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Department of Education OIG

Tennessee Department of Education’s Administration and Oversight of Emergency Assistance to Nonpublic Schools Grant Funds

Congress provided $5.5 billion for the Emergency Assistance to Nonpublic Schools (EANS) program. The purpose of the EANS programs, authorized under the Coronavirus Response and Relief Supplemental Appropriations Act (CRRSA) and American Rescue Plan (ARP), is to provide services or assistance to eligible nonpublic schools to address educational disruptions caused by the COVID-19 emergency. Our audit sought to determine whether the Tennessee Department of Education (Tennessee) designed and implemented (1) application processes that adequately assessed nonpublic schools’ eligibility for EANS...
Department of Education OIG

Yukon-Koyukuk School District’s Use of Elementary and Secondary School Emergency Relief Funds (Alaska)

We performed this review to determine whether the Yukon-Koyukuk School District’s (Alaska) expended Elementary and Secondary School Emergency Relief (ESSER) grant funds for allowable purposes in accordance with applicable requirements. We determined that all of the ESSER expenditures we reviewed for the Yukon-Koyukuk School District (Yukon-Koyukuk) were allowable. However, we found that Yukon-Koyukuk did not comply with key competitive procurement process or documentation requirements when procuring the goods or services associated with three (38 percent) of eight non-personnel expenditures...
Department of Education OIG

Linn-Mar Community School District’s Use of Elementary and Secondary School Emergency Grant Funds (Iowa)

We performed this review to determine whether Linn-Mar Community School District (Iowa) expended Elementary and Secondary School Emergency Relief (ESSER) grant funds for allowable purposes in accordance with applicable requirements. We determined that all 20 (100 percent) ESSER expenditures that we reviewed for Linn-Mar were allowable. However, we found that Linn-Mar did not comply with key competitive procurement process or documentation requirements when procuring the goods or services associated with 6 (40 percent) of the 15 non-personnel expenditures, totaling $228,510 (49 percent) of the...
Department of Education OIG

Lower Kuskokwim School District’s Use of Elementary and Secondary School Emergency Relief Funds (Alaska)

We performed this review to determine whether the Lower Kuskokwim School District expended Elementary and Secondary School Emergency Relief (ESSER) grant funds for allowable purposes in accordance with applicable requirements. We determined that all the ESSER expenditures we reviewed for Lower Kuskokwim were allowable and in accordance with applicable requirements. We also found that Lower Kuskokwim complied with key Federal procurement requirements, including those covering the procurement methods to be followed and contract cost, price, and provisions, when procuring the goods or services...
Department of Education OIG

Southeast Polk Community School District’s Use of Elementary and Secondary School Emergency Relief Grant Funds (Iowa)

We performed this review to determine whether the Southeast Polk Community School District t expended Elementary and Secondary School Emergency Relief (ESSER) grant funds for allowable purposes in accordance with applicable requirements. We determined that all 20 expenditures (5 personnel and 15 non-personnel) that we reviewed were allowable. Allowable activities generally include those authorized by the Elementary and Secondary Education Act, Individuals with Disabilities Education Act, Adult Education and Family Literacy Act, Carl D. Perkins Career and Technical Education Act of 2006, and...
Department of Education OIG

Matanuska-Susitna Borough School District’s Use of Elementary and Secondary School Emergency Relief Funds (Alaska)

We performed this review to determine whether the Matanuska-Susitna Borough School District expended Elementary and Secondary School Emergency Relief (ESSER) grant funds for allowable purposes in accordance with applicable requirements. We determined that all the ESSER expenditures we reviewed for Matanuska-Susitna were allowable and in accordance with applicable requirements. We also found that Matanuska-Susitna complied with key Federal procurement requirements, including those covering the procurement methods to be followed and contract cost, price, and provisions, when procuring the goods...
Department of Education OIG

Des Moines Independent Community School District’s Use of Elementary and Secondary School Emergency Relief Grant Funds

We performed this review to determine whether the Des Moines Independent Community School District expended ESSER grant funds for allowable purposes in accordance with applicable requirements. We determined that of the 20 expenditures that we reviewed, 17 were allowable and in accordance with applicable requirements. Two expenditures totaling $164,580 were unallowable because they were for advertising and public relations costs prohibited under the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (2 Code of Federal Regulations part 200), and a...
Department of Education OIG

Florida Department of Education’s Administration and Oversight of Emergency Assistance to Nonpublic Schools Grant Funds

Congress provided $5.5 billion for the Emergency Assistance to Nonpublic Schools (EANS) program. The purpose of the EANS programs, authorized under the Coronavirus Response and Relief Supplemental Appropriations Act (CRRSA) and American Rescue Plan (ARP), is to provide services or assistance to eligible nonpublic schools to address educational disruptions caused by the COVID-19 emergency. We conducted an audit to determine whether the Florida Department of Education (FDOE) designed and implemented (1) application processes that adequately assessed nonpublic schools’ eligibility for EANS-funded...
Department of Education OIG

Anchorage School District’s Use of Elementary and Secondary School Emergency Relief Grant Funds (Alaska)

We performed this review to determine whether Anchorage School District (Anchorage) expended ESSER grant funds for allowable purposes in accordance with applicable requirements. We determined that all the ESSER expenditures we reviewed for Anchorage were allowable and in accordance with applicable requirements. We also found that Anchorage complied with key Federal procurement requirements, including those covering the procurement methods to be followed and contract cost, price, and provisions, when procuring the goods or services associated with each ESSER expenditure we reviewed. Because we...
Department of Education OIG

Federal Student Aid’s Performance Measures and Indicators for Returning Borrowers to Repayment

The inspection sought to determine whether the Federal Student Aid office (FSA) established performance measures and indicators for returning borrowers to repayment. We found that FSA needed to establish effective performance measures and indicators to evaluate its performance for returning borrowers to repayment. Although FSA and the Office of the Undersecretary established operational and strategic objectives and operational goals for returning borrowers to repayment, they were not written in specific and measurable terms. In addition, although FSA identified several data metrics as...
Department of Education OIG

Burlington Community School District’s Use of Elementary and Secondary School Emergency Relief Grant Funds (Iowa)

We performed this review to determine whether the Burlington Community School District (Burlington) expended Elementary and Secondary School Emergency Relief (ESSER) grant funds for allowable purposes in accordance with applicable requirements. We determined that all the ESSER expenditures we reviewed for Burlington were allowable and in accordance with applicable requirements. We also found that Burlington complied with key Federal procurement requirements, including those covering the procurement methods to be followed and contract cost, price, and provisions, when procuring the goods or...
Department of Education OIG

Wisconsin’s Administration and Oversight of the Emergency Assistance to Non-Public Schools Grant Funds

Determine whether the Wisconsin Department of Public Instruction designed and implemented (1) application processes that adequately assessed nonpublic schools' eligibility for EANS-funded services or assistance and complied with other applicable requirements and (2) oversight processes to ensure that EANS-funded services or assistance were used for allowable purposes.

Department of Education OIG

Illinois’ Oversight of Local Educational Agency ARP ESSER Plans and Spending

The objectives of the audit were to determine whether the Illinois State Board of Education (Illinois) had an adequate oversight process in place to ensure that (1) local educational agencies’ (LEA) American Rescue Plan (ARP) Elementary and Secondary School Emergency Relief (ESSER) plans met applicable requirements and (2) LEAs use ARP ESSER funds in accordance with applicable requirements and their approved LEA ARP ESSER plans.We found that Illinois generally had adequate processes to ensure that LEA ARP ESSER plans met applicable requirements. However, it did not communicate accurate...
Department of Veterans Affairs OIG

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

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

U.S. Department of Education’s Higher Education Emergency Relief Fund Audit Resolution Activities

The report presents information on independent audits with findings pertaining to the Higher Education Emergency Relief Fund (HEERF) and audit resolution activities conducted by the U.S. Department of Education. Our review focused on independent audits of HEERF recipients from April 2020 through June 2023. We found that the number of independent audits with findings pertaining to HEERF and requiring resolution by the Office of Finance and Operations (OFO) increased significantly over the past few years, as did the number of audits with complex findings as determined by OFO staff. However, the...
Department of Education OIG

Kentucky’s Oversight of Local Educational Agency ARP ESSER Plans and Spending

The objectives of the audit were to determine whether the Kentucky Department of Education (Kentucky) had an adequate oversight process in place to ensure that (1) local educational agencies’ (LEA) American Rescue Plan (ARP) Elementary and Secondary School Emergency Relief (ESSER) plans met applicable requirements and (2) LEAs use ARP ESSER funds in accordance with applicable requirements and their approved LEA ARP ESSER plans. Overall, we found that Kentucky had adequate processes to ensure that LEA ARP ESSER plans met applicable requirements. We also determined that the ARP ESSER plans for...
Department of Veterans Affairs OIG

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

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

Washington’s Oversight of Local Educational Agency ARP ESSER Plans and Spending

The objectives of the audit were to determine whether the Washington Office of Superintendent of Public Instruction (Washington) had an adequate oversight process in place to ensure that (1) local educational agencies’ (LEA) American Rescue Plan (ARP) Elementary and Secondary School Emergency Relief (ESSER) plans met applicable requirements and (2) LEAs use ARP ESSER funds in accordance with applicable requirements and their approved LEA ARP ESSER plans. We found that Washington did not have an adequate review and approval process to ensure that LEA ARP ESSER plans met all applicable...
Department of Education OIG

Federal Student Aid’s Use of Pandemic Assistance Student Aid Administration Funds

We found that as of November 30, 2022, FSA obligated nearly 100 percent of the $161.1 million in appropriations it received for pandemic assistance student aid administration funds. Nine FSA business units obligated approximately $157.8 million (98 percent) of the total pandemic assistance student aid administration funds, with one business unit, the Next Gen FSA Program Office, accounting for 78 percent of the obligations. The pandemic assistance student aid administration funds were used for personnel compensation and benefits, information technology systems and services contracts, and...
Department of Education OIG

Federal Student Aid’s Processes for Waiving Return of Title IV Requirements, Cancelling Borrowers’ Obligation to Repay Direct Loans, and Excluding Pell Grants from Federal Pell Lifetime Usage

FSA had adequate processes for waiving R2T4 requirements, cancelling borrowers’ obligation to repay Direct Loans, and excluding Pell disbursements from Pell lifetime usage for impacted students. FSA also designed adequate processes for schools to report the number and amounts of R2T4 waivers applied.
Department of Veterans Affairs OIG

VHA Can Improve Controls Over Its Use of Supplemental Funds

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

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

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

University of Cincinnati’s Use of Higher Education Emergency Relief Fund Student Aid and Institutional Grants

Our objective was to determine whether the University of Cincinnati (University) used the Student Aid (Assistance Listing Number (ALN) 84.425E) and Institutional (ALN 84.425F) portions of its Higher Education Emergency Relief Fund (HEERF) funds for allowable and intended purposes.The University spent $109.9 million (83 percent) of its total HEERF allocation of $132.8 million as of September 30, 2021. The University generally used the Student Aid ($42.1 million) and Institutional ($67.8 million) portions of its HEERF grant funds for allowable and intended purposes but needs to strengthen its...
Department of Veterans Affairs OIG

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

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

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

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

The Department’s Use of Pandemic Assistance Program Administration Funds

The objective of our review was to determine the Department’s progress on spending program administration funds authorized by coronavirus response and relief laws, including how those funds have been used to date, and the Department’s plans for using remaining funds.We found that the Department has allocated nearly 100 percent2 of its pandemic assistance program administration funds and that the Department is on track to obligate all of its program administration funds prior to the dates the funds are set to expire. The Department allocated the funds to 11 principal offices and as of February...
Department of Education OIG

Allocation of ESSER I Funds at Selected Local Educational Agencies

The objective of our review is to describe how selected local educational agencies (LEA) allocated Elementary and Secondary School Emergency Relief (ESSER) funds provided under the Coronavirus Aid, Relief, and Economic Security Act (CARES Act).As of March 2022, the 46 LEAs spent over $19.2 million, or about 95 percent, of the $20.2 million in ESSER I funds that they were awarded. The majority of these ESSER I funds were spent on district-wide programs, and about 26 percent of ESSER I funds were allocated to specific schools, with the majority of that portion allocated to Title I schools over...
Department of Education OIG

Michigan’s Administration of the Governor’s Emergency Education Relief Fund

The objectives of the audit were to determine whether the State of Michigan (Michigan) designed and implemented awarding processes that ensured that the Governor’s Emergency Education Relief Fund (GEER grant) was used to support local educational agencies (LEAs) and institutions of higher education (IHEs) that were most significantly impacted by the coronavirus or LEAs, IHEs, or other education-related entities within the State that were deemed essential for carrying out emergency educational services; and monitoring processes to ensure that subgrantees used GEER grant funds in accordance with...
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...
Department of Education OIG

Oklahoma’s Administration of the Governor’s Emergency Education Relief Fund Grant

The objectives of the audit were to determine whether the State of Oklahoma (Oklahoma) designed and implemented awarding processes that ensured that the Governor's Emergency Education Relief Fund (GEER grant) was used to support local educational agencies (LEA) and institutions of higher education (IHE) that were most significantly impacted by the coronavirus or LEAs, IHEs, or other education-related entities within the State that were deemed essential for carrying out emergency educational services; and monitoring processes to ensure that subgrantees used GEER grant funds in accordance with...
Department of Education OIG

Duplicate Higher Education Emergency Relief Fund Grant Awards

This flash report presents our finding concerning duplicate Higher Education Emergency Relief Fund (HEERF) grant awards to institutions of higher education.1 This report includes a recommendation to enhance the U.S. Department of Education’s (Department) ability to prevent, identify, and correct duplicate HEERF grant awards.We identified 25 duplicate HEERF grant awards that OPE made to 24 schools, totaling about $73 million, which had not been corrected and documented in G5 as of August 2021. OPE officials stated that their processes for reviewing and approving HEERF applications and awards...
Department of Education OIG

The Office of Postsecondary Education’s Oversight of Higher Education Emergency Relief Fund Grants

The objective of the audit was to determine whether the Office of Postsecondary Education (OPE) has an adequate process in place to ensure that institutions of higher education (schools) use Higher Education Emergency Relief Fund (HEERF) grant funds appropriately and that performance goals are met. OPE needs to strengthen its oversight processes to ensure that schools use HEERF grant funds appropriately and that performance goals are met. OPE established and implemented several controls to promote transparency and accountability in program administration, including providing guidance and other...
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...
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...
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...
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...
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...
Department of Education OIG

Missouri’s Administration of the Governor’s Emergency Education Relief Fund Grant

The objectives of the audit were to determine whether the State of Missouri (Missouri) designed and implemented awarding processes that ensured that the Governor's Emergency Education Relief Fund (GEER grant) was used to support local educational agencies (LEAs) and institutions of higher education (IHEs) that were most significantly impacted by the coronavirus or LEAs, IHEs, or other education-related entities within the State that were deemed essential for carrying out emergency educational services; and monitoring processes to ensure that subgrantees used GEER grant funds in accordance with...
Department of Education OIG

The Department’s Implementation of CARES Act Flexibilities to TEACH Grant Service Obligations

The objective of our review was to evaluate the Department of Education’s plans and processes to ensure Teacher Education Assistance for College and Higher Education (TEACH) grantees receive full-time credit toward their service obligations for part-time and temporarily interrupted service due to Coronavirus Disease 2019 (COVID-19). We found weaknesses in FSA’s development and implementation of plans and processes to ensure TEACH grantees receive full-time credit towards their service obligations for part-time or temporarily interrupted service due to COVID-19. Additionally, we found that FSA...
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...
Department of Education OIG

Review of State Plans for Use of Governor’s Emergency Education Relief Funds

The objectives of our review were to review States’ initial 45-day GEER Fund reports to determine how States plan to allocate funds to entities within the three authorized categories: local educational agencies (LEA), institutions of higher education (IHE), and education-related entities, and the criteria upon which these decisions were based; and review GEER Fund annual reports to identify changes to and progress made from the initial plans in the 45-day reports.We found that within the three authorized entity categories, 45 States (87 percent) planned to allocate GEER funds to LEAs, 39...
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...
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...
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...
Department of Education OIG

Remington College’s Use of Higher Education Emergency Relief Fund Student Aid and Institutional Grants

The objective of our audit was to determine if Remington College used the Student Aid (Assistance Listing Number (ALN) 84.425E) and Institutional (ALN 84.425F) portions of its Higher Education Emergency Relief Fund (HEERF) grant funds for allowable and intended purposes.Remington College generally used the Student Aid portion of its HEERF grant funds for allowable and intended purposes but did not always use the Institutional portion of its funds in accordance with Federal requirements. We found that Remington College spent Institutional funds for several unallowable purposes and did not...
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...
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...
Department of Education OIG

Lincoln College of Technology’s Use of Higher Education Emergency Relief Fund Student Aid and Institutional Grants

The objective of our audit was to determine whether Lincoln College of Technology (Lincoln) used the Student Aid (Assistance Listing Number (ALN) 84.425E) and Institutional (ALN 84.425F) portions of its Higher Education Emergency Relief Fund (HEERF) funds for allowable and intended purposes. We also reviewed Lincoln’s cash management practices and the timeliness and quality of the data Lincoln reported on its use of HEERF funds.LESC generally used the Student Aid portion of Lincoln’s HEERF funds for allowable and intended purposes but did not always use the Institutional portion of its funds...
Department of Education OIG

Inconsistent Grantee and Subgrantee Reporting of Education Stabilization Fund Subprograms in the Federal Audit Clearinghouse

The purpose of this flash report is to share with the U.S. Department of Education (Department) observations made by the Office of Inspector General (OIG) concerning grantees and subgrantees inconsistently reporting audit data on Department subprograms, or unique components of a program, to the Federal Audit Clearinghouse (FAC), the designated repository of single audit data. We found that grantees and subgrantees are not consistently reporting expenditures of Education Stabilization Fund (ESF) subprogram awards in the FAC. Specifically, when entering Federal award information into the Data...
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...
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 Education OIG

Fraud Reporting Requirements for Federal Program Participants and Auditors

This guide summarizes the fraud reporting requirements most relevant to entities receiving pandemic relief funds and auditors of those entities.
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...
Department of Education OIG

Federal Student Aid’s Suspension of Involuntary Collection in Response to the Coronavirus Pandemic

The objective of our review was to evaluate the results of Federal Student Aid’s (FSA) process for suspending involuntary collection and refunding payments involuntarily collected on defaulted Department-held loans in response to the Coronavirus pandemic.We found that FSA suspended administrative wage garnishments and the U.S. Department of Treasury (Treasury) offsets for over 96 percent of the borrowers that FSA collected payments for within 90 days of March 13, 2020, the start of the suspension period. However, as of October 23, 2020, we found that FSA continued to receive administrative...
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...
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...
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...
Department of Veterans Affairs OIG

Inadequate Resident Supervision and Documentation of an Ophthalmology Procedure at the Oklahoma City VA Health Care System in Oklahoma

The VA Office of Inspector General (OIG) conducted an inspection in response to allegations related to ophthalmology resident supervision and quality of care by an attending ophthalmologist (subject ophthalmologist) at the Oklahoma City VA Health Care System in Oklahoma.The OIG substantiated that the subject ophthalmologist failed to provide adequate resident supervision and entered inaccurate documentation related to supervision for a single patient case. The ophthalmology residents were unable to reach the subject ophthalmologist when the patient experienced a complication during an eye...
Department of Education OIG

Risk of Closed Institutions of Higher Education Receiving Higher Education Emergency Relief Fund Grants

The purpose of this report is to share with the U.S. Department of Education (Department) observations made by the Office of Inspector General (OIG) concerning institutions of higher education (IHE) that ceased to provide educational instruction in all programs of study (closed) and received or had access to coronavirus response and relief aid through the Higher Education Emergency Relief Fund (HEERF). We found that 17 IHEs that closed on or before December 31, 2020, applied for and were awarded a total of $4,912,675 of HEERF grants by OPE. Of these 17 IHEs, 14 drew down HEERF funds and 3 did...
Department of Veterans Affairs OIG

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

This report will provide (1) a descriptive evaluation of Veterans Integrated Service Network facilities’ pandemic readiness and response as determined by recent Comprehensive Healthcare Inspection Program inspections.
 

Department of Veterans Affairs OIG

Inconsistent Documentation and Management of COVID-19 Vaccinations for Community Living Center Residents

While reviewing the Veterans Health Administration’s (VHA) plans to document receipt and distribution of the COVID-19 vaccine, the VA Office of Inspector General (OIG) determined that VHA facilities did not consistently document the COVID-19 vaccination status of veterans living in VA’s Community Living Centers (CLCs).The OIG determined that VHA could not know at a national level whether the vaccine was offered to some CLC residents, and if so, what their status was. Because CLC residents are in the highest COVID-19 vaccine priority group, they should be offered the vaccine, when possible...
Department of Veterans Affairs OIG

Review of Community-Based Outpatient Clinics Closed Due to the COVID-19 Pandemic

The VA Office of Inspector General (OIG) reviewed community-based outpatient clinic (CBOC) closures that occurred due to the COVID-19 pandemic to evaluate the impact on patient care. The OIG virtually interviewed Veterans Health Administration (VHA) staff at 140 facilities that oversaw the 1,031 CBOCs that were operational prior to the World Health Organization’s pandemic declaration.Of these CBOCs, 173 were closed to face-to-face visits on or after February 1, 2020. Reasons for closure fell into four categories including (a) safety of patients and staff, (b) need for consolidation of...
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...
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...
Department of Veterans Affairs OIG

Review of Veterans Health Administration’s Virtual Primary Care Response to the COVID-19 Pandemic

The VA Office of Inspector General (OIG) conducted a review to assess Veterans Health Administration’s (VHA) virtual primary care response to the COVID-19 pandemic, as well as the use of virtual care by primary care providers and their perceptions of VA Video Connect (VVC) between February 7 and June 16, 2020.The COVID-19 pandemic presented significant challenges to health care delivery worldwide. One strategy initiated by VHA, in accordance with the Centers for Disease Control and Prevention recommendation to social distance, included expanding the delivery of primary care via virtual care...
Department of Education OIG

Higher Education Emergency Relief Fund Reporting Requirements

The objective of our inspection was to determine (1) whether selected institutions receiving funds under the Institutional Portion of Higher Education Emergency Relief Fund (HEERF) met public reporting requirements and (2) the reported usage of the Institutional Portion of HEERF by selected institutions.We determined that 81 of the 100 institutions included in our sample complied with Institutional Portion reporting requirements.We were unable to locate Institutional Portion reports anywhere on the websites associated with 19 of the 100 (19 percent) institutions included in our sample.
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...
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)...
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 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...
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...
Department of Education OIG

Assessment of the Department’s Reconstitution Plans Following COVID-19

The objective of our inspection was to assess the U.S. Department of Education’s (Department) plans and procedures for returning employees to the federal office in the wake of the coronavirus pandemic, including what existing guidance the Department considered when developing its plans and procedures. We found that the Department generally incorporated available guidance, which was intended to provide for a safe and gradual return to federal offices, in its Workplace Reconstitution Transition Plan (Reconstitution Plan). However, we noted that the Department’s Reconstitution Plan does not...
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...
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...
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...
Department of Education OIG

Challenges for Consideration in Implementing and Overseeing the CARES Act

This management information report provides the Office of Inspector General’s (OIG) perspective on challenges the U.S. Department of Education (Department) may face as it implements and oversees the Coronavirus, Aid, Relief, and Economic Security (CARES) Act. In preparing this report, we reviewed recent audit work performed by OIG and the Government Accountability Office (GAO) as well as OIG’s annual Management Challenges reports. We also reviewed challenges that the Department faced when administering education-related grant programs funded by the American Recovery and Reinvestment Act...
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...
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...
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...
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...
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...