Reports
Search for reports and investigative results.
Showing 1 - 10 of 35 results
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 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 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 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
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
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: 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
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: 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...
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...