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Pandemic Response Accountability Committee

A Review of Pandemic Relief Funding and How It Was Used In Six U.S. Communities: Marion County, Georgia

To learn how communities across the nation responded to the pandemic, we initiated a multi-part review of six communities—two cities, two rural counties, and two Tribal reservations. This report is the fourth community-specific report and focuses on our work in Marion County, Georgia, where we previously identified that recipients, including city government, small businesses, and individuals, received almost $39 million from 27 pandemic relief programs and subprograms. This report provides a closer look at six pandemic programs and subprograms provided to Marion County by six federal...
Pandemic Response Accountability Committee

Semiannual Report to Congress: April 1, 2024 - September 30, 2024

Pandemic Response Accountability Committee

A Review of Pandemic Relief Funding and How It Was Used In Six U.S. Communities: Sheridan County, Nebraska

To learn how communities across the nation responded to the pandemic, we initiated a multi-part review of six communities—two cities, two rural counties, and two Tribal reservations. This report is the third community-specific report and focuses on our work in Sheridan County, Nebraska, where we previously identified that recipients, including city government, small businesses, and individuals, received almost $61 million from 31 pandemic relief programs and subprograms. This report provides a closer look at six pandemic programs and subprograms provided to Sheridan County by six federal...
Pandemic Response Accountability Committee

A Review of Pandemic Relief Funding and How It Was Used In Six U.S. Communities: Coeur d’Alene, Idaho

To learn how communities across the nation responded to the pandemic during the first 18 months, we initiated a multi-part review of six communities—two cities, two rural counties, and two Tribal reservations. This report is the second community-specific report and focuses on our work in Coeur d’Alene, Idaho, where we previously identified that recipients, including city government, small businesses, and individuals, received almost $314 million from 45 pandemic relief programs and subprograms. This report provides a closer look at eight pandemic programs and subprograms provided to Coeur d...
Pandemic Response Accountability Committee

A Review of Pandemic Relief Funding and How It Was Used In Six U.S. Communities: Springfield, Massachusetts

To learn how communities across the nation responded to the pandemic, we initiated a multi-part review of six communities—two cities, two rural counties, and two Tribal reservations. This report is the first community-specific report and focuses on our work in Springfield, Massachusetts, where we previously identified that recipients, including city government, small businesses, and individuals, received almost $1.88 billion from 52 pandemic relief programs and subprograms. This report provides a closer look at nine pandemic programs and subprograms provided to Springfield by eight federal...
Pandemic Response Accountability Committee

Why Unemployment Insurance Fraud Surged During the Pandemic

UI was already a strained system, but the pandemic exacerbated existing challenges and created new ones which lead to massive fraud. We sampled 45 cases and learned about the schemes and methods fraudsters used. Find out what can be done to improve UI for the future. Read our report to find out more.
Pandemic Response Accountability Committee

Pandemic Relief Experiences: A Focus on Six Communities

The PRAC along with 10 of our member Offices of Inspectors General conducted this second phase of our review in order to provide insights on the experiences of the two cities, two rural counties, and two Tribal reservations that, during the first part of our review, received a combined $2.65 billion in pandemic relief funding across 89 pandemic programs and subprograms. We found that the six communities shared similar experiences even though their populations, demographics, locations, and contexts were unique. Specifically, we identified four themes which provide valuable insights to...
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.
Pandemic Response Accountability Committee

Agile Oversight in a Time of Crisis: Lessons Learned and Best Practices in Conducting Oversight during the COVID-19 Pandemic

Recognizing the importance of an agile process, the PRAC, in coordination with CIGIE, hosted an Agile Oversight Forum in January 2023. This report captures the lessons learned and best practices shared by oversight experts from around the country at the Forum. The product is intended to be a starting point for offices and is not a standard for conducting oversight work.
Pandemic Response Accountability Committee

Semiannual Report to Congress: April 1, 2023 - September 30, 2023

Pandemic Response Accountability Committee

Key Insights: Contracts and Grants Workforce Response to the COVID-19 Pandemic

During the pandemic, the contracts and grants workforce played a critical role in providing support to taxpayers, local governments, and other recipients through pandemic relief programs. The CARES Act directed the PRAC to review the sufficiency of contract and grant staffing and other resources from agencies across the federal government to determine if they had the resources necessary to adequately perform their duties. The PRAC conducted a survey of 29 agencies, and each provided their experiences on the impact the pandemic had on their agency’s ability to effectively perform their work...
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...
Pandemic Response Accountability Committee

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

While personnel shortages existed in the health care community before the pandemic, the pandemic exacerbated these shortages. Maintaining an appropriate level of personnel in health care facilities is essential to providing a safe work environment for health care personnel and safe care to patients. The Pandemic Response Accountability Committee’s (PRAC) Health Care Subgroup developed this report to share insights into personnel shortages across four select federal health care programs, or the providers they reimburse. Together, these four programs provide health care services to approximately...
Pandemic Response Accountability Committee

Identity Fraud Victim Redress Processes and Systems

Following up on our previous work which highlights the decentralized nature of identity fraud redress across the federal government, the Pandemic Response Accountability Committee commissioned the MITRE Corporation to conduct an independent study and define the elements needs for a whole-of-government approach to identity fraud victim redress. The report proposes a federal redress process that places the victim at the center and requires agencies to assist in a comprehensive manner. Framed as a single enterprise or “one-stop shop,” this process would provide an equitable experience for all...
Pandemic Response Accountability Committee

Tracking Pandemic Relief Funds that Went to Local Communities Reveals Persistent Data Gaps and Data Reliability Issues

The PRAC along with 10 of our member Offices of Inspectors General began a case study-based review, in part, to learn more about how much pandemic relief funding went to recipients within six randomly selected communities. Using a combination of federal, state, and local data sources, we identified that 10 federal agencies provided approximately $2.65 billion in pandemic relief funds to the six communities through approximately 89 pandemic relief programs and subprograms during the first 18 months of the pandemic (March 2020 through September 2021). We also found that tracking pandemic funds...
Pandemic Response Accountability Committee

Semiannual Report to Congress: October 1, 2022 - March 31, 2023

Pandemic Response Accountability Committee

FRAUD ALERT FOLLOW-UP: Improved Sharing of Death Records and Use of the Do Not Pay System Would Strengthen Program Integrity and Better Protect the Public

This update expands on our January 2023 Fraud Alert that identified 69,000 questionable Social Security Numbers (SSNs) used to obtain $5.4 billion in potentially fraudulent loans made in the COVID-19 Economic Injury Disaster Loan (EIDL) program and Paycheck Protection Program (PPP). As detailed in that Fraud Alert, PRAC data scientists, using our Pandemic Analytics Center of Excellence, identified the questionable SSNs after determining that the names, SSNs, and/or dates of birth used in connection with COVID-19 EIDL/PPP applications did not match Social Security Administration’s (SSAs)...
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...
Pandemic Response Accountability Committee

FRAUD ALERT: PRAC Identifies $5.4 Billion in Potentially Fraudulent Pandemic Loans Obtained Using Over 69,000 Questionable Social Security Numbers

The PRAC’s Pandemic Analytics Center of Excellence (PACE) data scientists identified $5.4 Billion in potential identity fraud associated with over 69,000 questionable Social Security Numbers (SSNs) used on applications across disbursed loans in the Small Business Administration’s COVID-19 Economic Injury Disaster Loan Program and Paycheck Protection Program. Through collaborative verification methods with the Social Security Administration, we identified that these SSNs were used in connection with over 99,000 applications and warrant further scrutiny. The results of this Fraud Alert...
Pandemic Response Accountability Committee

Semiannual Report to Congress: April 1, 2022 - September 30, 2022

This report is a summary of the Pandemic Response Accountability Committee’s accomplishments between April 1, 2022, and September 30, 2022.
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...
Pandemic Response Accountability Committee

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

Recognizing how critical telehealth has been to the federal COVID-19 response, the PRAC Health Care Subgroup—which includes six Federal Offices of Inspectors General—worked together to provide insights on the use of telehealth and its associated program integrity risks.
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...
Pandemic Response Accountability Committee

Risk Advisory – Potential Identity or Other Fraud in SBA Pandemic Relief Programs

The Pandemic Response Accountability Committee (PRAC) is issuing this Risk Advisory to notify Small Business Administration (SBA) management of potential identity or other fraud in its COVID-19 Economic Injury Disaster Loan (EIDL) program, EIDL Advance program, and Paycheck Protection Program. The PRAC identified possible identity or other fraud in one or more of these SBA programs involving 945 minors (under 18 years old) and 231 elderly individuals (80 years and older) who are also listed as household members in the Department of Housing and Urban Development’s Low Rent and/or Housing Choice...
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...
Pandemic Response Accountability Committee

Key Insights: Identity Fraud Reduction and Redress in Pandemic Response Programs

This Insights Report highlights identity fraud related challenges in federal programs during the COVID-19 pandemic. By evaluating previous oversight work in this space from members of the PRAC’s Identity Fraud Reduction and Redress Working Group, this report presents best practices to reduce identity fraud before it occurs and to assist victims of identity fraud if it does occur. These best practices may be helpful for federal agencies to utilize moving forward. This report also identifies that across the federal government there is a larger focus on reducing identity fraud up front, while...
Pandemic Response Accountability Committee

Semiannual Report to Congress: October 1, 2021 - March 31, 2022

The Pandemic Response Accountability Committee’s (PRAC) Semiannual Report to Congress, covering the period from October 1, 2021 through March 31, 2022.
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...
Pandemic Response Accountability Committee

BEST PRACTICES AND LESSONS LEARNED FROM THE ADMINISTRATION OF PANDEMIC RELATED UNEMPLOYMENT BENEFITS PROGRAMS

The Pandemic Response Accountability Committee (PRAC) is charged with conducting oversight of pandemic-related spending to prevent and detect fraud, waste, abuse, and mismanagement. In May 2021, we engaged MITRE, a not-for-profit federally funded research and development center, to conduct an independent study of lessons learned from the administration of pandemic-related emergency funding for unemployment insurance (UI) benefit programs in a sample of states. The objective of this study was to increase understanding of how states implemented pandemic UI benefit programs and how their...
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...
Pandemic Response Accountability Committee

Small Business Administration Paycheck Protection Program Phase III Fraud Controls

The PRAC examined whether the Small Business Administration (SBA) Phase III fraud controls, which were applied to process Paycheck Protection Program (PPP) loans in 2021, would have likely detected the earlier fraud found in PPP criminal cases. SBA designed the PPP Phase III controls to address significant fraud identified in the earlier phases of the program and some were later used by the SBA in its Restaurant Revitalization Fund (RRF) 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...
Pandemic Response Accountability Committee

Key Insights: State Pandemic Unemployment Insurance Programs

This insights report provides a contextual understanding of the cross-cutting challenges states faced within their unemployment insurance (UI) programs and highlights the substantial work that has been done by State Auditors to ensure their states’ UI programs are functioning effectively. This report examines four common insights across 16 State Auditor Offices: (1) UI workloads surged for states; (2) the claims surge exploited internal control weaknesses; (3) uncommon and varying fraud schemes began to occur as the amount of federal funding expanded; and (4) state workforce agencies...
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...
Pandemic Response Accountability Committee

Semiannual Report to Congress: April 1, 2021 - September 30, 2021

The Pandemic Response Accountability Committee's (PRAC) Semiannual Report to Congress covering the period April 1, 2021 through September 30, 2021
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...
Pandemic Response Accountability Committee

Increasing Transparency into COVID-19 Spending

The objective of this review was to identify specific gaps in transparency in award data for federal assistance spending in response to COVID-19. We looked at 51,000 awards worth $347 billion that supported the pandemic response (as of June 15, 2021). The report includes three findings, including we found more than 15,400 awards worth $33 billion with meaningless descriptions that make it difficult to know how COVID-19 relief money was used. The report includes five recommendations to help improve the transparency into COVID-19 relief spending.
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...
Pandemic Response Accountability Committee

Lessons Learned in Oversight of Pandemic Relief Funds

The Pandemic Response Accountability Committee (PRAC) supports independent oversight of $5 trillion worth of relief funds provided by Congress to respond to the coronavirus pandemic. This is an unprecedented amount of money, and it was disbursed quickly. The PRAC has worked with dozens of Inspectors General across the federal government to examine whether it was spent correctly and reached those it was intended to help. Together, we have issued more than 275 oversight reports that reveal common challenges facing agencies across major relief programs like unemployment insurance and loans to...
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.

Pandemic Response Accountability Committee

Observations: Fiscal Year 2020 COVID-19 Federal Contracting

The PRAC’s objective was to review pandemic-related federal contracts and identify first-time contractors and contracts awarded without competitive bidding. We found that first-time federal contractors received $4.4 billion worth of pandemic contracts in Fiscal Year 2020 and that $128 million was deobligated from contracts with first-time federal contractors during the same period. Additionally, we identified the four most common flexibilities identified to justify limited competition were urgency, only one source, simplified acquisition procedures, and authorized by statute. Of these, we...
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...
Pandemic Response Accountability Committee

COVID-19 Pandemic Impact - Select Case Studies

Federal agencies were allocated more than $5 trillion in pandemic response funding to be disbursed to the public and to state and local governments, where a state or local government could have received pandemic response funds from multiple federal programs to improve the overall pandemic response in their communities. Access to information about the total amount of funds received, the purpose of those funds, and the progress made toward achieving the program goals and objectives is not always centralized and can be difficult for the public to track down or may not even be available to the public. The PRAC will conduct impact case studies at 6 different locations and seek to identify the federal pandemic response funds provided to the 6 locations and the purpose of those funds, and to determine if the federal program spending aligned with the intended goals and objectives. The 6 locations identified for this project include: Springfield, Massachusetts; Coeur d’Alene, Idaho; Marion County, Georgia; Sheridan County, Nebraska; White Earth Indian Nation, Minnesota; and Jicarilla Apache Nation, New Mexico.

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...
Pandemic Response Accountability Committee

Transparency in Pandemic-related Federal Spending: Report of Alignment and Gaps

A commissioned study by MITRE that identifies gaps in federal data sources and how we can close them to improve the quality of the information we provide to the public.
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...
Pandemic Response Accountability Committee

Key Insights: COVID-19 in Correctional and Detention Facilities

Correctional and detention facilities present unique challenges in preventing and controlling the spread of COVID-19. When compared to the general population, a disproportionate number of COVID-19 outbreaks and deaths occur in jails, prisons, and detention facilities across the country. The Centers for Disease Control and Prevention has noted that the confined nature of correctional and detention facilities, combined with their congregate environments, heightens the potential for COVID-19 to spread once introduced into a facility. Individuals typically eat, sleep, and participate in activities...
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.
 

Pandemic Response Accountability Committee

Semiannual Report to Congress: October 1, 2020 - March 31, 2021

The Pandemic Response Accountability Committee's (PRAC) Semiannual Report to Congress covering the period October 1, 2020 through March 31, 2021.
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 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...
Pandemic Response Accountability Committee

Update: Top Challenges in Pandemic Relief and Response

Since the beginning of the COVID-19 pandemic, the federal government has appropriated over $3.5 trillion to address the public health and economic crises. Given the changing nature of the pandemic and the federal government’s response, we re-visited our original top management challenges to ensure that the PRAC is providing timely information to Congress and the new Administration about the response efforts. The following four challenges have been added: Preventing and Detecting Fraud against Government Programs; Informing and Protecting the Public from Pandemic-Related Fraud; Data...
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)...
Pandemic Response Accountability Committee

Federal COVID-19 Testing Report: Data Insights from Six Federal Health Care Programs

This report examines COVID-19 testing efforts for six federal health care programs during the first seven months following the declaration of a public health emergency in the United States. Published by the PRAC Health Care Subgroup, the report takes a detailed look at testing data in each of the programs that, when combined, provide benefits or care for about 64 million individuals. We hope this report will help policymakers as they continue to develop and refine their testing efforts related to testing accessibility and availability for at-risk populations, cost effectiveness, and...
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...
Pandemic Response Accountability Committee

Transparency in Pandemic-Related Federal Spending: Report of Alignment and Gaps

A commissioned study that identifies gaps in federal data sources and how we can close them to improve the quality of the information we provide to the public.
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...
Pandemic Response Accountability Committee

Agile Toolkit

The PRAC released the Toolkit as a resource to assist federal, state, and local oversight agencies and professionals in conducting timely reviews and oversight of federal funding. The Toolkit provides OIGs and other oversight offices a set of guidelines, best practices, and lessons learned to help prepare these types of reports for CARES Act oversight and beyond.
Pandemic Response Accountability Committee

Semiannual Report to Congress: April 1, 2020 - September 30, 2020

The Pandemic Response Accountability Committee’s (PRAC) first Semiannual Report to Congress, covering the period from April 1, 2020 through September 30, 2020.
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 Veterans Affairs OIG

Review of Veterans Health Administration’s COVID-19 Response and Continued Pandemic Readiness

On March 26, 2020, the VA Office of Inspector General (OIG) published its first COVID-19-focused report, OIG Inspection of Veterans Health Administration’s COVID-19 Screening and Pandemic Readiness. In that report, the OIG evaluated how the Veterans Health Administration (VHA) was preparing facilities to meet anticipated rising demands. This report outlines VHA’s continued response to the pandemic and provides VHA leaders’ descriptions of the evolving challenges they faced in caring for veterans and potentially nonveteran patients as well. The OIG engaged leaders from 70 selected facilities in...
Department of Veterans Affairs OIG

Review of Highly Rural Community-Based Outpatient Clinics Limited Access to Select Specialty Care

The VA Office of Inspector General (OIG) reviewed the accessibility of dermatology, orthopedics, and urology specialty care for patients in the 17 Veterans Health Administration (VHA) community-based outpatient clinics (CBOCs) classified as highly rural. The OIG also reviewed accessibility, barriers, and the availability and utilization of resources for the time frame March 1, 2018 (or from the date the CBOC became highly rural), through February 28, 2019. VHA utilized clinical consults, electronic consults (eConsults), telehealth, and community care to provide specialty care at the highly...
Pandemic Response Accountability Committee

PRAC Strategic Plan

Pandemic Response Accountability Committee

Top Challenges Facing Federal Agencies: COVID-19 Emergency Relief and Response Efforts

The objective of this report is to provide insight into the top management challenges facing federal agencies that received pandemic relatedfunding as identified by Offices of Inspector General.
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...