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Department of Labor OIG

ETA and State Workforce Agencies Need to do more to Recover Pandemic UI Program Improper Payments

Department of Labor OIG

COVID-19: Data Sharing Project Finds Billions Paid to Same Likely Fraudsters under Both the Unemployment Insurance and Economic Injury Disaster Loan Programs

Department of Labor OIG

COVID-19: ETA Could Have Done More to Ensure States Had Sufficient Staffing to Deliver Timely Pandemic Unemployment Benefits

Department of Labor OIG

FY 2024 Independent Auditors' Report on DOL's Consolidated Financial Statements

Department of Labor OIG

ETA Did Not Ensure States Sufficiently Implemented Mixed Earners Unemployment Compensation Program

Department of Labor OIG

COVID-19: ETA's Oversight of Short-Time Compensation Did Not Detect $126.9 Million in Questioned Costs

Department of Labor OIG

The U.S. Department of Labor Did Not Meet the Requirements for Compliance with the Payment Integrity Information Act for FY 2023

Department of Veterans Affairs OIG

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

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

COVID-19: Jobs for Veterans State Grants (JVSG) Program

The COVID-19 pandemic presented new challenges for VETS in its mission to: (1) prepare America’s veterans and transitioning service members for meaningful careers, (2) provide them with employment resources and expertise, (3) protect their employment rights, and (4) promote their employment opportunities. VETS’s JVSG program provides individualized career services to veterans with significant barriers to employment, especially veterans who are economically or educationally disadvantaged. The program also aims to increase employment opportunities for veterans and encourage the hiring of disabled veterans. To this end, it conducts outreach to employers and business associations and engages in advocacy efforts with hiring executives. The audit will focus on how the pandemic impacted the JVSG program as well as the effectiveness of the program during a health crisis.

Department of Labor OIG

COVID-19: Effectiveness of UI ARPA Grants

The American Rescue Plan Act, as amended by the Fiscal Responsibility Act of 2023, provided $1 billion in funding to DOL to prevent and detect fraud, promote equitable access, ensure timely payment of benefits, and reduce backlogs. Of these funds, DOL provided approximately $219 million in grants to improve UI claimant outreach and customer service processes, implement strategies to reduce backlog, and improve access for workers in communities that may historically experience barriers. These grants will provide funding for states to improve public awareness and service delivery. This audit will focus on determining if ETA administered these grants in accordance with ARPA and DOL’s objectives for UI access and if recipients are on target to achieve performance outcomes.

Department of Labor OIG

FY 2023 Independent Auditors' Report on DOL's Consolidated Financial Statements

Department of Labor OIG

COVID-19: MSHA Did Not Complete or Accurately Report Mandatory Inspections

Department of Labor OIG

COVID-19: ETA Needs a Plan to Reconcile and Return to the U.S. Treasury Nearly $5 Billion Unused by States for a Temporary Unemployment Insurance Program

Department of Labor OIG

COVID-19: The Employment and Training Administration Needs to Improve Oversight of Grants Awarded in New Jersey

Department of Labor OIG

OSHA Needs to Do More to Address High Injury Rates of Warehouse Workers

Department of Labor OIG

COVID-19: Pandemic Unemployment Assistance For Non-Traditional Claimants Weakened By Billions In Overpayments, Including Fraud

Department of Labor OIG

Alert Memorandum: ETA Needs to Incorporate Data Analytics Capability to Improve Oversight of the Unemployment Insurance Program

Department of Labor OIG

COVID-19 - ETA Can Improve its Oversight to Ensure Integrity over CARES Act UI Programs

Department of Veterans Affairs OIG

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

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

COVID-19: Unemployment Relief For Governmental Entities And Nonprofit Organizations Should Have Been Better Managed

Department of Labor OIG

COVID-19: Employment and Training Grantee Sub-Recipients - New York

In March 2020, the COVID-19 pandemic caused many of ETA’s job training programs to cease operation. This interrupted participants’ job training, potentially preventing them from completing their training and getting a job in the areas in which they were trained. This series of audits will focus on how effectively ETA ensured workforce development grant funds were used as intended in the State of New York during the pandemic.

Department of Labor OIG

COVID-19: OSHA Needs To Strengthen Its Process for Awarding Future Emergency Supplemental Funds to State Plans

Department of Labor OIG

ETA Did Not Provide Adequate Oversight of Emergency Administrative Grants

Department of Labor OIG

COVID-19: Impact of Waivers on UI Overpayments, Fraud Investigations, and Recoveries

On February 7, 2022, DOL issued Unemployment Insurance Program Letter 20-21, Change 1, regarding states’ ability to waive the recovery of certain UI overpayments under the CARES Act program. There are concerns these waivers could adversely impact the pursuit of fraud in the UI program. Also, the waivers could potentially allow for fraudulent CARES Act UI payments to go unrecovered. This audit will determine the impact of waivers on UI overpayments, fraud investigations, and recoveries.

Department of Labor OIG

The U.S. Department of Labor Did Not Meet the Requirements for Compliance with the Payment Integrity Information Act for FY 2022

Department of Veterans Affairs OIG

VHA Can Improve Controls Over Its Use of Supplemental Funds

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

COVID-19: ETA Grant Sub-Recipient Audit - Texas

In March 2020, the COVID-19 pandemic caused many of ETA’s job training programs to cease operation. This interrupted participants’ job training, potentially preventing them from completing their training and getting a job in the areas in which they were trained. This series of audits will focus on how effectively ETA ensured workforce development grant funds were used as intended in the State of Texas during the pandemic.

Department of Veterans Affairs OIG

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

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

Alert Memorandum: ETA and States Need to Ensure the Use of Identity Verification Service Contractors Results in Equitable Access to UI Benefits and Secure Biometric Data

Department of Labor OIG

FY 2022 Independent Auditors' on DOL's Consolidated Financial Statements Report

Department of Labor OIG

Insights on Telehealth Use and Program Integrity Risks in DOL Workers' Compensation Programs During the Pandemic

As part of the Pandemic Response Accountability Committee’s (PRAC)1 effort toprovide policymakers and stakeholders with information about the nature oftelehealth and its use across federal health care programs, the Office ofInspector General (OIG) conducted an evaluation to: (1) examine the use oftelehealth across the Department of Labor’s (DOL) workers’ compensationprograms during the first year of the COVID-19 pandemic, and (2) identifyemerging risks related to the use of telehealth.
Department of Veterans Affairs OIG

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

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

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

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

COVID-19: OSHA's Enforcement Activities Did Not Sufficiently Protect Workers From Pandemic Health Hazards

Department of Labor OIG

COVID-19: ETA and States Did Not Protect Pandemic-Related UI Funds from Improper Payments Including Fraud or from Payment Delays

Department of Labor OIG

COVID 19 – UI Claims With Deceased Persons' Social Security Numbers

In September 2022, the Office of Inspector General (OIG) alerted U.S. Department of Labor to over $45 billion in potential fraud paid in four high-risk areas. One high-risk area was Unemployment Insurance (UI) claimants filing with Social Security numbers (SSN) of deceased persons. Through Employment and Training Administration (ETA), the OIG provided states with underlying methodology as well as specific claimant information for follow-up action. This audit will examine the extent to which ETA and states have taken action to follow up on potentially fraudulent CARES Act UI claims filed with SSNs of deceased persons identified and referred by the OIG.

Department of Labor OIG

Alert Memorandum: Potentially Fraudulent Unemployment Insurance Payments in High-Risk Areas Increased to $45.6 Billion

Department of Labor OIG

COVID-19 – UI Claims with Federal Prisoners' Social Security Numbers

In September 2022, the Office of Inspector General (OIG) alerted U.S. Department of Labor to over $45 billion in potential fraud paid in four high-risk areas. One high-risk area was UI claimants filing with Social Security numbers (SSNs) of federal prisoners. Through Employment and Training Administration (ETA), the OIG provided states with underlying methodology as well as specific claimant information for follow-up action. This audit will examine the extent to which ETA and states have taken action to follow up on potentially fraudulent CARES Act Unemployment Insurance (UI)claims filed with SSNs of federal prisoners identified and referred by the OIG. 

Department of Labor OIG

COVID-19 – Multi-State UI Claimants

In September 2022, the Office of Inspector General (OIG) alerted the U.S. Department of Labor to over $45 billion in potential fraud paid in four high-risk areas. Multistate claimants were the largest high-risk area. Through Employment and Training Administration (ETA) the OIG provided states with underlying methodology as well as specific claimant information for follow-up action. This audit will examine the extent to which ETA and states have taken action to follow up on potentially fraudulent CARES Act Unemployment Insurance (UI) claims identified and referred by the OIG.

Department of Labor OIG

COVID-19 – UI Claims with Suspicious Email Accounts

In September 2022, the Office of Inspector General (OIG) alerted U.S. Department of Labor to over $45 billion in potential fraud paid in four high-risk areas. One high-risk area was Unemployment Insurance (UI) claimants filing with suspicious email accounts. Through Employment and Training Administration (ETA), the OIG provided states with underlying methodology as well as specific claimant information for follow-up action. This audit will examine the extent to which ETA and states have taken action to follow up on potentially fraudulent CARES Act UI claims filed with suspicious email accounts identified and referred by the OIG.

Department of Veterans Affairs OIG

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

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

Alert Memorandum: Employment and Training Administration Needs to Ensure State Workforce Agencies Report Activities Related to CARES Act Unemployment Insurance Programs

Department of Labor OIG

The U.S. Department of Labor Did Not Meet the Requirements for Compliance with the Payment Integrity Information Act for FY 2021

Department of Veterans Affairs OIG

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

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

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

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

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

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of Veterans Integrated Service Networks (VISNs) 2, 5, and 6 facilities’ COVID-19 pandemic readiness and response. This evaluation focused on emergency preparedness; supplies, equipment, and infrastructure; staffing; access to care; community living center patient care and operations; facility staff feedback; and VA and VISNs 2, 5, and 6 vaccination efforts.The OIG has aggregated findings on COVID-19 preparedness and responsiveness from routine inspections to ensure...
Department of Labor OIG

COVID-19: To Protect Mission Critical Workers, OSHA Could Leverage Inspection Collaboration Opportunities with External Federal Agencies

Department of Veterans Affairs OIG

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

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

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

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Martinsburg VA Medical Center (facility) in West Virginia to assess allegations of failure to schedule a Care in the Community (CITC) COVID Priority 1 cardiology consult within Veterans Health Administration requirements, and delays in CITC consult scheduling caused by inadequate CITC staffing.The OIG substantiated that a COVID Priority 1 CITC cardiology consult was not scheduled within 30 days of the clinically indicated date. The OIG determined that the consult was amongst a backlog of approximately 5,000...
Department of Labor OIG

COVID-19: Delays In Providing Disaster Relief Jeopardize $366 Million Disaster Worker Grant Program

Department of Veterans Affairs OIG

Audit of Community Care Consults during COVID-19

During COVID-19, VHA’s Office of Community Care (OCC) took steps to ensure veterans continued to have expanded access to health care in the community, as required by the VA MISSION Act of 2018. OCC issued policies to VA facilities to postpone nonurgent appointments and offer alternatives to in-person care, such as telehealth. The VA Office of Inspector General (OIG) conducted this audit to determine whether VHA effectively managed community care consults for routine appointments during the pandemic.The OIG found that routine community care consults were unscheduled for an average of 42 days...
Department of Veterans Affairs OIG

Systems and Tools Implemented to Track COVID-19 Vaccine Data

The VA Office of Inspector General (OIG) examined whether the Veterans Health Administration (VHA) implemented data collection and reporting systems to report on the supply of COVID-19 vaccines to VA medical facilities and doses administered to VA employees and veterans enrolled in VA’s healthcare system (approximately 9.5 million individuals). Although essential for national reporting, tracking VA vaccine data is difficult because VA does not have a centralized national pharmacy inventory management system to track vaccine supply at facilities.Although VHA staff swiftly developed data...
Department of Labor OIG

FY 2021 Independent Auditor's Report on the DOL Financial Statements

Department of Veterans Affairs OIG

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

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of Veterans Integrated Service Network (VISN) 1 and 8 facilities’ COVID-19 pandemic readiness and response. This evaluation focused on emergency preparedness; supplies, equipment, and infrastructure; staffing; access to care; community living center patient care and operations; facility staff feedback; and VA and VISN 1 and 8 vaccination efforts.The OIG has aggregated findings on COVID-19 preparedness and responsiveness from routine inspections to ensure prompt...
Department of Labor OIG

COVID-19: Safety and Remote Learning Challenges Continue for Job Corps

Department of Veterans Affairs OIG

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

The VA Office of Inspector General (OIG) conducted a national review of stat community care consults generated during the outset of the COVID-19 pandemic to evaluate consult processes. Patient involvement in care urgency disagreements and reporting of adverse events in community care were also reviewed. When the OIG identified deficiencies in processes, electronic health records (EHRs) of the patients at issue were further examined for potential negative outcomes. The OIG did not identify any negative care outcomes.For the 2,236 stat community care consults generated from March 20, 2020...
Department of Labor OIG

COVID-19: The Pandemic Highlighted the Need to Strengthen Wage and Hour Division's Enforcement Controls

Department of Veterans Affairs OIG

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

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

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

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

COVID-19: Pandemic Causes Delays in FECA Claims Adjudication

Department of Veterans Affairs OIG

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

The VA Office of Inspector General (OIG) conducted a healthcare inspection regarding allegations of incompletely screening for COVID-19 and treatment of a patient with serious mental illness who presented for same-day care at the Michael E. DeBakey VA Medical Center (facility).The OIG substantiated that facility staff did not complete the patient’s COVID-19 temperature screening.The OIG substantiated that facility staff failed to medically manage the patient with COVID-19 symptoms, sent the patient to the drive-through testing area without medical evaluation, and did not isolate the patient...
Department of Veterans Affairs OIG

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

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

Department of Labor OIG

The U.S. Department of Labor Complied with The Payment Integrity Information Act for FY 2020, but Reported Unemployment Insurance Information Did Not Represent Total Program Year Expenses

DOL's reported Unemployment Insurance improper payment rate of 9.17 percent is compliant with Payment Integrity Information Act of 2019, it is not representative of total unemployment expenses for program year 2020. This occurred for the following reasons: (1) DOL excluded CARES Act of 2020 because these unemployment payments were not in existence for more than 12 months, and (2) DOL received direction from Office of Management and Budget to utilize the results from the first three quarters of the program year. This allowed state workforce agencies to suspend work on improper payment sampling...
Department of Veterans Affairs OIG

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

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of Veterans Integrated Service Network (VISN) 19 facilities’ COVID-19 pandemic readiness and response. This evaluation focused on emergency preparedness; supplies, equipment, and infrastructure; staffing; access to care; community living center patient care and operations; facility staff feedback; and VA and VISN 19 vaccination efforts.The OIG has aggregated findings on COVID-19 preparedness and responsiveness from routine inspections to ensure prompt dissemination of...
Department of Labor OIG

Alert Memorandum: The Employment and Training Administration Does Not Require the National Association of State Workforce Agencies to Report Suspected Unemployment Insurance Fraud Data to the Office of Inspector General or the Employment and Training A

Department of Labor OIG

Alert Memorandum: The Employment and Training Administration Needs to Issue Guidance to Ensure State Workforce Agencies Provide Requested Unemployment Insurance Data to the Office of Inspector General

Department of Veterans Affairs OIG

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

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

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

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

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

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

COVID-19: States Struggled to Implement Cares Act Unemployment Insurance Programs

Department of Veterans Affairs OIG

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

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

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

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

Department of Veterans Affairs OIG

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

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

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

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

Comprehensive Healthcare Inspection of Facilities' COVID-19 Pandemic Readiness and Response in Veterans Integrated Service Networks 10 and 20

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of Veterans Integrated Service Network (VISN) 10 and 20 facilities’ COVID-19 pandemic readiness and response. This evaluation focused on emergency preparedness; supplies, equipment, and infrastructure; staffing; access to care; community living center patient care and operations; and facility staff feedback.The OIG has aggregated findings on COVID-19 preparedness and responsiveness from routine inspections to ensure prompt dissemination of information given the quickly...
Department of Veterans Affairs OIG

Potential Risks Associated with Expedited Hiring in Response to COVID-19

This management advisory memo identifies potential risks associated with the Veterans Health Administration’s (VHA) efforts to expedite adding new staff to meet increased demand caused by the COVID-19 pandemic. The VA Office of Inspector General (OIG) recognizes the tremendous pressure to quickly hire staff to meet unprecedented needs. To achieve VHA’s goal of bringing all new employees on duty within three days of making a tentative offer, VHA has modified or deferred tasks such as fingerprinting, background investigations, drug testing, credentialing, and preplacement physicals.The potential...
Department of Veterans Affairs OIG

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

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

COVID-19: Increased Worksite Complaints and Reduced OSHA Inspections Leave U.S. Workers' Safety at Increased Risk

Department of Veterans Affairs OIG

Reporting and Monitoring Personal Protective Equipment Inventory during the Pandemic

The spread of COVID-19 drastically increased the demand for personal protective equipment (PPE) such as masks, gloves, and gowns, and significantly disrupted the global supply chain. As the nation’s largest integrated healthcare system, the Veterans Health Administration (VHA) had to compete for PPE for its personnel and patients. The VA Office of Inspector General (OIG) received hotline allegations that VHA medical facilities could not acquire and maintain enough PPE to keep pace with escalating needs. The OIG assessed how VHA reported and monitored PPE supply levels during the pandemic. The...
Department of Labor OIG

Alert Memorandum: The Employment and Training Administration (ETA) Needs to Ensure State Workforce Agencies (SWA) Implement Effective Unemployment Insurance Program Fraud Controls for High Risk Areas

Department of Veterans Affairs OIG

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

The VA Office of Inspector General (OIG) conducted an inspection to assess allegations related to delayed medication delivery from the VA Manila Outpatient Clinic (clinic) pharmacy in Pasay City, Philippines, prior to and during the COVID-19 pandemic.The OIG substantiated a patient experienced medication delivery delays and did not timely receive morphine from the clinic pharmacy in October and November 2019. While the patient requested a renewal in a timely manner, pharmacists could not fill the medication because there was no available stock from the Veterans Health Administration’s (VHA)...
Department of Veterans Affairs OIG

VHA’s COVID-19 Vaccine Planning and Implementation

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

Department of Veterans Affairs OIG

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

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

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

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

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

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

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

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

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

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

Appointment Management During the COVID-19 Pandemic

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

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

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

COVID-19: OSHA Needs To Improve Its Handling Of WhistleBlower Complaints During the Pandemic

Department of Labor OIG

COVID-19: More Can Be Done to Mitigate Risk to Unemployment Compensation Under The CARES Act