Reports

We audited HUD and its grantees’ monitoring of subrecipients and contractors in HUD’s Emergency Solutions Grants Coronavirus Aid, Relief, and Economic Security Act (ESG-CV) program to assess subrecipient monitoring in the program. ESG and ESG-CV grantees often rely on subrecipients and contractors to carry out ESG-CV-funded activities on behalf of the grantees, and are required to monitor subrecipients to ensure that the purpose of the grant funds awarded is achieved and funds are spent on only eligible applicants and activities. HUD is responsible for ensuring that grantees are performing...

We audited the City and County of Honolulu’s Department of Budget and Fiscal Services’ and Department of Community Services’ (City) fraud risk management practices for its Emergency Solutions Grants Coronavirus Aid, Relief, and Economic Security Act (ESG CARES Act) program with the objective of assessing the maturity of the City’s fraud risk management framework that encompasses control activities to prevent, detect, and respond to fraud. Fraudulent activity in the ESG CARES Act program can lead to significant financial losses; reputational damage to the grantee and the U.S. Department of...

We audited the California Department of Housing and Community Development (HCD) with the objective of evaluating HCD’s fraud risk management practices for its Emergency Solutions Grants Coronavirus Aid, Relief, and Economic Security Act (ESG CARES Act) program and assessing the maturity of its efforts to prevent, detect, and respond to fraud. Fraudulent activity in the ESG CARES Act program can lead to significant financial losses, reputational damage to the grantee and the U.S. Department of Housing and Urban Development (HUD), breach of fiduciary duty, and most importantly, loss of funding...

Servicers followed the COVID-19 pandemic foreclosure moratorium requirements. However, they could have better communicated the moratorium requirements to delinquent borrowers who were subject to foreclosure proceedings. This situation occurred because HUD did not require servicers to notify borrowers directly about the foreclosure moratorium and that occupancy would pause the foreclosure process. Borrowers who were not informed about the moratorium or impacts of vacancy could have abandoned their homes, not realizing that remaining in the home would have afforded them additional time to...

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.

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...

We audited the U.S. Department of Housing and Urban Development (HUD), Office of Native American Programs’ (ONAP) coronavirus disease of 2019 (COVID-19) recovery programs. We performed this audit to provide HUD with insight and a nationwide perspective on the challenges that grantees experienced with those programs. Our audit objectives were to identify 1) the information, guidance, and training HUD provided to the grantees for the ONAP COVID-19 recovery programs and 2) the challenges that grantees faced in implementing and using program-provided funding.HUD provided information, guidance, and...

We audited Nationstar Mortgage, LLC’s (doing business as Mr. Cooper (Nationstar)) compliance with the Federal Housing Administration’s (FHA) requirements for providing loss mitigation assistance to borrowers after their COVID-19 forbearance ended. We concurrently conducted a nationwide audit of servicers’ compliance with the U.S. Department of Housing and Urban Development’s (HUD) COVID-19 loss mitigation requirements (HUD Office of Inspector General (OIG) Report 2023-KC-0005). This audit complements that audit by examining how a single provider, Nationstar, provided loss mitigation for...

We performed an audit of loan servicers’ compliance with the Federal Housing Administration’s (FHA) requirements for providing loss mitigation assistance to borrowers after their COVID-19 forbearance ended. We initiated the audit based on the large number of borrowers exiting forbearance, because the loss mitigation programs available to these borrowers were new and created a risk for both borrowers and the FHA insurance fund when servicers do not properly provide loss mitigation. Our audit objective was to determine whether servicers provided borrowers of FHA-insured loans proper loss...

We audited the U.S. Department of Housing and Urban Development’s (HUD) Real Estate Assessment Center’s inspection process. The audit objectives were to determine whether the Center (1) ensured that public housing properties were inspected within required timeframes before the coronavirus disease 2019 (COVID-19) pandemic; (2) could improve its Big Inspection Plan for inspecting high-priority non-National Standards for the Physical Inspection of Real Estate (NSPIRE) demonstration public housing properties; and (3) had experienced delays in inspecting the physical condition of public housing...

We audited the U.S. Department of Housing and Urban Development’s (HUD) temporary policy for endorsement of loans with COVID-19 forbearance activity because an analysis of data in HUD’s systems showed that there may have been loans that did not comply with the policy’s requirements. The policy was one aspect of HUD’s broader emergency response to COVID-19, which also included an eviction moratorium and loan forbearance for borrowers experiencing financial hardship. The objectives of the audit were to determine (1) whether HUD’s temporary endorsement policy related to COVID-19 forbearance...

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...

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...

We audited the U.S. Department of Housing and Urban Development’s (HUD) efforts to proactively communicate information related to the coronavirus disease of 2019 (COVID-19) to homeowners with Federal Housing Administration (FHA)-insured mortgages. We initiated this work based on a U.S. Government Accountability Office report that identified helping borrowers understand the protections available to them as a key challenge and prior audit and evaluation work that found issues related to communication and COVID-19. Our audit objective was to assess HUD’s communication to homeowners with FHA...

We audited the U.S. Department of Housing and Urban Development (HUD), Office of Native American Programs’ (ONAP) Coronavirus Aid, Relief, and Economic Security (CARES) Act and American Rescue Plan (ARP) Act to identify drawdown levels for its block grant programs and assessed information ONAP made publicly available.As of October 4, 2022, grantees had drawn $231.6 million of the $300 million in CARES Act block grant funds and $135.8 million of the $735 million in ARP Act block grant funds. A total of $19.1 million of the appropriated funds was not authorized for access to grantees because...

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...

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...

In coordination with the Pandemic Response Accountability Committee, we conducted an audit to identify potential fraud schemes that could affect HUD’s pandemic funds. We reviewed the funds appropriated by the Coronavirus Aid, Relief, and Economic Security (CARES) Act and the American Rescue Plan (ARP) Act for the Tenant-Based Rental Assistance (TBRA), Project-Based Rental Assistance (PBRA), HOME Investment Partnerships, and Public Housing Operating Fund programs to identify the fraud risks and potential fraud schemes that they face while delivering services to the public.Our objective was to...

We audited the U.S. Department of Housing and Urban Development’s (HUD) Community Development Block Grant Coronavirus Aid, Relief, and Economic Security (CARES) Act program.Our audit objective was to determine what challenges grantees faced in using program funds for activities that prepare for, prevent, or respond to the coronavirus and its impact. We used a survey questionnaire to gather feedback and insight directly from 1,047 program grantees. As of July 30, 2022, grantees had drawn more than $1.79 billion, or 36 percent, of the $4.99 billion in program funds. We performed this audit to...

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...

We audited the U.S. Department of Housing and Urban Development’s (HUD) Emergency Solutions Grants Coronavirus Aid, Relief, and Economic Security Act (CARES Act) (ESG-CV) program. Our audit objective was to determine what challenges ESG-CV grant recipients faced in implementing the program and using grant funds. We used a survey questionnaire to gather feedback and insight directly from the 362 recipients of ESG-CV grants. At the time we initiated this audit in July 2021, ESG-CV grant recipients had spent $563,178,336 of available $3.96 billion grant funds. We performed this audit to assist...

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...

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...

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...

We conducted a limited review of nursing home owners to identify their operational challenges and needs of nursing homes in responding to the Coronavirus Disease 2019 (COVID-19) pandemic. Our objective was to determine the biggest challenges operators of Section 232 nursing home facilities face related to the COVID-19 pandemic and whether nursing homes are prepared to meet their future financial obligations. Most of the owners who responded to our survey indicated that nursing homes experienced financial and operational challenges during the pandemic. These challenges included staffing...

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...

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...

We audited the U.S. Department of Housing and Urban Development’s (HUD) transitioning of offices from mandatory to maximum telework during the coronavirus disease 2019 (COVID-19) pandemic, based on a request from Representative Gerald Connolly, to review whether HUD was employing best practices and existing guidance when deciding whether or when to require Federal employees to return to their offices. Transitioning an office to maximum telework allowed HUD employees to voluntarily return to an office.We focused our audit on whether HUD complied with its internal Resuming Normal Operations...

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...

The U.S. Department of Housing and Urban Development (HUD), Office of Inspector General (OIG), completed an audit to determine whether FHA-insured borrowers properly received the COVID-19-related forbearance. The Coronavirus Aid, Relief, and Economic Security Act (CARES Act), signed into law on March 27, 2020, provided a mortgage payment forbearance option for all borrowers who suffered a financial hardship due to the COVID-19 national emergency.We found that at least one-third of the nearly 335,000 borrowers who were delinquent on their FHA-insured loans and not on forbearance in November...

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...

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...

We conducted a limited review of the U.S. Department of Housing and Urban Development’s (HUD) Coronavirus Aid, Relief, and Economic Security (CARES) Act supplemental public housing operating funds (supplemental funds). Our objective was to assess public housing agencies’ (PHA) experiences and challenges and HUD’s efforts in providing guidance related to the administration of the supplemental operating funds under the CARES Act.We found that the PHA survey respondents generally cited positive experiences and no major challenges related to the administration of supplemental funds under the CARES...

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...

On March 27, 2020, the Coronavirus Aid, Relief, and Economic Security (CARES) Act made available $5 billion in supplemental CDBG funding for grants to prevent, prepare for, and respond to the coronavirus pandemic (CDBG-CV grants). Because of similarities, we reviewed 132 CDBG-DR program audits and evaluations issued from May 2002 to March 2020 to summarize the common CDBG-DR program weaknesses and risks for CPD to consider to help its CDBG-CV grantees effectively and efficiently manage their CDBG-CV program operations.We found that grantees had common areas of weaknesses and risks in the...

We conducted this engagement in coordination with the Pandemic Response Accountability Committee (PRAC) to gain an understanding of the U.S. Department of Housing and Urban Development’s (HUD) fraud risk management practices and develop an inventory of fraud risks that HUD had not already identified for the funds appropriated by the Coronavirus Aid, Relief, and Economic Security (CARES) Act for the Community Development Block Grant (CDBG) and Emergency Solutions Grant (ESG) programs.We identified five overall risk factors that contribute to the risk of fraud for the CDBG and ESG CARES Act...

The VA Office of Inspector General (OIG) conducted an inspection at the VA Illiana Health Care System in Danville, Illinois, to determine the validity of allegations, specific to COVID-19 and the Community Living Center (CLC), of failure to observe infection control practices, failure to minimize risk of exposure to COVID-19, inconsistent ongoing testing, and failure to notify residents, families, and staff of positive test results. During the inspection, the OIG identified concerns related to leaders’ post-outbreak actions.The OIG substantiated a failure to observe general infection control...

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Fayetteville VA Coastal Health Care System in North Carolina to assess concerns related to the quality, coordination, and timeliness of care, and the impact of COVID-19 on a patient with unintentional weight loss who was later diagnosed with oral cancer and died at another VA medical center.The OIG substantiated that the primary care provider and dietitians did not provide quality care to the patient. The primary care provider’s failure to follow-up on an earlier finding and not place an order for a medical test...

The 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...

We audited lender reporting of COVID-19 forbearances for Federal Housing Administration (FHA)-insured loans in the Single Family Default Monitoring System (SFDMS). We compared default reporting data from SFDMS to loan data provided by five sampled servicing lenders that serviced a third of the FHA single-family portfolio. Our audit objective was to determine whether COVID-19 forbearance data available in SFDMS were consistent with the information maintained by loan servicers. We found that COVID-19 forbearance data available in SFDMS were generally consistent with the information maintained by...

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

We conducted a limited review of the U.S. Department of Housing and Urban Development’s (HUD) Office of the Chief Procurement Officer’s (OCPO) administration of five procurement activities under the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). The CARES Act and related Office of Management and Budget memorandums gave HUD flexibility in modifying existing contracts and required rapid delivery of CARES Act funds. Our objective was to determine what HUD had done to accommodate contractors’ pandemic-related issues while ensuring that HUD met its business objectives. In addition...

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...

HUD OIG will summarize the conclusions/findings and recommendations reported by seven participating OIGs and the General Accountability Office related to natural disaster preparedness.  Our objective is to inform Federal agencies and the OIG community of the reported conclusions/findings and recommendations regarding preparing for and responding to natural disasters.
 

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...

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...

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...

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...

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.
 

As of March 31, 2021, HUD had disbursed $3.4 billion and obligated $7.4 billion of its $12.4 billion in CARES Act funds. Meanwhile, HUD has more than $1.6 billion in CARES Act funds unobligated. These funds have various expiration dates. For example, HUD has until September 30, 2021, to obligate $28 million of the remaining management and administration CARES Act funds and until September 30, 2022, to obligate more than $1.3 billion of the remaining Office of Community Planning and Development’s CARES Act funds. If HUD is unable to obligate funds properly before its appropriations expire, it...

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...

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...

The U.S. Department of Housing and Urban Development (HUD), Office of Inspector General (OIG), has completed a survey of the impact of the Coronavirus Disease 2019 (COVID-19) pandemic on HUD’s Community Development Block Grant Disaster Recovery (CDBG-DR) grantees. Our objective was to determine the challenges that HUD and its CDBG-DR grantees are experiencing related to the COVID-19 pandemic and to help inform the Office of Community Planning and Development and Congress on the issues faced in responding to the pandemic.HUD’s CDBG-DR grantees across the country reported facing similar...

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...

We prepared this memorandum to provide the Office of Housing at the U.S. Department of Housing and Urban Development (HUD) with key considerations from prior audits of the HUD Single Family Default Monitoring System (SFDMS) and the partial claim loss mitigation option. These audits identified HUD’s lack of effective controls to ensure that lenders reported default information accurately and in a timely manner, lenders promptly filed and reported partial claims, and partial claims fully reinstated delinquent loans. Prior audits also identified that the current design of partial claims results...

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...

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...

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...

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)...

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

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...

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...

We audited the U.S. Department of Housing and Urban Development’s (HUD) response to COVID-19 to determine if it appropriately, effectively, and efficiently tracked, monitored, and issued Federal Housing Administration (FHA) refunds owed to homeowners with terminated loans. During our field work, the Coronavirus 2019 (COVID-19) pandemic began and as a result, we developed a second, more urgent audit objective to determine how COVID-19 has affected policies, procedures, and distribution of FHA refunds and whether HUD’s response was appropriate. We determined that COVID-19 generally did not...

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...

We conducted this limited review to identify the U.S. Department of Housing and Urban Development’s (HUD) Coronavirus Aid, Relief, and Economic Security Act (CARES Act) drawdown levels for the initial round of Emergency Solutions Grants (ESG) funding. In addition, we researched information published by grantees on how they have used and will use their funds. Our objective was to highlight the grantees’ (1) drawdown levels for the initial round of ESG CARES Act funding and (2) published information on how the funds have and will be used. Our review determined that as of July 1, 2020, the ESG...

HUD OIG is conducting a limited review of HUD's administration of supplemental operating funds under the CARES Act. The CARES Act authorized an additional $685 million in public housing operating funds to prevent, prepare for, and respond to COVID-19.  The review objective is to assess Public Housing Agencies' (PHA) experiences and challenges and HUD's efforts in providing guidance related to the administration of supplemental operating funds under the CARES Act.

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...

As part of the Office of Inspector General’s effort to provide oversight of the U.S. Department of Housing and Urban Development’s (HUD) relief efforts provided by the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), we reviewed HUD’s communication to renters regarding the eviction moratorium found in Section 4024. The objective of our review was to highlight the progress HUD has made and identify areas for improvement. We found that HUD provided critical information to many of these renters through its website and published guidance. However, we identified several aspects of...

The U.S. Department of Housing and Urban Development (HUD), Office of Inspector General (OIG) conducted this study to follow up on information we shared previously regarding what information servicers of mortgage loans insured by Federal Housing Administration (FHA) are providing to borrowers regarding forbearance options available under the Coronavirus Aid, Relief, and Economic Security Act (CARES Act).We reported on April 27, 2020, that our review of 30 FHA servicers who service approximately 90 percent of FHA loans, revealed that FHA servicer websites provided incomplete, inconsistent...

As part of the Office of Inspector General’s (OIG) effort to provide oversight of the U.S. Department of Housing and Urban Development’s (HUD) relief efforts provided by the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), we reviewed HUD’s responses to inquiries regarding forbearance and foreclosure relief. The objective of our review was to evaluate the accuracy of HUD’s responses to inquiries from borrowers, industry partners, and the general public regarding forbearance and foreclosure relief provided by the CARES Act. We found that HUD could improve its customer service to...

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...

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...

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...

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...

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...

The purpose of this memorandum is to notify you that we are researching prior audits of HUD’s Single Family Default Monitoring System to provide HUD information regarding lessons learned and risks identified in these prior audits that HUD should act on now to ensure program integrity and mitigate the risk of financial loss for COVID-19 related forbearance assistance and foreclosure moratorium related to single family loans.

The purpose of this memorandum is to notify you that we are researching prior audits of HUD’s partial claims loss mitigation option to provide HUD information regarding lessons learned and risks identified in these prior audits that HUD should act on now to ensure program integrity and mitigate the risk of financial loss for COVID-19 related partial claims.

HUD OIG is researching Public and Indian Housing and Multifamily use of vacant units during previously Presidentially Declared Disasters and the COVID-19 declared Disaster, as well as PIH and Multifamily’s ability to place a waitlist preference for the homeless and how many homeless individuals had a 50058 or 50059 new move-in during the COVID pandemic.  Since the introduction of the CARES act, there has been an emphasis to review how HUD has reacted to the COVID-19 disaster.  HUD allocated $1 billion to keep America's homeless population safe.  The purpose of this research is to issue memorandums for both PIH and Multifamily addressing the research topics.

HUD OIG is  researching prior audits of HUD’s partial claims loss mitigation option.  On July 8, 2020, FHA issued Mortgagee Letter 2020-22 informing mortgagees the full suite of loss mitigations available to single family borrowers affected by the COVID-19 pandemic.  The purpose of this research is to provide HUD information regarding lessons learned and risks identified in these prior audits that HUD should act on now to ensure program integrity and mitigate the risk of financial loss for COVID-19 related partial claims.

HUD OIG is performing research to help HUD's Community Development Block Grant Coronavirus pandemic (CDBG-CV) grantees be aware of known risks and lessons learned from audits and evaluations of the Community Development Block Grant Disaster Recovery Program grants (CDBG-DR).  The purpose of our research is to issue a report that is intended to assist HUD’s Office of Community Planning and Development (CPD) by developing lessons learned from past reviews and common risk areas to help its CDBG-CV grantees prevent, prepare for, and respond to the coronavirus pandemic.

This memorandum report summarizes survey and interview results on the impact mandatory telework is having on U.S. Housing and Urban Development’s (HUD) operations. The HUD Office of Inspector General (OIG) conducted surveys and interviews to evaluate HUD’s use of agency-wide telework in response to the novel coronavirus disease of 2019 (COVID-19) pandemic. The study was designed to provide insights into the types of obstacles that impeded HUD operations and how HUD responded to identified limitations. HUD demonstrated a capacity to sustain mission essential operations during a period of...

The U.S. Department of Housing and Urban Development (HUD), Office of Inspector General (OIG) conducted this study to assess what information servicers of mortgage loans insured by Federal Housing Administration (FHA) are providing to borrowers regarding forbearance options available under the Coronavirus Aid, Relief, and Economic Security Act (CARES Act).

The U.S. Department of Housing and Urban Development Office of Inspector General assessed what information servicers of mortgage loans that the Federal Housing Administration (FHA) insures were providing on their public facing websites to borrowers regarding forbearance. On March 27, 2020, the President signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) to provide economic relief to individuals and businesses impacted by the COVID-19 pandemic. On April 17, 2020, 22 days after enactment of the Act, we reviewed the top 30 servicers’ websites to identify readily...

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...