Reports
Search reports, investigative results, and agency plansShowing 1 - 79 of 79 results
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 the Interior OIG
Summary: NPS Employee Wrongfully Obtained Unemployment Insurance/Pandemic Unemployment Compensation
We found that a full-time NPS employee wrongfully obtained State unemployment insurance and Federal Pandemic Unemployment Compensation.
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 the Interior OIG
USBR Employee Wrongfully Obtained Unemployment Insurance/Pandemic Unemployment Assistance
We found that a USBR employee wrongfully obtained $28,524 in combined Unemployment Insurance and Pandemic Unemployment Assistance.
Department of Veterans Affairs OIG
VHA Can Improve Controls Over Its Use of Supplemental Funds
The Coronavirus Aid, Relief, and Economic Security (CARES) Act appropriated about $17.2 billion in supplemental funds to the Veterans Health Administration (VHA) to support VA’s efforts to prevent, prepare for, and respond to the COVID-19 pandemic. The OIG conducted this audit to assess the effectiveness of VA’s controls over VHA’s use of these funds.Because VA’s financial management system does not support the direct obligation of supplemental funds for all expenses, staff used expenditure transfers to shift funds between appropriation accounts. Expenditure transfers are documented using...
Department of Veterans Affairs OIG
Audie L. Murphy Memorial Veterans’ Hospital Missed Opportunities to Distribute Excess Ventilators during the COVID-19 Pandemic
The COVID-19 pandemic caused a surge in demand for ventilators and provoked concerns about potential supply shortages across VA medical facilities. During the course of a previous broader review, the VA Office of Inspector General (OIG) uncovered a potential issue with the number of ventilators procured and stored at the Audie L. Murphy Memorial Veterans’ Hospital in San Antonio, Texas, and sought to determine whether they had been properly requested, acquired, received, and accounted for.The OIG found the facility acquired more ventilators from March 1, 2020, through November 30, 2021, than...
Department of the Interior OIG
The Bureau of Indian Affairs Great Plains Region Did Not Oversee CARES Act Funds Appropriately
We determined that the BIA Great Plains Region did not hold three Tribes accountable for submitting CARES Act financial reports or narrative reports.
Department of the Interior OIG
The Omaha Tribe Did Not Account for CARES Act Funds Appropriately
We determined that the Omaha Tribe did not follow applicable requirements in an agreement with the BIA.
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 the Interior OIG
The Bureaus of Indian Affairs and Indian Education Have the Opportunity To Implement Additional Controls To Prevent or Detect Multi-dipping of Pandemic Response Funds
We recommended the BIA and the BIE implement controls designed to prevent or detect instances of multi-dipping of pandemic response funds.
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 the Interior OIG
The Three Affiliated Tribes Did Not Account for CARES Act Funds Appropriately
We determined that the Three Affiliated Tribes did not follow applicable requirements in an agreement with the BIA.
Department of the Interior OIG
The Lower Brule Sioux Tribe Did Not Account for CARES Act Funds Appropriately
We determined that the Lower Brule Sioux Tribe did not follow applicable requirements in its agreements with the BIA.
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 Veterans Affairs OIG
The Veterans Health Administration Needs to Do More to Promote Emotional Well-Being Supports Amid the COVID-19 Pandemic
The Veterans Health Administration (VHA) Office of Emergency Management issued the initial COVID-19 Response Plan on March 23, 2020, and then an updated version on August 7, 2020. The National Center for Organization Development created a COVID-19 rapid response consultation process for VHA leaders in a supervisory role. The Organizational Health Council developed a team that coordinated with multiple VHA program offices to create a COVID-19 Employee Support Toolkit and other resources. Additionally, several program offices independently created and disseminated employee well-being resources...
Department of Veterans Affairs OIG
Purchases of Smartphones and Tablets for Veterans’ Use during the COVID-19 Pandemic
The COVID-19 pandemic accelerated efforts by the Veterans Health Administration (VHA) to expand veteran access to telehealth. Accordingly, VHA’s Connected Care Office created a new digital divide consult to issue iPhones to veterans experiencing homelessness who were enrolled in the Department of Housing and Urban Development VA Supportive Housing (HUD-VASH) Program. VHA was already loaning iPads to other veterans who lacked telehealth capable devices through the digital divide consult process. The VA Office of Inspector General (OIG) initiated this review to evaluate whether purchases of...
Department of Veterans Affairs OIG
Comprehensive Healthcare Inspection of Facilities’ COVID-19 Pandemic Readiness and Response in Veterans Integrated Service Networks 2, 5, and 6
This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of Veterans Integrated Service Networks (VISNs) 2, 5, and 6 facilities’ COVID-19 pandemic readiness and response. This evaluation focused on emergency preparedness; supplies, equipment, and infrastructure; staffing; access to care; community living center patient care and operations; facility staff feedback; and VA and VISNs 2, 5, and 6 vaccination efforts.The OIG has aggregated findings on COVID-19 preparedness and responsiveness from routine inspections to ensure...
Department of Veterans Affairs OIG
VA’s Compliance with the VA Transparency & Trust Act of 2021
In November 2021, Congress passed the VA Transparency & Trust Act of 2021 to oversee VA’s spending of emergency relief funding related to the COVID-19 pandemic. The law requires VA to report to Congress how it will spend the funding and provide biweekly updates thereafter.The law also requires the VA OIG to report within 120 days on whether VA is spending the funds according to its plan and must address waste, fraud, and abuse. This inaugural report focuses on whether the spend plans VA provided to Congress on December 22, 2021, satisfy the requirements of the Transparency Act.VA’s spend plans...
Department of Veterans Affairs OIG
Care in the Community Consult Management During the COVID-19 Pandemic at the Martinsburg VA Medical Center in West Virginia
The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Martinsburg VA Medical Center (facility) in West Virginia to assess allegations of failure to schedule a Care in the Community (CITC) COVID Priority 1 cardiology consult within Veterans Health Administration requirements, and delays in CITC consult scheduling caused by inadequate CITC staffing.The OIG substantiated that a COVID Priority 1 CITC cardiology consult was not scheduled within 30 days of the clinically indicated date. The OIG determined that the consult was amongst a backlog of approximately 5,000...
Department of the Interior OIG
Fulfillment of Purchase Card Orders
Our inspection identified $155,575 in CARES Act and pandemic-related purchase card transactions with insufficient documentation.
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 Veterans Affairs OIG
Comprehensive Healthcare Inspection of Facilities' COVID-19 Pandemic Readiness and Response in Veterans Integrated Service Networks 1 and 8
This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of Veterans Integrated Service Network (VISN) 1 and 8 facilities’ COVID-19 pandemic readiness and response. This evaluation focused on emergency preparedness; supplies, equipment, and infrastructure; staffing; access to care; community living center patient care and operations; facility staff feedback; and VA and VISN 1 and 8 vaccination efforts.The OIG has aggregated findings on COVID-19 preparedness and responsiveness from routine inspections to ensure prompt...
Department of Veterans Affairs OIG
Deficiencies in Select Community Care Consult (Stat) Processes During the COVID-19 Pandemic
The VA Office of Inspector General (OIG) conducted a national review of stat community care consults generated during the outset of the COVID-19 pandemic to evaluate consult processes. Patient involvement in care urgency disagreements and reporting of adverse events in community care were also reviewed. When the OIG identified deficiencies in processes, electronic health records (EHRs) of the patients at issue were further examined for potential negative outcomes. The OIG did not identify any negative care outcomes.For the 2,236 stat community care consults generated from March 20, 2020...
Department of the Interior OIG
Pandemic Purchase Card Use
Our inspection identified several issues with CARES Act and pandemic-related purchase card transactions made through September 30, 2020.
Full Details:
Oversight.gov Report Page for Pandemic Purchase Card Use
Department of the Interior OIG
Pandemic-Related Contract Actions
Our inspection identified several concerns with CARES Act and pandemic-related contract actions made through October 31, 2020.
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 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 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 the Interior OIG
The Bureau of Land Management’s COVID-19 Response at Recreation Management Areas
We reviewed the actions the BLM has taken to protect its employees, volunteers, and the visiting public during the COVID-19 pandemic.
Department of Veterans Affairs OIG
Medical/Surgical Prime Vendor Contract Emergency Supply Strategies Available Before the COVID-19 Pandemic
VA medical facilities’ demand for personal protective equipment (PPE) increased dramatically during the COVID-19 pandemic. The VA Office of Inspector General (OIG) reviewed how the Veterans Health Administration (VHA) ensured the Medical/Surgical Prime Vendor-Next Generation (MSPV-NG) program and its prime vendors met contract requirements by offering medical facilities a no-cost option to develop advance-order supply lists tailored to catastrophic events and contingency plans. The OIG also assessed whether facilities took advantage of those options and strategies and relied on the contracts...
Department of Veterans Affairs OIG
Review of VHA’s Financial Oversight of COVID-19 Supplemental Funds
In response to the Coronavirus Aid, Relief, and Economic Security (CARES) Act, the VA Office of Inspector General (OIG) reviewed the Veterans Health Administration’s (VHA) tracking and reporting of COVID-19 supplemental funding from legislation for pandemic relief.VA met monthly reporting requirements to OMB and Congress on supplemental fund obligations and expenditures. VA also submitted required weekly obligations and expenditures from supplemental funding to OMB by program activity. Of approximately $17.3 billion in medical care supplemental funds, VA reported it had obligated about $7.11...
Department of Veterans Affairs OIG
Use and Oversight of the Emergency Caches Were Limited during the First Wave of the COVID-19 Pandemic
The OIG assessed how effectively VA managed its emergency caches during the first wave of the COVID-19 pandemic in early 2020. These caches contain a standard supply of drugs and medical supplies, including some personal protective equipment, for use during a public health emergency.The review team found that use and oversight of the emergency caches were limited. Only nine of 144 medical facilities activated their emergency caches during the review period (February through June 2020). Among the reasons they were not used included medical facility directors reporting supplies were not needed...
Department of Veterans Affairs OIG
Inadequate Resident Supervision and Documentation of an Ophthalmology Procedure at the Oklahoma City VA Health Care System in Oklahoma
The VA Office of Inspector General (OIG) conducted an inspection in response to allegations related to ophthalmology resident supervision and quality of care by an attending ophthalmologist (subject ophthalmologist) at the Oklahoma City VA Health Care System in Oklahoma.The OIG substantiated that the subject ophthalmologist failed to provide adequate resident supervision and entered inaccurate documentation related to supervision for a single patient case. The ophthalmology residents were unable to reach the subject ophthalmologist when the patient experienced a complication during an eye...
Department of 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 the Interior OIG
Where’s the Money? DOI Use of CARES Act Funds as of January 31, 2021
On March 27, 2020, Coronavirus Aid, Relief, and Economic Security Act (CARES Act) was enacted. To date the CARES Act has provided the U.S. Department of the Interior (DOI) with $909.7 million, which includes direct apportionments of $756 million to support the needs of DOI programs, bureaus, Indian Country, and the Insular Areas, and a $153.7 million transfer from the U.S. Department of Education to the BIE.This report presents the DOI’s progress as of January 31, 2021, in spending CARES Act appropriations. Specifically, the DOI’s expenditures to date total $613,068,783, and its obligations...
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 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 the Interior OIG
Where’s the Money? DOI Use of CARES Act Funds as of December 31, 2020
On March 27, 2020, the President signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). To date the CARES Act has provided the U.S. Department of the Interior (DOI) with $909.7 million, which includes direct apportionments of $756 million to support the needs of DOI programs, bureaus, Indian Country, and the Insular Areas, and a $153.7 million transfer from the U.S. Department of Education to the BIE.This report presents the DOI’s progress as of December 31, 2020, in spending CARES Act appropriations. Specifically, the DOI’s expenditures to date total $600,876,882...
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 the Interior OIG
The Bureau of Indian Affairs’ Coronavirus Response at Indian Country Detention Facilities
On March 27, 2020, the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) was enacted. It included $8 billion for direct payments to Indian Tribes and $522 million of direct appropriations to the Bureau of Indian Affairs (BIA) and Bureau of Indian Education (BIE) for COVID-19 response. Given this infusion of funding, we examined the impact of COVID-19 on the Indian detention system from April 1, 2020, to May 31, 2020, including the actions the BIA and the tribes have taken to respond to outbreaks of this virus, and how other longstanding challenges have affected the BIA’s response...
Department of the Interior OIG
Where’s the Money? DOI Use of CARES Act Funds as of November 30, 2020
On March 27, 2020, the President signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). To date the CARES Act has provided the U.S. Department of the Interior (DOI) with $909.7 million, which includes direct apportionments of $756 million to support the needs of DOI programs, bureaus, Indian Country, and the Insular Areas, and a $153.7 million transfer from the U.S. Department of Education to the BIE.This report presents the DOI’s progress as of November 30, 2020, in spending CARES Act appropriations. Specifically, the DOI’s expenditures to date total $582,466,112...
Department of the Interior OIG
Departmental Offices CARES Act Funding Snapshot
Under the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) enacted on March 27, 2020, the U.S. Department of the Interior (DOI) received $909.7 million to prevent, prepare for, and respond to the coronavirus pandemic. The Office of the Secretary (OS) received $158.4 million of the DOI’s CARES Act funding and transferred funds to the U.S. Fish and Wildlife Service (FWS), National Park Service (NPS), Bureau of Land Management (BLM), Office of Inspector General (OIG), Bureau of Reclamation (BOR), and Office of Wildland Fire (OWF). As of November 30, 2020, 5.3 percent of the funding...
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 the Interior OIG
Where’s the Money? DOI Use of CARES Act Funds as of October 31, 2020
On March 27, 2020, the President signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). To date the CARES Act has provided the U.S. Department of the Interior (DOI) with $909.7 million, which includes direct apportionments of $756 million to support the needs of DOI programs, bureaus, Indian Country, and the Insular Areas, and a $153.7 million transfer from the U.S. Department of Education to the BIE.This report presents the DOI’s progress as of October 31, 2020, in spending CARES Act appropriations. Specifically, the DOI’s expenditures to date total $566,168,083...
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 the Interior OIG
Where’s the Money? DOI Use of CARES Act Funds as of September 30, 2020
On March 27, 2020, the President signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). To date the CARES Act has provided the U.S. Department of the Interior (DOI) with $909.7 million, which includes direct apportionments of $756 million to support the needs of DOI programs, bureaus, Indian Country, and the Insular Areas, and a $153.7 million transfer from the U.S. Department of Education to the BIE.This report presents the DOI’s progress as of September 30, 2020, in spending CARES Act appropriations. Specifically, the DOI’s expenditures to date total $546,908,092...
Department of the Interior OIG
Lessons Learned From Oversight of the Coastal Impact Assistance Program Grants
On March 27, 2020, the President signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). To date, the CARES Act has provided the U.S. Department of the Interior (DOI) with $909.7 million, which includes direct apportionments of $756 million to support the needs of DOI programs, bureaus, Indian Country, and the Insular Areas, and a $153.7 million transfer from the U.S. Department of Education (ED) to the BIE.In this report, we present lessons learned from and the risks identified in our earlier audit and investigation work related to the Coastal Impact Assistance...
Department of the Interior OIG
Where’s the Money? DOI Use of CARES Act Funds as of August 31, 2020
On March 27, 2020, the President signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). To date the CARES Act has provided the U.S. Department of the Interior (DOI) with $909.7 million, which includes direct apportionments of $756 million to support the needs of DOI programs, bureaus, Indian Country, and the Insular Areas, and a $153.7 million transfer from the U.S. Department of Education to the BIE.This report presents the DOI’s progress as of August 31, 2020, in spending CARES Act appropriations. Specifically, the DOI’s expenditures to date total $526,662,366...
Department of the Interior OIG
The Bureau of Safety and Environmental Enforcement’s Safety Inspection Program COVID-19 Response
During the COVID-19 pandemic, the Bureau of Safety and Environmental Enforcement (BSEE) continued to fulfill its mission by performing safety and environmental inspections for offshore oil and gas operations. We reviewed the actions BSEE’s three regions—the Gulf of Mexico Region, Pacific Region, and Alaska Region—have taken to protect inspectors and offshore employees from COVID-19 and evaluated any impacts the virus had on inspections BSEE conducted since March 2020. We found that BSEE:• Developed, communicated, and updated COVID-19 guidance for all personnel involved with offshore...
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 the Interior OIG
Where’s the Money? DOI Use of CARES Act Funds as of July 31, 2020
On March 27, 2020, the President signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). Among its provisions, the CARES Act provided the U.S. Department of the Interior (DOI) with $756 million to support the needs of DOI programs, bureaus, Indian Country, and the Insular Areas.This report presents the DOI’s progress as of July 31, 2020, in spending CARES Act appropriations. Specifically, the DOI’s expenditures to date total $502,312,984 and its obligations total $599,016,669.We are also monitoring the DOI’s progress on reporting milestones established by the CARES...
Department of the Interior OIG
CARES Act Funds for DOI’s Wildland Fire Management Program as of June 19, 2020
On March 27, 2020, the President signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), which provided the U.S. Department of the Interior (DOI) with $756 million to support the needs of DOI programs, bureaus, Indian Country, and the Insular Areas.As part of the $756 million, the Office of the Secretary received $157.4 million to prevent, prepare for, and respond to the coronavirus across DOI operations, which includes wildland fire management. The DOI approved $11.3 million in funding for the DOI’s Wildland Fire Management (WFM) program through September 30, 2020...
Department of the Interior OIG
Where’s the Money? DOI Use of CARES Act Funds as of June 30, 2020
On March 27, 2020, the President signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). To date, the CARES Act has provided the U.S. Department of the Interior (DOI) with $909.7 million, which includes direct apportionments of $756 million to support the needs of DOI programs, bureaus, Indian Country, and the Insular Areas and a $153.7 million transfer from the U.S. Department of Education to the Bureau of Indian Education in June.This report presents the DOI’s progress as of June 30, 2020, in spending CARES Act appropriations. Specifically, the DOI’s expenditures...
Department of Veterans Affairs OIG
Review of Veterans Health Administration’s COVID-19 Response and Continued Pandemic Readiness
On March 26, 2020, the VA Office of Inspector General (OIG) published its first COVID-19-focused report, OIG Inspection of Veterans Health Administration’s COVID-19 Screening and Pandemic Readiness. In that report, the OIG evaluated how the Veterans Health Administration (VHA) was preparing facilities to meet anticipated rising demands. This report outlines VHA’s continued response to the pandemic and provides VHA leaders’ descriptions of the evolving challenges they faced in caring for veterans and potentially nonveteran patients as well. The OIG engaged leaders from 70 selected facilities in...
Department of the Interior OIG
Bureau of Indian Education Snapshot
On March 27, 2020, the President signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), which provided the U.S. Department of the Interior (DOI) with $756 million to support the needs of DOI programs, bureaus, Indian Country, and the Insular Areas.As part of the CARES Act, the Bureau of Indian Education (BIE) received $69 million from the DOI to prevent, prepare for, and respond to the coronavirus pandemic. In addition to the CARES Act funding appropriated directly to the DOI, the CARES Act’s Education Stabilization Fund required the U.S. Department of Education to...
Department of Veterans Affairs OIG
Review of Highly Rural Community-Based Outpatient Clinics Limited Access to Select Specialty Care
The VA Office of Inspector General (OIG) reviewed the accessibility of dermatology, orthopedics, and urology specialty care for patients in the 17 Veterans Health Administration (VHA) community-based outpatient clinics (CBOCs) classified as highly rural. The OIG also reviewed accessibility, barriers, and the availability and utilization of resources for the time frame March 1, 2018 (or from the date the CBOC became highly rural), through February 28, 2019. VHA utilized clinical consults, electronic consults (eConsults), telehealth, and community care to provide specialty care at the highly...
Department of the Interior OIG
Management Advisory - Recommendations for Reimbursing Contractors’ Paid Leave Under the Coronavirus Aid, Relief, and Economic Security (CARES) Act
CARES Act Section 3610 allows Federal agencies to reimburse their contractors and subcontractors for any paid leave, including sick leave, that the contractors provide to keep their employees or subcontractors in what the section refers to as a “ready state.” Because these reimbursements present a number of risks and the U.S. Department of the Interior (DOI) is already receiving Section 3610 claims from contractors, the DOI urgently needs to put policies in place to ensure consistent oversight of reimbursed leave costs.In this management advisory memorandum, we offer three recommendations that...
Department of the Interior OIG
The National Park Service's Coronavirus Response Operating Plans
In response to the outbreak of the Coronavirus (COVID-19), the National Park Service (NPS) closed most park buildings, facilities, and restrooms, and in some cases, entire parks. With States now easing stay-at-home restrictions, and in response to the White House’s emphasis to open the national parks, some parks have already increased access by implementing a phased reopening. To facilitate a safe reopening, the NPS issued the National Park Service COVID-19 Adaptive Operations Recovery Plan to the parks on May 28, 2020. We contacted each of the 62 national park superintendents to report on...
Department of the Interior OIG
Lessons Learned for Indian Country
The DOI will award most of its CARES Act funding to Indian Country through grants to the Bureau of Indian Affairs (BIA) and the Bureau of Indian Education (BIE). Of the $756 million, $522 million (69.0 percent) will be funded to Indian Country. As of June 13, 2020, $419,462,721, or 80.4 percent, had been obligated.These emergency response awards from the DOI–together with more than $8.7 billion in awards to Indian Country from other Federal departments—present a higher risk because they must be spent in a short period of time. In addition, we have identified Indian Country as a high-risk area...
Department of the Interior OIG
The Office of Insular Affairs Took Appropriate Action With CARES Act Funds
Department of the Interior OIG
Where’s the Money? DOI Use of CARES Act Funds as of May 31, 2020
On March 27, 2020, the President signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). Among its provisions, the CARES Act provided the U.S. Department of the Interior (DOI) with $756 million to support the needs of DOI programs, bureaus, Indian Country, and the Insular Areas.This report presents the DOI’s progress as of May 31, 2020, in spending CARES Act appropriations. Specifically, the DOI’s expenditures to date total $337,105,190 and its obligations total $448,680,794.We are also monitoring the DOI’s progress on reporting milestones established by the CARES...
Department of the Interior OIG
Lessons Learned for CARES Act Awards
On March 27, 2020, the President signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). Among its provisions, the CARES Act provided the U.S. Department of the Interior (DOI) with $756 million to support the needs of DOI programs, bureaus, Indian Country, and the Insular Areas.The DOI will award most of its CARES Act funding through contracts and financial assistance agreements (such as grants and cooperative agreements). Our past work demonstrates that these awards are a vulnerable area for the DOI. Moreover, awards made as part of emergency response are riskier...
Department of the Interior OIG
DOI OIG CARES Act Oversight Plan
In March 2020, the President signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) for response and relief related to COVID-19. The Act provided the U.S. Department of the Interior (DOI) with $756 million to support the Bureau of Reclamation, Insular Affairs, Indian Affairs, Indian Education, and Department operations.Oversight of the DOI’s CARES Act spending is critical to safeguard health and safety, water, and Indian education. We describe our four-pronged approach in this document:• Monitoring for early detection• Reviews to uncover and report on wrongdoing•...
Department of the Interior OIG
Where’s the Money? DOI Use of CARES Act Funds, As of April 28, 2020
On March 27, 2020, the President signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). Among its provisions, the CARES Act provided the U.S. Department of the Interior (DOI) with $756 million to support the needs of DOI programs, bureaus, Indian Country, and the Insular Areas.This report presents the DOI’s progress as of April 28, 2020, in spending CARES Act appropriations. Specifically:• Total expenditures are $168,719,791 and total obligations are $387,887,389.• A total of 491 grants and contracts have been awarded, with total value of $390,845,278.•...
Department of Veterans Affairs OIG
OIG Inspection of Veterans Health Administration’s COVID-19 Screening Processes and Pandemic Readiness
The VA Office of Inspector General (OIG) conducted an inspection to evaluate novel coronavirus disease (COVID-19) screening processes at 237 VA facilities (medical centers, community-based outpatient clinics, and community living centers) and to collect data on pandemic preparations. Screening processes at 71 percent of visited medical centers were adequate, while 28 percent had opportunities for improvement. The vast majority of community-based outpatient clinics had screening procedures in place. Although VA announced a no visitors policy for community living centers on March 10, 2020, OIG...