affairs OIG

Comprehensive Healthcare Inspection of Facilities' COVID-19 Pandemic Readiness and Response in Veterans Integrated Service Network 19

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

Full Details: Oversight.gov Report Page

Department of Veterans Affairs OIG

Medical/Surgical Prime Vendor Contract Emergency Supply Strategies Available Before the COVID-19 Pandemic

VA medical facilities’ demand for personal protective equipment (PPE) increased dramatically during the COVID-19 pandemic. The VA Office of Inspector General (OIG) reviewed how the Veterans Health Administration (VHA) ensured the Medical/Surgical Prime Vendor-Next Generation (MSPV-NG) program and its prime vendors met contract requirements by offering medical facilities a no-cost option to develop advance-order supply lists tailored to catastrophic events and contingency plans. The OIG also assessed whether facilities took advantage of those options and strategies and relied on the contracts...

Full Details: Oversight.gov Report Page

Review | 6/14/2021

Department of Veterans Affairs OIG

Review of VHA’s Financial Oversight of COVID-19 Supplemental Funds

In response to the Coronavirus Aid, Relief, and Economic Security (CARES) Act, the VA Office of Inspector General (OIG) reviewed the Veterans Health Administration’s (VHA) tracking and reporting of COVID-19 supplemental funding from legislation for pandemic relief.VA met monthly reporting requirements to OMB and Congress on supplemental fund obligations and expenditures. VA also submitted required weekly obligations and expenditures from supplemental funding to OMB by program activity. Of approximately $17.3 billion in medical care supplemental funds, VA reported it had obligated about $7.11...

Full Details: Oversight.gov Report Page

Review | 6/10/2021

Department of Defense OIG

Audit of the Reimbursement for Department of Defense Mission Assignments for Coronavirus Disease–2019 Pandemic Response in the U.S. Northern Command Area of Responsibility

Full Details: Oversight.gov Report Page

Audit | 6/09/2021

D-2021-0091-D000AU-0001-0001 - Closed

Rec. 1: The DoD OIG recommended that the Deputy Comptroller (Program/Budget), Office of the Under Secretary of Defense (Comptroller)/Chief Financial Officer, DoD, in coordination with DoD Component comptrollers, initiate a review of all COVID-19 pandemic response mission assignments to ensure reimbursement requests for costs incurred are submitted in accordance with DoD policy.

D-2021-0091-D000AU-0001-0002.a - Closed

Rec. 2.a: The DoD OIG recommended that the Director, Army Budget, Office of the Assistant Secretary of the Army (Financial Management and Comptroller), immediately require tasked units to review costs incurred for mission assignments 4480DR-NY-DOD-10, 4480DR-NY-DOD-11, 4480DR-NY-DOD-12, and 4481DR-WA-DOD-02 as of July 31, 2020, for completeness and accuracy, and submit reimbursement requests for those costs with required documentation to the Federal Emergency Management Agency in accordance with DoD policy.

D-2021-0091-D000AU-0001-0002.b - Closed

Rec. 2.b: The DoD OIG recommended that the Assistant Director of the Office of Budget Fiscal Management, Office of the Assistant Secretary of the Navy (Financial Management and Comptroller), immediately require tasked units to review costs incurred for mission assignments 4482DR-CA-DOD-01, 4482DR-CA-DOD-02, and 4488DR-NJ-DOD-04 as of July 31, 2020, for completeness and accuracy, and submit reimbursement requests for those costs with required documentation to the Federal Emergency Management Agency in accordance with DoD policy.

D-2021-0091-D000AU-0001-0002.c - Closed

Rec. 2.c: The DoD OIG recommended that the Deputy for Budget, Office of the Assistant Secretary of the Air Force (Financial Management and Comptroller), immediately require tasked units to review costs incurred for mission assignment 4480DR-NY-DOD-10 as of July 31, 2020, for completeness and accuracy, and submit reimbursement requests for those costs with required documentation to the Federal Emergency Management Agency in accordance with DoD policy.

D-2021-0091-D000AU-0001-0002.d - Closed

Rec. 2.d: The DoD OIG recommended that the Comptroller of the United States Marine Corps immediately require tasked units to review costs incurred for 4482DR-CA-DOD-01, 4482DR-CA-DOD-02, and 4488DR-NJ-DOD-04 as of July 31, 2020, for completeness and accuracy, and submit reimbursement requests for those costs with required documentation to the Federal Emergency Management Agency in accordance with DoD policy.

D-2021-0091-D000AU-0001-0002.e - Closed

Rec. 2.e: The DoD OIG recommended that the Comptroller of the National Guard Bureau immediately require tasked units to review costs incurred for mission assignments 4480DR-NY-DOD-05, 4481DR-WA-DOD-05, 4482DR-CA-DOD-07, and 4491DR-MD-DOD-01 as of July 31, 2020, for completeness and accuracy, as well as any additional costs incurred and identified after July 31, 2020, and submit reimbursement requests for those costs with required documentation to the Federal Emergency Management Agency in accordance with DoD policy.

D-2021-0091-D000AU-0001-0003.a1 - Closed

Rec. 3.a.1: The DoD OIG recommended that the Director, Army Budget, Office of the Assistant Secretary of the Army (Financial Management and Comptroller), in coordination with the Financial Management Augmentation Team, develop and provide to tasked units, an Army-specific desk manual for mission assignments that includes, at a minimum, step-by-step procedures for initial set-up, real-time cost input, cost tracking, cost reporting, and submitting partial and final billings to ensure compliance with DoD policy.

D-2021-0091-D000AU-0001-0003.a2 - Closed

Rec. 3.a.2: The DoD OIG recommended that the Director, Army Budget, Office of the Assistant Secretary of the Army (Financial Management and Comptroller) train tasked-unit personnel on how to navigate the Army-specific desk manual and apply the procedures appropriately.

D-2021-0091-D000AU-0001-0003.b1 - Closed

Rec. 3.b.1: The DoD OIG recommended that the Assistant Director of the Office of Budget Fiscal Management, Office of the Assistant Secretary of the Navy (Financial Management and Comptroller), in coordination with the Financial Management Augmentation Team, develop and provide to tasked units, a Navy-specific desk manual for mission assignments that includes, at a minimum, step-by-step procedures for initial set-up, real-time cost input, cost tracking, cost reporting, and submitting partial and final billings to ensure compliance with DoD policy.

D-2021-0091-D000AU-0001-0003.b2 - Closed

Rec. 3.b.2: The DoD OIG recommended that the Assistant Director of the Office of Budget Fiscal Management, Office of the Assistant Secretary of the Navy (Financial Management and Comptroller) train tasked-unit personnel on how to navigate the Navy-specific desk manual and apply the procedures appropriately.

D-2021-0091-D000AU-0001-0003.d1 - Closed

Rec. 3.d.1: The DoD OIG recommended that the Comptroller of the United States Marine Corps, in coordination with the Financial Management Augmentation Team, develop and provide to tasked units, a Marine Corps-specific desk manual for mission assignments that includes, at a minimum, step-by-step procedures for initial set-up, real-time cost input, cost tracking, cost reporting, and submitting partial and final billings to ensure compliance with DoD policy.

D-2021-0091-D000AU-0001-0003.d2 - Closed

Rec. 3.d.2: The DoD OIG recommended that the Comptroller of the United States Marine Corps train tasked-unit personnel on how to navigate the Marine Corps-specific desk manual and apply the procedures appropriately.

D-2021-0091-D000AU-0001-0003.e1 - Closed

Rec. 3.e.1: The DoD OIG recommended that the Comptroller of the National Guard Bureau, in coordination with the Financial Management Augmentation Team, develop and provide to tasked units a National Guard-specific desk manual for mission assignments that includes, at a minimum, step-by-step procedures for initial set-up, real-time cost input, cost tracking, cost reporting, and submitting partial and final billing to ensure compliance with DoD policy.

D-2021-0091-D000AU-0001-0003.e2 - Closed

Rec. 3.e.2: The DoD OIG recommended that the Comptroller of the National Guard Bureau train tasked-unit personnel on how to navigate the National Guard-specific desk manuals and apply the procedures appropriately.

DODIG-2021-0091-D000AU-0001-0003.c1 - Closed

Rec. 3.c.1: The DoD OIG recommended that the Deputy for Budget, Office of the Assistant Secretary of the Air Force (Financial Management and Comptroller), in coordination with the Financial Management Augmentation Team, develop and provide to tasked units, an Air Force-specific desk manual for mission assignments that includes, at a minimum, step-by-step procedures for initial set-up, real-time cost input, cost tracking, cost reporting, and submitting partial and final billings to ensure compliance with DoD policy.

DODIG-2021-0091-D000AU-0001-0003.c2 - Closed

Rec. 3.c.2: The DoD OIG recommended that the Deputy for Budget, Office of the Assistant Secretary of the Air Force (Financial Management and Comptroller) train taskeDODIG-unit personnel on how to navigate the Air Force-specific desk manual and apply the procedures appropriately.

Department of Veterans Affairs OIG

Use and Oversight of the Emergency Caches Were Limited during the First Wave of the COVID-19 Pandemic

The OIG assessed how effectively VA managed its emergency caches during the first wave of the COVID-19 pandemic in early 2020. These caches contain a standard supply of drugs and medical supplies, including some personal protective equipment, for use during a public health emergency.The review team found that use and oversight of the emergency caches were limited. Only nine of 144 medical facilities activated their emergency caches during the review period (February through June 2020). Among the reasons they were not used included medical facility directors reporting supplies were not needed...

Full Details: Oversight.gov Report Page

Review | 6/09/2021

Department of Defense OIG

Audit of the DoD Coronavirus Aid, Relief, and Economic Security Act Awards to the Defense Industrial Base

Full Details: Oversight.gov Report Page

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...

Full Details: Oversight.gov Report Page

Inspection / Evaluation | 5/18/2021

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 Defense OIG

DoD OIG COVID-19 Oversight Plan – Q2 2021

Full Details: Oversight.gov Report Page

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...

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Department of Defense OIG

Audit of the U.S. Army Corps of Engineers Use of Undefinitized Contract Actions for the Conversion of Alternate Care Sites in Response to the Coronavirus Disease–2019 Pandemic

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Audit | 4/07/2021

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...

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Department of Defense OIG

Audit of Public Health Emergency Readiness at Military Installations

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Department of Defense OIG

Audit of the Impact of Coronavirus Disease–2019 on Basic Training

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Audit | 3/31/2021

D-2021-0069-D000RL-0001-0001.1 - Closed

(U) Rec. 1: The DoD OIG recommended that the Commanders of the U.S. Army Training and Doctrine Command; Marine Corps Training and Education Command; Naval Education and Training Command; Naval Service Training Command; and Air Education and Training Command develop procedures to ensure compliance with the implementation of COVID-19 guidance at basic training centers.

D-2021-0069-D000RL-0001-0001.2 - Closed

D-2021-0069-D000RL-0001-0001.3 - Closed

D-2021-0069-D000RL-0001-0001.4 - Closed

D-2021-0069-D000RL-0001-0002.1 - Closed

(U) Rec. 2: The DoD OIG recommended that the Commanders of Marine Corps Training and Education Command and Air Education and Training Command develop procedures to ensure compliance with screening and testing of recruits and training personnel, including procedures for timely testing and delivery of results.

D-2021-0069-D000RL-0001-0002.2 - Closed

D-2021-0069-D000RL-0001-0003 - Closed

(U) Rec. 3: The DoD OIG recommended that the U.S. Army Training and Doctrine Command develop procedures to ensure compliance with the use of personal protective equipment necessary for basic training, including defining social distancing requirements with additional emphasis on the use of masks for indoor and outdoor environments.

D-2021-0069-D000RL-0001-0004.1 - Closed

(U) Rec. 4: The DoD OIG recommended that the Commanders of the Marine Corps Training and Education Command; Naval Education and Training Command; Naval Service Training Command; and Air Education and Training Command develop procedures to ensure compliance with the use of cleaning supplies necessary for basic training.

D-2021-0069-D000RL-0001-0004.2 - Closed

D-2021-0069-D000RL-0001-0004.3 - Closed

D-2021-0069-D000RL-0001-0005.1 - Closed

(U) Rec. 5: The DoD OIG recommended that the Commanders of the Naval Education and Training Command; Naval Service Training Command; and Air Education and Training Command assess manpower requirements for training personnel to ensure compliance with COVID-19 procedures required by DoD guidance and take appropriate action based on that assessment.

D-2021-0069-D000RL-0001-0005.2 - Closed

Department of Defense OIG

Evaluation of Access to Department of Defense Information Technology and Communications During the Coronavirus Disease-2019 Pandemic

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Department of Defense OIG

Audit of Maintaining Cybersecurity in the Coronavirus Disease–2019 Telework Environment

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Audit | 3/29/2021

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 quickly...

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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 potential...

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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...

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Review | 3/11/2021

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...

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Review | 2/24/2021

Department of Defense OIG

Evaluation of the Armed Forces Retirement Home Response to the Coronavirus Disease-2019 Pandemic

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Inspection / Evaluation | 2/12/2021

Department of Defense OIG

Audit of Contracts for DoD Information Technology Products and Services Procured by DoD Components in Response to the Coronavirus Disease–2019 Pandemic

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Department of Defense OIG

Audit of Dual Status Commanders For Use in Defense Support of Civil Authorities Missions In Support of the Coronavirus

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Department of Defense OIG

Evaluation of the Navy’s Plans and Response to the Coronavirus Disease-2019 Onboard Navy Warships and Submarines

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Inspection / Evaluation | 2/04/2021

Department of Defense OIG

DoD OIG COVID-19 Oversight Plan – Q1 2021

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Department of Veterans Affairs OIG

Medication Delivery Delays Prior to and During the COVID-19 Pandemic at the Manila Outpatient Clinic in Pasay City, Philippines

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)...

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Inspection / Evaluation | 1/28/2021

Department of Defense OIG

Audit of Contracts for Equipment and Supplies in Support of the Coronavirus Disease–2019 Pandemic

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Department of Veterans Affairs OIG

VHA’s COVID-19 Vaccine Planning and Implementation

This review will assess VHA’s response, readiness, implementation, and outcomes with the administration of the COVID-19 vaccines to employees and veterans.

Department of Defense OIG

Audit of Infectious Disease Medical Treatment Capabilities at Al Udeid Air Base, Qatar

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Department of Veterans Affairs OIG

Added Measures Could Reduce Veterans’ Risk of COVID-19 Exposure in Transitional Housing

The VA Office of Inspector General (OIG) reviewed the measures taken by the Veterans Health Administration’s (VHA) Homeless Program Office, medical facilities, and community service providers to mitigate COVID-19 risks in transitional housing programs for veterans experiencing homelessness.The OIG found that while transitional housing service providers successfully implemented four of six specific Centers for Disease Control and Prevention (CDC) COVID-19 risk mitigation measures, the providers could have strengthened implementation of two others.VHA and service provider staff said the Homeless...

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Review | 12/18/2020

Department of Defense OIG

Audit of the Disinfection of Department of Defense Facilities in Response to the Coronavirus Disease–2019

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Department of Veterans Affairs OIG

Review of Veterans Health Administration’s Emergency Department and Urgent Care Center Operations During the COVID-19 Pandemic

The VA Office of Inspector General (OIG) conducted a review of the Veterans Health Administration’s response to anticipated demand and use of emergency department and urgent care center services when faced with the possibility of an influx of patients needing evaluation during the COVID-19 pandemic. A survey was deployed and 63 emergency department and urgent care center directors were interviewed.The OIG learned there was a decreased number of patient visits to the emergency departments (19.8 percent decline) and to the urgent care centers (28.6 percent decline) for January–June 2020 when...

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Department of Veterans Affairs OIG

Enhanced Strategy Needed to Reduce Disability Exam Inventory Due to the Pandemic and Errors Related to Canceled Exams

The COVID-19 pandemic has affected how the Veterans Benefits Administration (VBA) provides disability benefits to veterans. On April 3, 2020, VBA discontinued all in-person disability exams that help determine the severity of medical conditions and the amount of benefits paid. The OIG conducted this review to assess how VBA scheduled and conducted exams during the pandemic to limit veterans’ exposure, minimize processing delays, and ensure claims were not prematurely denied due to missed or canceled in-person exams. The OIG also evaluated VBA’s strategy for addressing the inventory of delayed...

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Review | 11/19/2020

Department of Veterans Affairs OIG

Veterans Crisis Line Challenges, Contingency Plans, and Successes During the COVID-19 Pandemic

The Office of Inspector General (OIG) reviewed Veterans Crisis Line (VCL) operations ranging from contingency planning to quality metrics and lessons learned during the COVID-19 pandemic. The OIG completed remote interviews, document reviews, and surveyed VCL employees and Suicide Prevention staff. VCL staff had historically worked from communal call centers with shared space and equipment, a model that posed a safety risk to staff during the pandemic. To continue operations, VCL’s primary challenge was to equip and transition nearly 800 employees to telework-based operations. Over the course...

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Department of Defense OIG

Evaluation of Department of Defense Medical Treatment Facility Challenges During the Coronavirus Disease-2019 (COVID-19) Pandemic

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Inspection / Evaluation | 9/30/2020

D-2020-2133-DEV0PB-0001-0001.a - Open

Rec. 1.a: The DoD OIG recommended that the Under Secretary of Defense for Personnel and Readiness, in conjunction with the Assistant Secretary of Defense for Health Affairs and Secretaries of the Military Departments, establish a working group within 30 days of this report's publication, to address the personnel, supplies, testing capabilities, information technology, communication, and lines of authority challenges that we identified during the Coronavirus Disease-2019 pandemic that exist between the Services and the Defense Health Agency. The working group should establish milestones to develop guidance for coordinating the staffing of multi-Service military treatment facilities during a pandemic.

D-2020-2133-DEV0PB-0001-0001.b - Closed

Rec. 1.b: The DoD OIG recommended that the Under Secretary of Defense for Personnel and Readiness, in conjunction with the Assistant Secretary of Defense for Health Affairs and Secretaries of the Military Departments, establish a working group within 30 days of this report's publication, to address the personnel, supplies, testing capabilities, information technology, communication, and lines of authority challenges that we identified during the Coronavirus Disease-2019 pandemic that exist between the Services and the Defense Health Agency. The working group should establish milestones to consolidate Coronavirus Disease-2019 reporting requirements and recipients to reduce duplication and inconsistent requirements.

D-2020-2133-DEV0PB-0001-0001.c - Closed

Rec. 1.c: The DoD OIG recommended that the Under Secretary of Defense for Personnel and Readiness, in conjunction with the Assistant Secretary of Defense for Health Affairs and Secretaries of the Military Departments, establish a working group within 30 days of this report's publication, to address the personnel, supplies, testing capabilities, information technology, communication, and lines of authority challenges that we identified during the Coronavirus Disease-2019 pandemic that exist between the Services and the Defense Health Agency. The working group should establish milestones to create a pandemic-related informational website and a toll-free number for beneficiaries to find Coronavirus Disease-2019-related information and ensure the website and toll-free number are advertised and maintained.

D-2020-2133-DEV0PB-0001-0001.d - Open

Rec. 1.d: The DoD OIG recommended that the Under Secretary of Defense for Personnel and Readiness, in conjunction with the Assistant Secretary of Defense for Health Affairs and Secretaries of the Military Departments, establish a working group within 30 days of this report's publication, to address the personnel, supplies, testing capabilities, information technology, communication, and lines of authority challenges that we identified during the Coronavirus Disease-2019 pandemic that exist between the Services and the Defense Health Agency. The working group should establish milestones to issue clarifying guidance for defining essential personnel for civilian healthcare workers.

D-2020-2133-DEV0PB-0001-0001.e - Open

Rec. 1.e: The DoD OIG recommended that the Under Secretary of Defense for Personnel and Readiness, in conjunction with the Assistant Secretary of Defense for Health Affairs and Secretaries of the Military Departments, establish a working group within 30 days of this report's publication, to address the personnel, supplies, testing capabilities, information technology, communication, and lines of authority challenges that we identified during the Coronavirus Disease-2019 pandemic that exist between the Services and the Defense Health Agency. The working group should establish milestones to update contracts to allow for more flexibility regarding the use of contracted personnel during extenuating circumstances, such as a pandemic.

Department of Defense OIG

Audit of Screening and Quarantine Procedures for Personnel Entering Al Udeid Air Base, Qatar (DODIG-2020-128)

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Department of Veterans Affairs OIG

Date of Receipt of Claims and Mail Processing During the COVID-19 National State of Emergency

The OIG reviewed the Veterans Benefits Administration’s (VBA) processing of mail and benefit claims during the COVID-19 pandemic. Specifically, the review team examined whether VBA staff documented the date of receipt for benefits-related correspondence as required by new guidance during the national state of emergency and continued mail operations at VA facilities to ensure benefit claims were processed. Based on its sample analysis, the OIG found VBA staff did not properly apply date of receipt documentation guidance for an estimated 98 percent of 3,200 claims established from April 7...

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Audit | 9/17/2020

Department of Defense OIG

Special Report: Controls Implemented by the Defense Health Agency to Control Costs for TRICARE COVID-19 Related Services

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Department of Veterans Affairs OIG

Appointment Management During the COVID-19 Pandemic

The Veterans Health Administration (VHA) took measures to protect patients and employees from COVID-19 by canceling face-to-face appointments that were not urgent and converting some of them to virtual appointments. The VA Office of Inspector General (OIG) assessed VHA’s appointment management strategies and the status of canceled appointments. The review team found that about five million appointments (68 percent) canceled from March 15 through May 1, 2020, had evidence of follow up or other tracking. Patients completed appointments predominantly by telephone and some by video. Other...

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Review | 9/01/2020

Department of Defense OIG

Lead Inspector General for East Africa And North And West Africa Counterterrorism Operations I Quarterly Report to the United States Congress | April 1, 2020 - June 30, 2020

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Department of Veterans Affairs OIG

Alleged Deficiencies in the Management of Staff Exposure to a Patient with COVID-19 at the VA Portland Health Care System in Oregon

The VA Office of Inspector General (OIG) conducted a healthcare inspection to determine the validity of allegations related to the management of staff exposure to a patient diagnosed with COVID-19 at the VA Portland Medical Center (facility) in Oregon. The events under review involved the facility’s first patient diagnosed with COVID-19. The OIG did not substantiate that emergency department staff failed to notify imaging department staff that a patient was suspected to have COVID-19 before sending the patient to the imaging department. At the time of the patient’s transport to the imaging...

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Inspection / Evaluation | 8/27/2020

Department of Defense OIG

Lead Inspector General for Operation Freedom’s Sentinel I Quarterly Report to the United States Congress I April 1, 2020 - June 30, 2020

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Department of Defense OIG

Lead Inspector General for Operation Pacific Eagle-Philippines I Quarterly Report to the United States Congress I April 1, 2020 - June 30, 2020

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Department of Defense OIG

Lead Inspector General for Operation Inherent Resolve Quarterly Report to the United States Congress | April 1, 2020 – June 30, 2020

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Department of Veterans Affairs OIG

Review of Veterans Health Administration’s COVID-19 Response and Continued Pandemic Readiness

On March 26, 2020, the VA Office of Inspector General (OIG) published its first COVID-19-focused report, OIG Inspection of Veterans Health Administration’s COVID-19 Screening and Pandemic Readiness. In that report, the OIG evaluated how the Veterans Health Administration (VHA) was preparing facilities to meet anticipated rising demands. This report outlines VHA’s continued response to the pandemic and provides VHA leaders’ descriptions of the evolving challenges they faced in caring for veterans and potentially nonveteran patients as well. The OIG engaged leaders from 70 selected facilities in...

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Department of Veterans Affairs OIG

Review of Highly Rural Community-Based Outpatient Clinics Limited Access to Select Specialty Care

The VA Office of Inspector General (OIG) reviewed the accessibility of dermatology, orthopedics, and urology specialty care for patients in the 17 Veterans Health Administration (VHA) community-based outpatient clinics (CBOCs) classified as highly rural. The OIG also reviewed accessibility, barriers, and the availability and utilization of resources for the time frame March 1, 2018 (or from the date the CBOC became highly rural), through February 28, 2019. VHA utilized clinical consults, electronic consults (eConsults), telehealth, and community care to provide specialty care at the highly...

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Inspection / Evaluation | 7/07/2020

Department of Defense OIG

Audit of DoD Implementation of Section 3610 Authorized by the Coronavirus Aid, Relief, and Economic Security Act

We plan to begin this audit in May 2020. The objective of this audit is to assess DoD’s implementation of section 3610 as authorized by the Coronavirus Aid, Relief, and Economic Security Act, including whether contracting officers properly authorized and reimbursed contractor costs. We may revise the objective as the audit proceeds, and will also consider suggestions from management for additional or revised objectives.

Department of Defense OIG

Special Report on Best Practices and Lessons Learned for DoD Contracting Officials in the Pandemic Environment

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Department of Defense OIG

Lead Inspector General for Operation Freedom’s Sentinel I Quarterly Report to the United States Congress I January 1, 2020 - March 31, 2020

Full Details: Oversight.gov Report Page

Department of Defense OIG

Lead Inspector General for Operation Inherent Resolve I Quarterly Report to the United States Congress I January 1, 2020 – March 31, 2020

Full Details: Oversight.gov Report Page

Department of Defense OIG

Lead Inspector General for Operation Pacific Eagle-Philippines I Quarterly Report to the United States Congress I January 1, 2020 - March 31, 2020

Full Details: Oversight.gov Report Page

Department of Defense OIG

Special Report on Protecting Patient Health Information During the COVID‑19 Pandemic

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Department of Defense OIG

COVID-19 Expenditures — Lessons Learned Regarding Awareness of Potential Fraud, Waste, and Abuse Risk

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Department of Veterans Affairs OIG

OIG Inspection of Veterans Health Administration’s COVID-19 Screening Processes and Pandemic Readiness

The VA Office of Inspector General (OIG) conducted an inspection to evaluate novel coronavirus disease (COVID-19) screening processes at 237 VA facilities (medical centers, community-based outpatient clinics, and community living centers) and to collect data on pandemic preparations. Screening processes at 71 percent of visited medical centers were adequate, while 28 percent had opportunities for improvement. The vast majority of community-based outpatient clinics had screening procedures in place. Although VA announced a no visitors policy for community living centers on March 10, 2020, OIG...

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Audit of DoD Use of the Government Purchase Card in Response to the Coronavirus Disease–2019 Pandemic

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Audit of Military Departments’ Processing of Coronavirus Disease–2019 Vaccination Exemptions and Disciplinary Actions for Active Duty Service Member

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Audit of DoD Actions Taken to Implement Cybersecurity Protections Over Remote Access Software in the Coronavirus Disease–2019 Telework Environment

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Audit of DoD Actions Taken to Protect DoD Information When Using Collaboration Tools During the COVID-19 Pandemic

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Review of VHA’s Telehealth Billing Practices for Community Care during the COVID-19 Pandemic

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Comprehensive Healthcare Inspection Program (virtual reviews) Reports VISN 6 & 2

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VHA’s COVID-19 Vaccine Planning and Implementation

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Audit of DoD Implementation of Section 3610 Authorized by the Coronavirus Aid, Relief, and Economic Security Act