Reports

FEMA's Emergency Non-Congregate Sheltering Interim Policy Provided Greater Flexibility for Emergency Sheltering During the COVID-19 Pandemic

The Federal Emergency Management Agency’s (FEMA)Emergency Non-Congregate Sheltering (NCS) Interim Policy104-009-18 (Interim Policy) provided an adequate and effectiveframework during the COVID-19 pandemic. Specifically, theInterim Policy waived the existing pre-approval requirement,allowing for faster and increased NCS implementation tosegregate individuals and families and limit spread of thedisease. The Interim Policy also included program details andrequirements for determining eligible work and costs for NCS inresponse to federally declared disasters during the COVID-19pandemic.

Full Details: Oversight.gov Report Page

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

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

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

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

Full Details: Oversight.gov Report Page

Audit | 8/24/2023

1 - Open

We recommend that the FEMA Administrator resolve questioned costs totaling an estimated $24,438,662 for expenses deemed ineligible by FEMA’s Individual Assistance Program and Policy Guide and determine the amount of any debts owed by recipients for erroneous payments.

2 - Closed

We recommend that the FEMA Administrator resolve other questioned costs included in our report and determine the amount of any debts owed by recipients for erroneous payments. Other questioned costs requiring resolution include: a) $1,348,546 for awards issued to multiple applicants for the same decedents; b) $554,653 for awards issued for applications that exceeded the $9,000 per decedent award limit; and c) $591,805 for 93 applications for which FEMA did not adequately review eligibility criteria of the applications.

3 - Open

We recommend that the FEMA Administrator ensure that future iterations of the Individual Assistance Program and Policy Guide and supporting procedures (a) provide consistent guidance on eligibility of funeral expenses for all future disaster declarations; and (b) allow for reimbursement of only necessary expenses and serious needs, consistent with the law.

4 - Closed

We recommend that the FEMA Administrator strengthen and monitor improvement of FEMA’s COVID-19 Funeral Assistance training practices with particular focus on: a) distinguishing legitimate sources of potential duplication such as decedent’s name and social security number from potential duplications that arise due to FEMA using a repurposed Individual Assistance processing system, with a data field such as damaged dwelling address; b) preventing FEMA from reimbursing expenses exceeding the maximum $9,000 per decedent; and c) deducting financial assistance received from outside sources such as pre-need funeral arrangements, burial insurance, and assistance from other voluntary or government agencies.

5 - Open

We recommend that the FEMA Administrator ensure that FEMA provides its COVID-19 Funeral Assistance call center contractor the guidance and training necessary to meet the quality control and production monitoring metrics as prescribed by its agreement with the contractor.

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

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

Full Details: Oversight.gov Report Page

Audit | 7/20/2023

1 - Closed

We recommend the FEMA Administrator clarify existing guidance and ensure FEMA personnel use the Logistics Supply Chain Management System or an alternative integrated solution as the system of record during disaster response operations to manage the distribution of FEMA-owned commodities, supplies, and equipment as well as those sourced by FEMA from partners across the Federal Government, non-governmental organizations, and the private sector to fulfill state, local, tribal, and territorial requests.

2 - Open

We recommend the FEMA Administrator take action to develop and improve the Logistics Management Directorate’s internal controls, guidance, and system integration to obtain more accurate information that enhances logistics decision making regarding the fulfillment of commodity requests during disaster response operations. At a minimum, FEMA should: a. develop internal controls to ensure appropriate information related to facility types, intermediate locations, and transportation-only orders is accurately reported in the Logistics Supply Chain Management System or an alternative integrated solution; b. update guidance and deliver training to ensure there is a clear audit trail when aggregating distribution data on FEMA-owned commodities, supplies, and equipment as well as those sourced by FEMA from partners across the Federal Government, non-governmental organizations, and the private sector to fulfill state, local, tribal, and territorial requests; and c. improve integration between the Logistics Supply Chain Management System and the Web Emergency Operations Center Crisis Management System to ensure the systems are, to the extent practicable, compatible and share information as required by the Post-Katrina Emergency Management Reform Act of 2006.

3 - Open

We recommend the FEMA Administrator issue guidance and ensure a standardized process for collecting and maintaining documentation to confirm delivery and receipt of FEMA-owned commodities, supplies, and equipment, as well as those sourced by FEMA from partners across the Federal Government, non-governmental organizations, and the private sector to fulfill state, local, tribal, and territorial requests. At a minimum, the guidance and standardized process should: a. identify the required types of documentation to confirm delivery and receipt such as signed bills of lading, packing slips, and other forms; b. include controls to ensure the shipment documentation includes item descriptions and the specific quantity of items delivered and received; c. clarify the procedures for executing and documenting the delivery of commodities, supplies, and equipment to locations where no FEMA personnel are present to receive shipments; and d. establish appropriate repositories for delivery and receipt documentation.

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.

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

FEMA Did Not Provide Sufficient Oversight of Project Airbridge

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

Full Details: Oversight.gov Report Page

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

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

FEMA’s Management of Mission Assignments to Other Federal Agencies Needs Improvement

Although the Federal Emergency Management Agency (FEMA) processed and obligated funds timely to other Federal agencies (OFA), it did not provide sufficient oversight to ensure OFAs used pandemic funding as required. Specifically, FEMA did not develop detailed cost estimates when initially establishing MAs, validate unliquidated and open obligations throughout the MA lifecycle, and verify cost eligibility against Public Assistance guidance before closing the MA.

Full Details: Oversight.gov Report Page

Audit | 9/30/2022

More than $2.6 Million in Potentially Fraudulent LWA Payments Were Linked to DHS Employees’ Identities

The Federal Emergency Management Agency (FEMA) did not implement controls to prevent state workforce agencies (SWA) from paying more than $2.6 million in Lost Wages Assistance (LWA) for potentially fraudulent claims made by Department of Homeland Security employees, or claimants who fraudulently used the identities of DHS employees to obtain LWA benefits.

Full Details: Oversight.gov Report Page

Audit | 9/28/2022

1 - Closed

: We recommend the FEMA Administrator develop and implement a standard risk assessment process before initiating new Federal grant programs. This risk assessment should focus on identifying and evaluating program risks that may affect FEMA’s ability to prevent waste, fraud, and abuse in its programs and mitigating those external risks to the extent practical.

2 - Closed

We recommend the FEMA Administrator conduct an after-action study of the Lost Wages Assistance program and update FEMA Individual Assistance programs based on the lessons learned from the study.

3 - Closed

We recommend the FEMA Administrator, when mandated to rely on eligibility determinations of non-FEMA programs, develop a process to assess the program controls and identify risk, where practical.

4 - Open

We recommend the Chief Human Capital Officer for DHS’ Management Directorate develop, implement, and communicate departmental policies and procedures for the Unemployment Compensation for Federal Employees program to each component to ensure compliance with Federal requirements.

5 - Closed

We recommend the FEMA Administrator develop and implement a process to monitor whether grantees implement and use the controls attested to in FEMA-approved state administrative plans.

5 - Closed

We recommend the FEMA Administrator develop and implement a process to monitor whether grantees implement and use the controls attested to in FEMA-approved state administrative plans.

6 - Closed

We recommend the FEMA Administrator develop and implement a process to review state administrative plans for consistency and ensure they include fraud prevention and mitigation strategies.

7 - Closed

We recommend the FEMA Administrator de-obligate and recover any monies determined to have been obtained fraudulently or other improper payments through the Lost Wages Assistance program from the state workforce agencies.

FEMA Did Not Implement Controls to Prevent More than $3.7 Billion in Improper Payments from the Lost Wages Assistance Program

The Federal Emergency Management Agency (FEMA) did not implement controls that may have prevented the 21 state workforce agencies (SWA) in our review from distributing more than $3.7 billion in improper payments through its Lost Wages Assistance (LWA) program.

Full Details: Oversight.gov Report Page

Audit | 9/22/2022

1 - Open

We recommend the FEMA Administrator develop and implement a standard risk assessment process before initiating new Federal grant programs. This risk assessment should focus on identifying and evaluating program risks that may affect FEMA’s ability to prevent waste, fraud, and abuse in its programs and mitigating those external risks to the extent practical.

2 - Closed

We recommend the FEMA Administrator, when mandated to rely on eligibility determinations of non-FEMA programs, develop a process to assess the program controls and identify risk to the extent practical.

3 - Open

We recommend the FEMA Administrator update the State Administrative Plan template to incorporate a requirement for grantees to include a description of the steps to prevent improper payments.

4 - Open

We recommend the FEMA Administrator develop and implement a process to monitor whether grantees implement and use the controls attested in FEMA-approved State Administrative Plans.

5 - Open

We recommend the FEMA Administrator work with state workforce agencies to evaluate the Lost Wages Assistance program payments and verify that all recipients who received payment have a self-certification on file, as required; to determine whether the claimant meets eligibility requirements if no self-certification is on file; and, if not, to recover the payment.

6 - Open

We recommend the FEMA Administrator conduct an after-action study of the Lost Wages Assistance program and update FEMA’s Individuals and Households Program based on the lessons learned from the study.

7 - Closed

We recommend the FEMA Administrator de-obligate and recover any monies determined to have been obtained fraudulently or other improper payments through Lost Wages Assistance from the state workforce agencies.

A Review of FEMA Funding for Coronavirus Disease 2019 (COVID-19) Response and Relie

The Federal Emergency Management Agency (FEMA) provided approximately $49.3 million of coronavirus disease 2019 (COVID-19) pandemic relief funds to Springfield, MA; Coeur D’Alene, ID; Sheridan County, NE; Marion County, GA; White Earth Nation in Minnesota; and Jicarilla Apache Nation in New Mexico.

Full Details: Oversight.gov Report Page

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

Violations of ICE Detention Standards at Folkston ICE Processing Center and Folkston Annex

The objective was to conduct an unannounced inspection of Folkston Processing Center and Folkston Annex to monitor compliance with select ICE detention standards.

Full Details: Oversight.gov Report Page

Inspection / Evaluation | 7/05/2022

1 - Closed

Ensure the Folkston facility conditions we identified as deficient are corrected and in compliance with 2011 PBNDS requirements.

10 - Closed

Provide ICE visitation schedules, including the time, duration, and location for housing unit visits, to ensure Folkston detainees are aware of their regular access to assigned ICE ERO deportation officers.

11 - Closed

Ensure ICE provides copies of ICE request forms and secure drop boxes in all Folkston housing units.

12 - Closed

Ensure Folkston maintains staffing levels outlined in the ICE contract.

13 - Closed

Ensure Folkston properly secures and stores detainee personal property.

2 - Closed

Establish coordination of medical care for detainees moved between Folkston IPC and Folkston Annex and ensure timely access to specialty care.

3 - Closed

Address medical staffing issues at Folkston IPC to ensure adequate mental health care for detainees.

4 - Closed

Require Folkston staff to complete daily medical monitoring of detainees in administrative segregation.

5 - Closed

Provide detainees in segregation at Folkston IPC access to recreation, legal calls, laundry services for bedding and clothing, mail, legal materials, law library, and commissary.

6 - Closed

Ensure Folkston segregation practices related to handcuffing comply with 2011 PBNDS requirements.

7 - Closed

Establish a grievance and facility request tracking system to ensure timely and complete responses to all detainee requests filed at Folkston.

8 - Closed

Ensure Folkston meets ICE’s COVID-19 requirements for wearing masks and social distancing.

9 - Closed

Establish a requests tracking system to ensure timely and complete responses to all detainee requests filed at Folkston.

ICE Did Not Follow Policies, Guidance, or Recommendations to Ensure Migrants Were Tested for COVID-19 before Transport on Domestic Commercial Flights

The objective was to determine the extent to which the U.S. Immigration and Customs Enforcement (ICE) mitigates safety risks by testing migrants for COVID-19 before transport on domestic commercial flights and whether a process is in place for escorting noncitizen unaccompanied children (UCs) during transport.

Full Details: Oversight.gov Report Page

Audit | 5/23/2022

Lessons Learned from DHS' Employee COVID-19 Vaccination Initiative

Our objective was to evaluate how DHS determined employee status for placement into vaccine distribution priority groups; determine how DHS, in conjunction with VHA, planned to triage and distribute available vaccine inventory and vaccinate frontline, mission-critical DHS staff; and evaluate how DHS executed its plan.

Full Details: Oversight.gov Report Page

Review | 5/13/2022

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

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

Management Alert - FEMA's COVID-19 Funeral Assistance Operating Procedures Are Inconsistent with Previous Interpretation of Long-Standing Regulations for Eligible Funeral Expenses

We are issuing this management alert to advise the Federal Emergency Management Agency (FEMA) that its Coronavirus disease 2019 (COVID-19) Funeral Assistance Program operating procedures contradict FEMA’s previous interpretation of long-standing regulations for ineligible funeral expenses established in FEMA’s Individual Assistance Program and Policy Guide (IAPPG). This interpretation of regulations for ineligible funeral expenses remains unchanged in FEMA Policy 104-21-0001 (COVID-19-specific policy).

Full Details: Oversight.gov Report Page

ICE Spent Funds on Unused Beds, Missed COVID-19 Protocols and Detention Standards while Housing Migrant Families in Hotels

ICE did not adequately justify the need for the sole source contract to house migrant families and spent approximately $17 million for hotel space and services at six hotels that went largely unused between April and June 2021.

Full Details: Oversight.gov Report Page

Inspection / Evaluation | 4/15/2022

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

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

Management Alert – Reporting Suspected Fraud of Lost Wages Assistance

The objective is to determine to what extent FEMA ensured states and territories distributed supplemental state lost wages assistance (LWA) from the Disaster Relief Fund (DRF) to eligible recipients.

Full Details: Oversight.gov Report Page

Audit | 3/04/2022

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.

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

CISA Should Validate Priority Telecommunications Services Performance Data

The objective of this review was to determine whether DHS effectively supported operable and interoperable emergency communications for Federal, state, local, tribal, and territorial government officials and critical infrastructure operators during the Coronavirus disease-19 (COVID-19) pandemic.

Full Details: Oversight.gov Report Page

Audit | 1/12/2022

Medical Processes and Communication Protocols Need Improvement at Irwin County Detention Center

The objective was to determine whether Irwin County Detention Center (ICDC), in Ocilla, Georgia provided Immigration and Customs Enforcement detainees adequate medical care and adhered to COVID-19 protections.

Full Details: Oversight.gov Report Page

Inspection / Evaluation | 1/06/2022

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

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

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

FEMA Did Not Always Accurately Report COVID-19 Contract Actions in the Federal Procurement Data System

The objective was to determine to what extent FEMA followed Federal and departmental procedures and guidelines for awarding COVID-19 contracts to vendors in unusual and urgent circumstances.

Full Details: Oversight.gov Report Page

Continued Reliance on Manual Processing Slowed USCIS’ Benefits Delivery During the COVID-19 Pandemic

The objective was to determine the effectiveness of USCIS’ technology systems to provide timely and accurate electronic processing of immigration and naturalization benefit requests while field offices, asylum offices, and application support centers were closed or operating on a reduced workforce during the COVID-19 pandemic.

Full Details: Oversight.gov Report Page

Audit | 11/03/2021

FLETC’s Actions to Respond to and Manage COVID-19 at Its Glynco Training Center

Before reopening in June 2020, FLETC developed a formal plan to resume in-person training. Through this plan, along with other policies and procedures, FLETC established protocols in accordance with Centers for Disease Control and Prevention guidance and medical expertise. DHS students and component officials we spoke with confirmed that these protocols were in place and told us that, overall, they were effective.

Full Details: Oversight.gov Report Page

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.

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

Lessons Learned from FEMA’s Initial Response to COVID-19

The objective was to determine how effectively FEMA supported and coordinated Federal efforts to distribute personal protective equipment (PPE) and ventilators in response to the COVID-19 outbreak. We determined that FEMA did not have reliable data to inform allocation decisions and ensure accurate adjudication of resource requests, it did not have a process to allocate the limited supply of PPE, and FEMA’s strategic documents did not clearly outline roles and responsibilities to lead the Federal response. We made three recommendations that FEMA improve the reliability of WebEOC, formally...

Full Details: Oversight.gov Report Page

Audit | 9/23/2021

DHS Needs to Enhance Its COVID-19 Response at the Southwest Border

The objective of this review was to determine to what extent the Department of Homeland Security has implemented COVID-19 measures for migrants at the southwest border. We reported that U.S. Customs and Border Protection (CBP) does not conduct COVID-19 testing for migrants who enter CBP custody and is not required to do so. Instead, CBP relies on local public health systems to test symptomatic individuals. According to CBP officials, as a frontline law enforcement agency, it does not have the necessary resources to conduct such testing. For migrants that are transferred or released from CBP...

Full Details: Oversight.gov Report Page

Audit | 9/21/2021

Violations of ICE Detention Standards at Otay Mesa Detention Center

During our unannounced inspection of Otay Mesa in San Diego, California, we identified violations of ICE detention standards that compromised the health, safety, and rights of detainees. Otay Mesa complied with standards for classification and generally provided sufficient medical care to detainees. In addressing COVID-19, Otay Mesa did not consistently enforce precautions including use of facial coverings and social distancing. Overall, we found that Otay Mesa did not meet standards for grievances, segregation, or staff-detainee communications. Specifically, Otay Mesa did not respond timely...

Full Details: Oversight.gov Report Page

Inspection / Evaluation | 9/16/2021

ICE’s Management of COVID-19 in Its Detention Facilities Provides Lessons Learned for Future Pandemic Responses

ICE has taken various actions to prevent the pandemic’s spread among detainees and staff at their detention facilities. At the nine facilities we remotely inspected, these measures included maintaining adequate supplies of PPE such as face masks, enhanced cleaning, and proper screening for new detainees and staff. However, we found other areas in which detention facilities struggled to properly manage the health and safety of detainees. For example, we observed instances where staff and detainees did not consistently wear face masks or socially distance. In addition, we noted that some...

Full Details: Oversight.gov Report Page

Inspection / Evaluation | 9/09/2021

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.

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.

CBP Needs to Strengthen Its Oversight and Policy to Better Care for Migrants Needing Medical Attention

U.S. Customs and Border Protection (CBP) needs better oversight and policy to adequately safeguard migrants experiencing medical emergencies or illnesses along the southwest border. CBP concurred with all three of our recommendations, which when implemented, should improve medical attention and procedures for migrants at the southwest border

Full Details: Oversight.gov Report Page

Audit | 7/22/2021

Violations of Detention Standards at Adams County Correctional Center

During our unannounced inspection of Adams in Natchez, Mississippi, we identified violations of ICE detention standards that threatened the health, safety, and rights of detainees. We made seven recommendations to ICE’s Executive Associate Director of Enforcement and Removal Operations (ERO) to ensure the New Orleans ERO Field Office overseeing Adams addresses identified issues and ensures facility compliance with relevant detention standards. ICE concurred with all seven recommendations.

Full Details: Oversight.gov Report Page

Inspection / Evaluation | 7/19/2021

1 - Closed

We recommend the Executive Associate Director of Enforcement and Removal Operations direct the New Orleans Enforcement and Removal Field Office responsible for Adams to ensure the Adams Medical Unit develops emergency care guidelines, documents patient treatment during sick call encounters, anddocuments interpretation and medical care provided based on laboratory testing results.

2 - Closed

3 - Closed

We recommend the Executive Associate Director of Enforcement and Removal Operations direct the New Orleans Enforcement and Removal Field Office responsible for Adams to ensure Adams reviews classification determinations, documents detainee special vulnerabilities, and documents language used to conduct detainee interviews.

4 - Closed

5 - Closed

We recommend the Executive Associate Director of Enforcement and Removal Operations direct the New Orleans Enforcement and Removal Field Office responsible for Adams to ensure Adams provides detainees in segregation access to laundry, legal materials, mail, required recreation time outside their cells,the commissary (for those in administrative segregation), ICE request forms, and secure drop-boxes.

6 - Closed

We recommend the Executive Associate Director of Enforcement and Removal Operations direct the New Orleans Enforcement and Removal Field Office responsible for Adams to establish a system to ensure timely ICE responses to requests.

7 - Closed

We recommend the Executive Associate Director of Enforcement and Removal Operations direct the New Orleans Enforcement and Removal Field Office responsible for Adams to update ICE’s contract with Adams to better identify requirements for detainee housing.

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

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

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

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

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

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.

Violations of Detention Standards at Pulaski County Jail

During our unannounced inspection of Pulaski County Jail, we identified violations of U.S. Immigration and Customs Enforcement (ICE) detention standards that threatened the health, safety, and rights of detainees. In addressing COVID-19, Pulaski did not consistently enforce precautions including use of facial coverings and social distancing, which may have contributed to repeated COVID-19 transmissions at the facility. Pulaski did not meet standards for classification, medical care, segregation, or detainee communication. We found that the facility was not providing a color-coded visual...

Full Details: Oversight.gov Report Page

Inspection / Evaluation | 5/03/2021

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...

Full Details: Oversight.gov Report Page

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...

Full Details: Oversight.gov Report Page

Violations of Detention Standards Amidst COVID-19 Outbreak at La Palma Correctional Center in Eloy, AZ

We identified violations of U.S. Immigration and Customs Enforcement (ICE) detention standards that threatened the health, safety, and rights of detainees. La Palma Correctional Center (LPCC) complied with the ICE detention standard regarding classification. However, detainee reports and grievances allege an environment of mistreatment and verbal abuse, including in response to peaceful detainee protests of the facility’s handling of the pandemic. In addressing the coronavirus disease 2019 (COVID-19), LPCC did not enforce ICE’s precautions including facial coverings and social distancing...

Full Details: Oversight.gov Report Page

Inspection / Evaluation | 3/30/2021

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...

Full Details: Oversight.gov Report Page

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...

Full Details: Oversight.gov Report Page

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...

Full Details: Oversight.gov Report Page

Review | 3/11/2021

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...

Full Details: Oversight.gov Report Page

Review | 2/24/2021

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)...

Full Details: Oversight.gov Report Page

Inspection / Evaluation | 1/28/2021

Ineffective Implementation of Corrective Actions Diminishes DHS' Oversight of Its Pandemic Planning

DHS OIG issued a series of three reports between August 2014 and October 2016 examining DHS’ pandemic activities, including 28 recommendations to improve the efficiency and effectiveness of DHS planning and response activities. We conducted this verification review to determine the adequacy and effectiveness of DHS’ corrective actions. We focused our review on 11 of 28 key recommendations that dealt with DHS-wide pandemic planning and response activities. We determined that DHS provided the OIG with adequate documentation of its initial plans and actions to address the recommendations to...

Full Details: Oversight.gov Report Page

Review | 12/23/2020

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.

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...

Full Details: Oversight.gov Report Page

Review | 12/18/2020

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...

Full Details: Oversight.gov Report Page

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...

Full Details: Oversight.gov Report Page

Review | 11/19/2020

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...

Full Details: Oversight.gov Report Page

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...

Full Details: Oversight.gov Report Page

Audit | 9/17/2020

Early Experiences with COVID-19 at Border Patrol Stations and OFO Ports of Entry

o We surveyed staff at Border Patrol stations and OFO ports of entry from April 22, 2020 to May 1, 2020. The 136 Border Patrol stations and 307 OFO ports of entry that responded to our survey described various actions they have taken to prevent and mitigate the pandemic’s spread among travelers, detained individuals, and staff. These actions include increased cleaning and disinfecting of common areas, and having personal protective equipment for staff, as well as supplies available to those individuals with whom they come into contact. However, facilities reported concerns with their inability...

Full Details: Oversight.gov Report Page

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...

Full Details: Oversight.gov Report Page

Review | 9/01/2020

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...

Full Details: Oversight.gov Report Page

Inspection / Evaluation | 8/27/2020

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...

Full Details: Oversight.gov Report Page

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...

Full Details: Oversight.gov Report Page

Inspection / Evaluation | 7/07/2020

Early Experiences with COVID-19 at ICE Detention Facilities

We surveyed U.S. Immigration and Customs Enforcement (ICE) detention facilities from April 8-20, 2020 regarding their experiences and challenges managing COVID-19 among detainees in their custody and among their staff. The facilities that responded to our survey described various actions they have taken to prevent and mitigate the pandemic’s spread among detainees. These actions include increased cleaning and disinfecting of common areas, and isolating new detainees, when possible, as a precautionary measure. However, facilities reported concerns with their inability to practice social...

Full Details: Oversight.gov Report Page

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...

Full Details: Oversight.gov Report Page

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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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